Curbside Consult with Dr. Jayne 3/2/15

I received an email from ONC on Thursday that they were extending the deadline for nominations to the HIMSS Interoperability Showcase, citing “feedback that organizations needed more time to submit nominations for participation.” From the time the email arrived, that’s a whopping three business days until the deadline. It made me wonder exactly why the deadline was extended and what their current applicant pool looks like. If they were delaying because they didn’t have many applicants, then they hardly gave much of a window for organizations that weren’t already prepared. Was the announcement a way to raise awareness about the Showcase rather than being designed truly to solicit participants?

Perhaps organizations didn’t apply because they didn’t want to spend $8,000 to participate. That’s just for the kiosk at the Showcase, which includes a monitor, keyboard, mouse, power, and Internet connectivity as well as two exhibitor badges. Travel, meals, and lodging will be on top of that. We’re doing some cool things with interoperability at my health system, but they’re not about to spend upwards of $12K for developers to go show it off at HIMSS.

Whatever the reason, I can’t help but think about the ongoing list of government initiatives that have to be delayed, extended, or otherwise modified because they don’t seem to be achieving the desired results. Being a process improvement person, I’m always looking for the root cause when outcomes are not achieved or when projects run off the rails. Recently, we’ve had delays in ICD-10, Meaningful Use, and Healthcare.gov. Some of us, however, remember delays in the implementation of the 5010 claim standard and those of us deep in the weeds know about dozens of lesser-known parts of HIPAA and other omnibus legislation that are virtually unimplementable.

In medicine, we have a doctrine about ordering laboratory and diagnostic tests: don’t order it if it’s not going to change your plan for the patient. I do a lot of work with reporting from our EHR data and we have a similar dictum: don’t run the report if you’re not equipped to act on it. You’d think there would be a similar mantra about not making rules that people can’t actually follow, but that doesn’t seem to be a factor for those happily engaged in rulemaking. Only in healthcare do we come up with creatures like the “Two Midnight” rule and other similar nonsense.

My extended family is always asking about some of the wacky things that go on, such as provider-based billing, which allows hospital-owned practices to charge both a professional fee and a facility fee for outpatient visits. I’ve become as expert at explaining the Medicare Part D “donut hole” as I am at teaching patients to use a home blood glucose monitor. In trying to find some method to the madness, I stumbled on an article that attempts to explain why healthcare regulation is so complex. The first paragraph opens with a perfect summary: “Health care professionals may feel that they spend more time complying with the rules that direct their work than actually doing the work itself.”

The author contends that “regulation arises largely from a set of confrontations between opposing interests that created the system.” I agree that there are clashing agendas and learned that first hand as a young physician when the hospital’s chief of staff wanted to know why he wasn’t getting my referrals. It felt more than a little like a shakedown. He wasn’t aware that I sent nearly all of my referrals in his specialty to one of his partners, so at least his practice was seeing volume if he wasn’t personally. It didn’t matter, though, since it was apparently all about his ego. These conflicting agendas are ongoing, and “Doctored: The Disillusionment of an American Physician” talks about one physician’s struggle.

Although there are certainly turf wars at play, the regulatory soup includes rulemaking at so many levels that it’s nearly impossible to keep track of what needs to be done. I have to follow the rules of multiple hospital medical staff organizations, two state licensing boards, two specialty certification boards, one professional society, dozens of payers, the city, the county, the state, and the federal government. These rules (and non-rules that often have the force of law) sometimes conflict each other and often fail to make sense.

Several times in the last few decades, studies have looked at everything a primary care physician should be doing for his or her patients and how long that would take. An article in the Washington Post summarized the most recent data from the Annals of Family Medicine, which found that for a typical panel of 2,300 patients, the physician would have to spend nearly 22 hours a day to provide all the recommended care. That’s just delivering the care itself – it doesn’t factor in the time needed to comply with everything else a physician does such as arguing with payers, managing staff, dealing with regulations, worrying about compliance with programs, and trying to stay current with medical knowledge.

That’s what we’re dealing with in the ambulatory setting. Hospitals and health systems deal with many more rules and countless regulatory bodies. Similarly their IT departments are trying to keep the systems up and running, prevent breaches, avoid breaking something that’s required for Meaningful Use, and so on. It’s no surprise that people are not coming out of the woodwork to sign up for the Interoperability Showcase.

What regulations keep you hamster wheel spinning? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/26/15

I literally had almost 100 people forward me news articles about the CMS announcement pushing the Medicare Meaningful Use attestation and PQRS reporting deadlines to March 20. Although no specific reason was announced, possibilities include winter weather emergencies, the fear (or reality) of attestation site glitches, the complexity of preparing reports and audit documentation, and lack of vendor readiness as possibilities. Buried below the fold of several articles was the fact that this does not impact the Medicaid Incentive Program, so I hope those practices realize they’re still on the hook for the original deadline.

The hideous cold and repeated snows pounding a good chunk of the country have put a cramp in the style of many fitness enthusiasts. Although I once had a serious dislike of treadmills in general, I’m glad that I finally got one at home at least to be able to get some miles in despite the cold. I might have been more fond of treadmills sooner had I known about iFit, which allows compatible fitness equipment to automatically deliver uphills and downhills to match real-world routes while showing pictures from Google street view.

I’ve now run through Ireland, Paris, Norway, and my own neighborhood and definitely like it better than the standard programs on the treadmills at the gym. Once people’s New Year’s resolutions start failing, used equipment will start popping up for sale and I’m glad I have something to talk about with patients who think walking on a treadmill is boring. I also found a National Geographic “Everest” video workout on the site and although it bested me the first time, I’ll be back for more. Having the ability to track and quantify my efforts to stay in shape has been a benefit for me, although I draw the line at sharing every workout to Facebook.

A reader who has picked up on my running habit shared these high-tech socks from Sensoria that use sensors and conductive fibers to gather information about a runner’s speed, distance, steps, and how their feet strike the ground. They debuted at the recent Consumer Electronics Show and are from the same people who brought us shirts and running bras to sync with heart rate monitors. A magnetic anklet communicates with Android and Apple devices to provide real-time feedback. I’m not sure I want my socks to coach me and they aren’t cheap, so I think I’m going to take a pass this time. I do enjoy reading about wellness-related tech, so keep sending your finds.

I do some volunteering at a local school and they asked me to speak at an upcoming career day. When I get requests like that, I always have to ask whether they want me to talk about my “doctor job” or my “computer job” or both. When I decided to become a family physician, I never imagined myself on the cutting edge so I was happy to come across this piece on physician informaticists to help explain exactly what it is that I do all day. Apparently UCLA is thinking outside the box and is making their informaticists available for consultation with other Epic customers. It looks like a win-win situation to me – in addition to assisting other organizations, their team can also bring back successful approaches from other sites.

NCQA is offering the opportunity for the public to provide feedback on proposed change to 2016 HEDIS measures. There are a handful of proposed new measures and changes to several existing ones, so plan to get your comments in before the March 18 deadline.

Speaking of deadlines, Friday is the cutoff for HIMSS hotel changes. I’m mixing it up this year and staying somewhere swanky with a couple of my gal pals since I was able to get ridiculously cheap airfare. Although registration for HIStalkapalooza is closed, I know Mr. H is poring over the guest list and I’m looking forward to seeing many of you there (anonymously, of course). The event is one of the most fun parts of being on the HIStalk team, although I am feeling the pressure when it comes to finding a pair of outstanding shoes. Maybe Sensoria should make an insert to gather data on what happens to the feet of fashionable ladies and gents out for a night on the town.

Have you put together your HIMSS wardrobe plan yet? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/23/15

I’m leaning heavily towards staying with my current employer as we move to a single platform for all our hospitals and practices, but lots of people keep sending opportunities my way. Today a juicy CMIO position came across my desk. It’s in a great location and with a well-known health system that I’ve had some dealings with previously.

It looked pretty exciting until I got to the part about the heavy inpatient focus and complete disregard for those of us who have come up through the ambulatory ranks. I started to move it to my recycle pile until something caught my eye. They’re looking for someone “politically savvy with a high tolerance for ambiguity… who can put all the pieces together and deliver on time and on budget.”

I’ve got a lot of experience delivering the undeliverable and creating successes despite some of the people I work with. Usually hard work and pixie dust are involved, but we never admit it. My general rule of thumb is that organizations are typically 30-50 percent more dysfunctional than they admit, so I’m wondering what that looks like when they’re already warning candidates about ambiguity and the need to be able to patch things up to get a project out the door. They also mention frequent interruptions and constantly changing priorities. I’m not rushing to submit my CV.

Another prospective position (thanks to the reader who sent me an opportunity in a warm climate) looks like it’s much more up my alley. The nine responsibilities bulleted in the job description are things I’ve been doing for years. I’m less sure, however, about the tenth one – supervising and assigning projects to physician informaticists on the CMIO’s team. Sometimes it feels like I’m lucky to get an administrative assistant to support me, so the idea of multiple physicians helping deliver value from healthcare IT is awfully tempting. They’re also looking for someone either board certified in clinical informatics or with a masters degree in the field, so that tells me they value the education and training that many of us can bring to the table.

In the mean time, I’m still waiting to find out how my health system is going to handle the clinical leadership structure for the EHR consolidation project. I don’t have a lot of time to dwell on it, however, since we’re preparing more than a dozen practices to seek recognition as Patient-Centered Medical Homes.

The first time I went through the process was on paper. Although there are certain aspects of the requirements that are significantly easier with an EHR in place, there are still elements that are much simpler in the paper world. Some of our practice managers have actually laughed out loud when I ask them to use a simple three-ring binder for some of the requirements. Although I’m obviously a fan of technology, sometimes a manual process is quicker, easier, and doesn’t require anyone from IT to give it a blessing.

I’d estimate that three-quarters of our practices are ready, with stable processes and solid physician buy-in. The other few still need some work. We’re likely to urge the others to move forward while we continue to tweak workflows in those that aren’t quite ready. They also need some refinement in staff roles and responsibilities. We’re finally helping our administrators understand that PCMH is not a technology project so much as an operational initiative. I want to try to get as many of our joint operational and technical projects completed before the transition to the new system begins in earnest.

I’m also staying occupied looking for interesting ways to use some of my accumulated vacation time. As of January 1, our health system has gone to a “use it or lose it” philosophy and has capped the vacation hours we can have on the books. I’m dangerously close to the limit and certainly don’t want to leave any hours on the table. I’m planning a wilderness adventure for July, and if I don’t get eaten by a bear, I’m looking for a trip in the fall that will provide not only some R&R but some continuing education hours. I also hope to take some long weekends once the weather gets nice. The new policy should make for some interesting resource challenges as everyone tries to lower their balances.

What’s your plan for R&R in 2015? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/19/15

We always love hearing about ways that vendors are contributing to the greater good. I was excited to receive a Valentine’s Day card from our sponsor Medicomp Systems, who offered to donate $10 to Doctors Without Borders for each person who views a brief demo of Quippe. It was supposed to end this week, but the executive team generously agreed to extend it a few more days for HIStalk readers. They’re willing to donate up to $5,000, so stop by to do your part for Doctors Without Borders. You’ll also be able to pre-register to compete in their Quipstar game show during HIMSS. I was a celebrity contestant in 2013, so I can attest that it’s a lot of fun.

The Texas Regional HIMSS Conference is taking place this week in Austin. Thursday’s keynote was Ed Marx, speaking on, “Extraordinary Tales From A Rather Ordinary Guy.” Other topics included screening for emerging diseases, interoperability, population health management, health literacy, and of course Meaningful Use. Texas has a reputation for hospitality, but one of my readers was not impressed when another attendee made snarky comments about the fact that she was taking notes during the meeting, asking, “Did you get all your work done?”

Wednesday was National Drink Wine Day, which reminds me of an EHR story a friend shared with me. During a trip to the emergency department, she was asked about her alcohol intake. Do you drink alcohol? Yes. How often – once a day or socially? Yes. She was told she had to pick one or the other. As a clinician, I always wondered what documenting “socially” really tells me about a patient. Does that mean they have drinks once a year at the company Christmas party or twice a week in the stands at their kids’ baseball games? Are they socializing at the bar every night after work? It just goes to illustrate that data collected for the sake of collecting data (and without valid clinical intent) is not only a poor use of scarce time, but meaningless.

There are plenty of phishing scams riding the coattails of the recent Anthem breach, but they’re a drop in the bucket compared to the daily deluge of random emails trying to grab our attention. I am always amused by people trying to get content on HIStalk when they clearly don’t read it. One of yesterday’s offerings tried to convince us that we need guest bloggers to keep up a constant flow of content so that we can relax. There were also a handful of emails that were barely coherent and those are just the ones that made it through the spam filter. I recently read “The 4-Hour Workweek” and the idea of having someone to pre-screen my email is more appealing every day.

Speaking of email, my EHR vendor sent a nice one this week about the recent CMS approval for lung cancer screening using low-dose CT scanning. What would have been even nicer would have been instructions on the best way to identify and track impacted patients since they have to be in a certain age group, have smoked a certain amount, and must be either current smokers or have quit within the last 15 years.

Even as a member of the HIStalk team, I can’t possibly keep up with all the health IT news out there. HIStalk Practice mentioned a study at Michigan State University. It looks at using children’s fingerprints to track immunization records. Comments on the article immediately seized on it as a way for the government to force individuals to provide their fingerprints. The article reminded me of VeriChip, which was similar to the computer chips many of us use to permanently identify our pets. Reading the article about its FDA approval in 2004 was a blast from the past as it referenced then-President Bush’s EHR initiative. It also mentioned the disparities in animal vs. human medicine, noting that implantation for a pet would have been $50 but for a person it would have been $150 to $200.

Jenn also told me about a review on physician dress done by a team at University of Michigan Health System. The team performed a comprehensive review of studies on physician dress, looking at 30 studies involving more than 11,000 patients in 14 countries. They confirmed what many of us suspected: that older patients prefer their physicians to be more formally dressed, where members of Generation X and Y were more accepting of casual attire. There were some differences in preference depending on physician specialty. The team plans to conduct their own study, “Targeting Attire to Improve Likelihood of Rapport” or TAILOR. Hospitals in three countries have already agreed to participate. My new clinical posting involves monogrammed scrubs, so I might just spring for a new pair of clogs to match.

With this winter’s seemingly-perpetual cold and abundant snow, I’ve been tending to warm, non-skid footwear. But with the promise of spring around the corner, a reader shared these smart little shoes. “There’s No Data Like Home” by artist Steven Rodrig definitely lifts my spirits, appealing to both my fashion sense and techie tendencies.

What warms your heart with thoughts of spring? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/16/15

A reader with a keen eye sent me this warning sign, saying it reminded him of the modern workplace. The beach is lovely… except for the sharks, hippos, and crocodiles. It arrived while I was preparing some thoughts on what the workplace has become. The recent Wall Street Journal piece “Everything is Awesome! Why You Can’t Tell Employees They’re Doing a Bad Job” is making the rounds at our hospital. If the pay wall won’t let you read it, I recommend a search using key words from the title – that’s how I got the full text.

I have to admit that I was drawn in by the opening paragraph: “Fearing they’ll crush employees’ confidence and erode performance, employers are asking managers to ease up on harsh feedback.” I’m a firm believer in public praise and private criticism. However, the article seems to advocate swinging the pendulum pretty far to avoid any negative feedback for employees. Suggested employee review phrases include “we haven’t done this” rather than “we can’t do this,” which tells me something about the companies advocating this approach: they are probably not in healthcare. What might work at VMware Inc. or the Boston Consulting Group isn’t going to work in a Joint Commission-accredited, CMS-regulated, state-licensed facility where we’re forced to say “we can’t do this” every single day.

For those of us on the clinical side, as young nurses or physicians in training, we didn’t get to pick our assignments. We did what we were told and we did it as well as we could possibly do it, with the hope that our next assignment would be more educational or at least less odious. At the end of medical school, physicians almost get raffled off (National Residency Matching Program, anyone?) to hospitals for an additional three to seven years of on-the-job training. The vast majority of us work really hard, in part to make sure we continue to be at the top of our games, but also because we realize that people’s lives are on the line every day when we go to work.

In my organization, we’re seeing that as Baby Boomers retire and are replaced by Millennials, we’re being asked more and more to consider employees’ feelings as we assign work to them. I’m not a Baby Boomer, but as someone who has worked in a top-down, mission-critical environment for most of her career, I share a lot of the psychology. For those of us used to doing what needs to be done regardless of how we feel about it, worrying about employees’ feelings is not the first thing one thinks of when something goes terribly wrong. Hospital work places an incredible amount of pressure on everyone to have a zero-error workplace; we need to be able to deliver constructive criticism or even corrective action when it is required. When the Code Blue is over and the patient has either survived or died, we debrief. We talk about the team, how things went, and sometimes the emotional side of it. But that’s well after the fact.

When an employee has a lot of issues or requires more remediation than makes sense for their skills and role, the ability to provide clear feedback is essential. Feedback needs to be ongoing — no one should ever be surprised by what they hear in a performance review. Additionally, we’ve seen employees (and former employees) become more litigious over the last few years. Having appropriate documentation of non-performance and resulting interventions is essential to managing those situations. It’s more difficult for someone to come back at you for wrongful termination when you have a well-organized history of events.

The article cites experts who agree that “tough feedback sometimes motivates people better than praise,” but it was well below the fold. Tough feedback certainly doesn’t mean yelling at staff or belittling them, but it may mean making clear statements of events and their consequences that workers are not ready to hear.

I recently asked a lab analyst to review some normalization work that his co-worker did as a peer review. The reviewer “corrected” the work, adding new values that were clearly incorrect. I marked up the review, provided specific explanations of why each element was incorrect, and met with the analyst to review it. I thought he was going to have a breakdown. Unfortunately, he was less concerned by the fact that his work might have caused a serious patient safety issue and more concerned that I was “going after him.” If he thinks a private meeting where we discuss the facts around why one cannot round lab values or change their units inappropriately is “going after” someone, then he probably doesn’t need to be in healthcare. He also probably doesn’t belong at Netflix, either, which the article cites as “devoted to toughness.”

Reading through the 130+ comments on the piece, I’m not the only one with second thoughts about some of the approaches recommended. One had a great point about the concept of work teams: “Playing on a team is based on performance, perform well = get to play, if I don’t, I remain on bench or I am removed. Regular coaching includes what an employee does well and recommendations on what will allow them to reach the next level of performance.” Another asked, “If we equate a company department or division to an orchestra, how long would the conductor let bad musicians ruin the entire performance?

One comment gave a lot of food for thought: “Under-performers do not hurt their managers nearly as much as they hurt their peers, who daily must compensate for their failures and sometimes watch them reap rewards for inadequate work. Any organization of any real size can compensate for a few under-performers, mostly because their peers pick up their slack, usually with no recognition or reward. However, I have repeatedly observed that when left unchecked, these situations quickly tank morale and end with the departure of those who can afford to leave, usually with no statement of why they are leaving, because they don’t want trouble.”

I’ve seen that situation first hand, when more than half of a manager’s subordinates applied for transfers over a 12-month period. The underlying issue was his inability to deal with two members of the team who were not performing. They were perceived as favorites and the others were afraid to speak out, so they left. I’ve also seen the dark side of ignoring poor performance, when the team members who were tired of picking up the slack went on the offensive. They ultimately took down not only the underperformers, but also the manager.

Every workplace is different. Although some management strategies involve clear expectations and performance goals, others can be quite murky. There may be hidden (or blatantly advertised) agendas and infighting. In other words, the beach may be lovely… but watch out for the wildlife.

How does your organization find the right balance between praise and correction? What did you think about the WSJ article? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/12/15

AMIA announces its Third Annual Student Design Challenge. Teams of graduate students are invited to submit “novel and original ways to facilitate engagement between humans and computing data-analytic systems.” Eight finalists will be invited to present posters at the AMIA Annual Symposium, with the top four teams delivering formal presentations. Proposals are due by June 1.

My wish list of things that would immediately better my own human-computer interaction: high-quality real-time voice recognition that could immediately map to discrete data fields in my EHR to facilitate interoperability and E&M coding support; a reporting platform that would let me do clinical queries based on concept associations rather than painstaking identification of specific data fields; and ways to manage constantly-changing clinical recommendations that don’t require a fleet of IT staffers.

This week has been a whirlwind. We’re delivering the first burst of training for ICD-10. Our corporate decision-makers wanted to maximize physician time out of the office, so they have bundled education on readmissions, length of stay, and preventable harms together as well. Although it may have saved providers from making multiple trips to the hospital for training, I’m pretty sure most of their brains stopped absorbing about 45 minutes into the session. Our team was batting cleanup with the ICD-10 content, so we’ll be planning repeat sessions both online and in-person.

I’ve also been busy preparing a lecture for Grand Rounds. It used to be that Grand Rounds was about presenting interesting clinical cases or new advances in treating diseases, but now we spend a lot of time talking about Meaningful Use and other regulatory concerns. I’ve been tapped to talk about the Security Risk Assessment needed for successful Meaningful Use attestation. It’s probably a reasonable topic since it’s been part of the HIPAA requirements for nearly a decade, yet many physicians act as if they haven’t heard of it.

Not only can providers be asked to pay back incentive money, but they can risk other penalties from the Office for Civil Rights. It’s a complex topic because it’s not once-and-done like “implement a certified EHR” or “turn on drug/allergy checking.” It requires physicians to create the assessment and maintain it as a living document, reassessing risk as they purchase new technology or change their information strategies. Given all the recent breaches, I’d think there would be more interest in security and risk. I’m looking forward to it since I do enjoy helping community providers learn how to navigate some of the thorny issues that employed physicians don’t necessarily have to deal with.

There are a lot of free resources available to providers and they’ll be taking home a tool kit to keep them headed in the right direction, whether they decide to try to perform the risk analysis on their own or hire an outside professional to complete it. I’ll also ask them to suggest topics for the next “administrative” Grand Rounds. Reading the comments and suggestions on their evaluation forms is usually good for a laugh or two.

The New Year always brings new vendor contracts. In addition to a new benefits manager for our flexible spending accounts, we also have a new purchasing agreement for office supplies. My assistant ran across this informational popup today. I’m going to have to seriously indulge my office supply habit if I’m going to hit that minimum.

Are you hoping your Valentine brings you a fragrant bouquet of Mr. Sketch markers? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/9/15

One of the most fun things about being part of the HIStalk team is the ability to interact with readers. I asked last week if the “Fireside Chat” at the ONC annual meeting (with former Senate Majority Leaders Tom Daschle and Bill Frist) actually had a fire. A reader quickly replied with his summary: “Well attended, interesting, some controversy, but an informative and enjoyable event.” But alas, no fire.

Another reader sent this sweet little bit of shoe love. It arrived in the middle of a crazy, crazy week and I enjoyed the smile it put on my face. I probably would have enjoyed the smile a little better if I hadn’t been caught multitasking in a meeting, when my grin made it clear I wasn’t paying attention to the ridiculous discussion around patient satisfaction scores that was going on at the time. I bet if we gave patients one of these treats at checkout, we’d get better scores. I’m not being flippant, but it’s at least as good as some of the plans I heard thrown out by the 24-year-old MBAs who seem to be running the place.

From the practicing physician side, many of us are at a point in our careers where the daily grind of dealing with insurance, regulators, and government entities seems to outweigh the satisfaction we get from actually caring for patients. I was inspired to hear from a young IT consultant who answered my question about, “If you could be anything you wanted, what would you be?”

I asked myself this very question last fall and decided without a doubt that I wanted to be a doctor. I have a liberal arts degree, almost zero science background, and have never taken the MCAT but am in the process of applying to post-baccalaureate pre-medical programs. Seeing firsthand how people approach healthcare convinced me that this was something I needed to do. Thanks for contributing to a great site and being part of the industry driving me towards my dream.

I sent back some words of encouragement and hope he will stay in touch. I don’t think many would argue with the idea that being part of the healing professions is a calling. Given all the pressures associated with healthcare today, I think it may be even more so than it has been in the past. My medical school class had a large number of people without science degrees and I know many medical schools are looking for non-traditional students, so I wish him the best of luck.

Another reader who has worked his way up through the industry over a lengthy career offered some options for what he would do if he had the choice to do something different:

• Start over. Go back to school and learn something new. Concentrate on helping people help themselves in this messed up world of healthcare.
• Change. Do something you love and you won’t work a day in your life. So maybe cooking or entertaining. Thoughts of starting a coffee shop or something very new and very social come to mind.
• Hang in there. Continue to fight the good fight and go down with the ship when the time comes – a comfortable option because I make good money and my schedule is mine (for the most part).
• Give up. Find some way to make a bunch of money so I don’t have to think about a career. Suing a doctor over something has interest!

I hope he was kidding about the last item, but some of the others do resonate. Right now I’m leaning towards his third bullet – hanging in there. At times my work is crazy, but there’s something to be said about the devil you know vs. the alternative. Option #2 definitely resonates. We used to tease one of our residency colleagues about her hobby of raising goats until the organic movement really took off. Now her income in the niche dairy business allows her to volunteer at a free clinic, which has been greatly satisfying.

In the same vein, one reader would become a professional volunteer. “I do my share of volunteering and giving back, but I always think I could do so much more.” Watching my parents volunteer during their retirement has been great and I’m glad they remain healthy enough to do so. My favorite answer to the “what would you do” question is from a long-time reader. I had to change a few of his answers to protect his anonymity, but I hope you have as much fun reading them as I did:

I would continue to battle the politics and personalities of a non-profit health system. I would work tirelessly for days on end for the same amount of money I could make delivering for FedEx or tending bar. I would get dressed up so that I can sit in a poorly-lit work area in a chair that has celebrated its own retirement working on a computer that can only be classified as “retro” to anyone else familiar with technology.

I would learn the names of the faceless consultants who roam the halls with shined shoes, sharp ties, and opinions on everything. I would let individuals that have no stake in the community or organization play Russian Roulette with our financial and social futures. I would wake up and be the butt of every motivational poster. I would be the buzzword people are looking for. I would wake up and do mock Joint Commission audits every day because it is fun and everyone loves the villain. I would “operationalize” bad ideas more. Since that is the new word, I would need to be great at it, because the consultants said so.

Although he paints a bleak future, it’s a good reminder to some of us about why we went into this in the first place. If I wanted to make more money than the night team at Taco Bell did, I would have quit during residency. (Yes, I did the math, and it wasn’t pretty). If I wanted glamour and a windowed corner office, I would have gone to business school or law school. If I wanted shiny shoes and sharp ties, I could have gone into pharma. 

I chose healthcare, not for the saggy scrubs and rubberized clogs, but because I wanted to make things better. In the immortal words of Dr. Mark Greene, “Helping them is more important than how we feel.” Whether it’s a sick patient or an ailing hospital, I’m here to stay.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/5/15

Although our local groundhog said that spring was just around the corner, I’m not sure I believe it. The grey skies seem to match the mood of many of our hospital’s administrators, as they come up with long lists of IT-related projects to keep us busy even though we already have plenty to do.

Regardless of the CMS plans to shorten this year’s reporting period to 90 days, we now have a month’s worth of data and are heading out to our practices to remediate staff and reinforce workflows. It’s a good time to deliver training since business tends to be down in many practices during the first part of the year. With patients having not yet met their ever-increasing deductibles, they tend to be reluctant to come in unless absolutely needed.

I’ve been in touch with some friends in vendor circles, hearing about their plans for HIMSS and specifically what they are planning to help draw people into their booths. I’m not a fan of so-called booth babes (unless they are wearing amazing shoes and can also talk about the product they are representing) and “must be present to win” giveaways don’t do the trick either. One vendor promises a close encounter of the sensory kind, including both aromas and edibles. Knowing the team involved, I can’t way to see what they cook up.

As I sat having dinner with someone wearing a watch that would have made Dick Tracy do a double take, I remembered that an intrepid reader had sent me an article about jewelry that camouflages  tech rather than showing it off. I’ve been keeping my eye on Ringly but hadn’t realized they raised more than $5 million last month. Although I’ve enjoyed my GPS watch and think it’s motivated me to be more active, I do wish Garmin offered something that didn’t scream “Runner!” and looked a little more businesslike.

One of the email digests I receive had a link to a fluff piece about the November round of ICD-10 testing. The American Academy of Professional Coders polled 2,000 participants, concluding that the results were positive with 90 percent reporting no payment shifts in test claims. I wasn’t able to get my hands on the full results, but some of the numbers cited looked a bit strange without current ICD-9 results for comparison. If anyone participated in testing, we’d love to hear about your experience. Additional testing is planned for April.

Speaking of ICD-10, we are planning to start training (again) at our hospital and outpatient offices within the next month. We had begun orienting providers prior to the delay and I have to admit there no longer seems to be any urgency about it. Some probably think it will be delayed again and others are just tired of the ongoing parade of regulatory changes. Our online sign-up sheets are remarkably empty, so we’ll have to start doing outreach to try to draw people in. Some specialties will face larger challenges than others and I’d rather not have a flurry of “emergency” training in September.

ONC held its annual meeting this week in Washington DC. I’d be interested to hear impressions from attendees. In particular, was there actually a fire for the Fireside Chat with Former Senate Majority Leaders Tom Daschle and Bill Frist? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/2/15

Although I still haven’t answered the "should I stay or should I go" question regarding my day job, I did make a decision to leave the practice where I’m currently providing urgent care services. I haven’t resigned yet since there’s enough strangeness that I want to have my final paycheck in hand before I do.

I didn’t really pay attention to the calendar when I sent my available days for this month, so I’m spending Super Bowl Sunday seeing patients. So far, sinusitis is leading otitis media 13 to 2 going into halftime, where we expect a rousing performance by indie rock band Motor Vehicle Accident.

I’m certainly not a job hopper. Prior to this job, I had been with the same emergency and urgent care staffing company for nearly six years. They had a huge portfolio of customers, which allowed me to experience quite a few different care settings and a variety of different inpatient and outpatient EHR systems, health information exchanges, and more. 

Last year, they lost their contracts with most of the facilities in my area when another staffing company underbid them. I’m not sure the facilities were aware that all the part-time and as-needed physician providers were going to be replaced with non-physicians, but they should have seen it coming based on the pricing model. Along with more than a dozen other part-timers, I was let go.

I didn’t see patients for a couple of months while I evaluated my options. Eventually I received a call from a recruiter which led me to this opportunity — an independently-owned urgent care with two locations. The facilities are recently renovated, the drive was reasonable, and the pay was in my range, so I gave it a shot.

The only downside was their lack of EHR. For some, that might be a bonus — the learning curve for charting is certainly very small. But for someone who is used to the safety features of an EHR (allergy and interaction checking, pediatric dosage calculation, etc.) it was a little rough. I dabbled with a freestanding eRx system for a while, but the dual data entry was a bear.

My employer is certainly nice enough, but he’s suffering from the same things that are impacting most small practices. They don’t run themselves. Without a dedicated physician leader or a hands-on management style, it’s easy to start a death spiral with staff unhappiness, turnover, patient unhappiness, and ultimately physician unhappiness. All of these conditions contribute to a negative impact on the bottom line, as does his obsession with the salt water aquarium in the waiting room.

He tends to manage from afar, yet micromanages at times. Policies and procedures are lacking, but he shows up unpredictably and criticizes how work is being done. Poor performance is not addressed and high performers are not rewarded. The staff is relatively young, and without consistent leadership or supervision, they tend to fall into the behaviors that college-age people do. Smartphone use is rampant, which not only hampers productivity, but leads to some interesting conversations that patients overhear. Staff regularly shows up either at the exact time the office is supposed to open or even after and management doesn’t seem willing to address it for fear of losing people.

Although I can put up with a fair amount of chaos, I recently figured out that there were some significant irregularities in my onboarding. Apparently I’m not fully credentialed with most payers (not even Medicare / Medicaid), which is surprising for the length of time I’ve been here. That’s a red flag right there. The next red flag was when he emailed me to let me know there was an error on my 1099 tax form and I’d have to handle it on my own. Running a practice, or any small business for that matter, is not for the faint of heart or those without education, experience, or solid advisors.

Before making the decision to leave, I put myself in his shoes and considered whether there was anything he could offer to make me stay. He’s not going to run out and implement an EHR tomorrow, so the patient safety issue remains. It’s also an efficiency issue (although a bad EHR would certainly be worse than handwriting on pre-printed paper templates). Then there’s the clinical quality issue. I have no way of sending copies of our notes to primary care physicians unless I personally fax them since there is no system in place unless there is a specific request for release of information. The primary care practices in the area have yet to embrace the patient-centered medical home model. Few of them are open outside the hours of 9 a.m. and 4 p.m. and I can’t name any that have evening or weekend hours, so we’re essentially the safety net. We don’t have access to the local HIE or the state immunization registry, so we’re actively contributing to the fragmentation of care.

I don’t see him hiring a strong office lead or spending more time at the practice himself, so the staff will continue to be relatively undisciplined. The owner isn’t clinical and there’s not a named medical director, so I don’t see any expansion of policies or procedure that could help bring things into line. Strangely enough, he’s opening a third location in a fairly dangerous part of town without commitment by providers or staff that they’re willing to work there. I’m sure that will further dilute his ability to manage the practice effectively and might make staff turnover even more of an issue than it already is.

Although I don’t see him embracing new technology like the HIE or immunization registry web portals, I also don’t see him abandoning some of the problematic technology we already have. The computer-assisted coding system is a concern since it codes the visits after documentation is complete and providers don’t have a chance to confirm or correct the E&M codes before they’re released to the practice management system. Although most of my coding has been consistent with what I would have manually coded, it’s just another red flag.

On one hand I feel bad leaving because the patients are genuinely appreciative and certainly need physicians who understand their needs. But on the other hand, knowing what’s at stake from a regulatory standpoint and that I could wind up personally liable for any creative coding or billing that is occurring, I can’t afford to stay. 

I’ve got a new clinical endeavor lined up, one where they’ll ensure I’m fully credentialed before I see patients and where an EHR is already in place. They’re using a system I’ve never worked with, so I am looking forward to the new challenge. If nothing else, learning a brand new system will surely make for some good stories.

What makes a new employee run shrieking? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/29/15

The physician lounge was buzzing this morning with discussion of HHS secretary Sylvia Burwell’s newly-announced goals for the Medicare program. The plan is to move 90 percent of Medicare fee-for-service (FFS) payments to a quality-based system by 2018 and to move 50 percent of FFS payments into “value-based alternative payment models” on the same timetable.

Although we’re pretty far along with the quality-based payments, we’re nowhere near that far with alternative models (such as ACOs). When you consider the number of providers who have failed to join (or dropped out of) ACO programs, that’s a pretty audacious goal. The general tone among my colleagues is this: they’re supportive of quality, but would like to see other institutions (especially the Medicare and Medicaid bureaucracies and Healthcare.gov) held to the same standards.

I didn’t watch the State of the Union Address to hear about the President’s “Precision Medicine Initiative” but have been asked a couple of times what I think about it. Although it is very sexy, precision medicine is also very expensive. I surfed around for some quote from the Address and the Initiative purports “to give all of us access to the personalized information we need to keep ourselves and our families healthier.” It reminds me a little of end users who refuse to use the EHR because it doesn’t have one sexy feature or another. I have to talk them into using it to get the benefits it actually has rather than worry about what it doesn’t have. We need to figure out how to better encourage patients to take advantage of the general (but very effective as well as inexpensive) medicine advice we already have: eat less, move more, make healthy choices. Alas, daily exercise and delayed gratification aren’t as exciting as the idea that technology will fix all that ails us.

As a CMIO, I spend a fair amount of time listening to what physicians don’t like about our software. It’s always interesting when we perform an upgrade, and while some users like it, others consider it a “downgrade.” Sometimes the complaining is justified, but it always feels more acute when it’s a problem with the EHR rather than consumer software. I was interested to see a software firm other than Microsoft or Yahoo make a blunder recently. Intuit is under fire for realigning the features of its popular TurboTax product. Since I’ve already spent a couple of hours this week preparing all my documentation, I’m glad I saw this letter to customers that explained that the version many of us have used for years will no longer meet our needs. They’re trying to make it up to users with a $25 rebate. That’s about 50 percent of the purchase price of the version in question. Extrapolate it for what we pay for medical software and that could get interesting for a vendor who wanted to make good on a dodgy software release.

Speaking of vendors, I have a couple of physician friends who work in the vendor space. If you’ve ever wondered why they’re not spending all their time creating usable new features that physicians need and want, take a look at the test procedures they have to follow in order to get the product certified. If you’ve never seen them, let’s just say they make CMS billing regulations look like a pre-K reader.

Researchers at the University of Pennsylvania have harnessed Twitter to predict rates of coronary heart disease. Analyzing the content of tweets by county, “they found that expressions of negative emotions such as anger, stress, and fatigue in a county’s tweets were associated with higher heart disease risk.” Although there is no expectation of privacy when using Twitter, I couldn’t help but think about the documentation needed to do this kind of human studies research. Maybe Twitter should add something about it to their terms of service.

Another interesting twist on their work is the comment by one researcher that, “You’ll never get the psychological richness that comes with the infinite variables of what language people choose to use.” This is exactly what EHR-using physicians have been saying for years – that it’s impossible to get the “flavor” of the patient’s story through checkboxes and templates. I’m looking forward to the day when I can go back to dictating my notes and letting voice recognition and natural language processing do the heavy lifting of turning it into something appropriate for coding, billing, and interoperability.

The research team has experience with linguistic analysis, showing it can be as effective as questionnaires in assessing personality characteristics. I hope they’re not looking at my tweets, because given their recent infrequent nature, they would likely determine that I’ve become reclusive.

What does your Twitter history say about your personality? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/26/15

I know many readers are on the edge of their chairs waiting to find out the answer to the career question I pondered in last week’s Curbside Consult. I spent several days out of the office last week putting my thoughts around whether I want to join our health system’s migration to a single vendor platform or pursue other career options.

Although I enjoyed the day I spent thinking about nothing work-related, things became complicated mid-week when I received an unexpected phone call. One of my CMIO colleagues knew I was off the grid and not checking email while I weighed the situation. He wanted me to know that a draft organizational chart was circulating and it had some interesting features.

First, the physician leadership is remarkably absent. We knew that there would be consolidation in the leadership, but not to the degree represented. My colleague wanted to know if I thought there was some kind of supplemental organizational chart that would have us on it. I don’t think there is one, but seeing it confirmed the fears of some of our medical leaders who have already jumped ship.

Second, although the number of mid-level administrators was as bad as we expected, they didn’t seem to be arrayed in a way that will be effective given our history and culture. With all the work that needs to be done, we almost need two teams for each hospital or entity, one for managing the transition and conversion and one preparing the new system. Of course they would have to work closely together, but given how we’ve worked historically, I can’t imagine a team being able to focus on two things at once and not end up cutting corners in favor of one side or the other.

Third, we were surprised to see a senior leadership level that was much smaller than anticipated. I’m not sure how they think a handful of top executives will have enough bandwidth to deal with the magnitude of change we’re expecting. The “Chief Culture Officer” I hoped would materialize was nowhere to be found. It looks like, at least to some degree, that we’re going to continue to try to do things the same ways we have always done them, yet are expecting they will have different outcomes.

Depending on where the organization is thinking about plugging some of the other CMIOs, there may not even be a place for me. Those of us that came up through the ambulatory ranks have a little less status than those who are purely hospital CMIOs.

The good thing about my time off is that I was able to come up with a self-employment business plan that makes sense, at least in the short term, if I end up being downsized. I bounced it off of some smart people I know and they agreed it was viable. My clinical group is willing to let me flex my hours as much as I need. It doesn’t hurt that they just opened a sixth location and are a little short covering some of the weekend and evening shifts, which I’m happy to do.

Since we don’t even have a signed vendor contract yet, I still have some time. I have to admit I’m leaning towards staying if there ends up being a position that is a good fit. Knowing I have a fallback plan (as well as a respectable nest egg) makes it a little easier to handle the uncertainty. Regardless of how it turns out, it will be entertaining and educational to watch all the players jockey for position.

In the mean time, I can find my entertainment with the reader responses to my question from last week: If you could do anything you wanted, what would it be? So far, early retirement, gardening, and travel continue to be themes. I haven’t had a lot of people saying they’d stay in healthcare, information technology, or the wild and wacky universe we call healthcare IT. Of the clinicians who have responded, no one wants to go back to direct patient care and that’s a sad commentary about healthcare in the US.

I saw patients two days this week and was reminded how miserably our system has treated some of our patients. I was also reminded of the sacred trust our patients place in us and how things that are not a big deal to us can make us look like superheroes to others. If you’ve ever seen the look on a parent’s face when you reduce their child’s Nursemaid’s Elbow, you know what I’m talking about.

What makes you feel like a superhero? Email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/23/15

While everyone is waiting for the Meaningful Use Stage 3 shoe to drop, let’s not forget we are only eight months away from ICD-10. CMS announced that those organizations that participated in their January end-to-end testing event have already been registered for the upcoming testing week in April. If you missed out on the fun, you can volunteer through your Medicare Administrative Contractor. The chosen few will be announced by February 13. Don’t miss out on this exciting pre-Valentine’s Day gift — volunteer today!

CMS has also released an enhanced version of its Open Payments data search tool, allowing users to view summary information about physicians such as total dollar value of all payments and total transactions. I looked up a couple of friends and am wondering exactly what kind of “Informational Meal” one of them enjoyed for $2.68. I’m guessing that the colleague who enjoyed the $168.72 “food and beverage” line item might have had a better time.

I’m behind on email, but wanted to comment on the recent article in JAMA titled “Wearable Devices as Facilitators, Not Drivers, of Health Behavior Change.” I agree with its conclusion that having a device in and of itself isn’t going to change behavior, but putting strategies around use of the device could help reinforce behavior. They mention improving the design of feedback loops as a way to get wearers to continue, specifically lottery-based designs and the concept of “anticipated regret.”

As part of the annual conference this year, HIMSS is promoting the “HIMSS 15 Wellness Challenge.” Registrants can either purchase a Misfit Shine device or use their own. I was initially enthused and registered, but when presented with the fine print, had a case of actual regret. Winners will be announced at the Connected Patient Learning Gallery throughout the conference but must be actually present to win. I’m pretty sure by the end of each day I’m going to just want to put my feet up.

Usually I don’t read JAMA, but this week’s table of contents was a winner. They must be taking their headlines straight from the tabloids. For a moment I thought I was reading The Onion:

• The Implications of Marijuana Legalization in Colorado
• Improving Long-term Psychiatric Care: Bring Back the Asylum
• Navigating the Rise of High-Deductible Health Insurance: Childbirth in the Bronze Age
• Flamed on the Net

Because nothing says professional like addressing a c-level as “Hey %%FirstName%%”: I’m begging HIMSS to please engage some proofreaders. As many teachers have said over the years, “Hey [sic] is for horses.”

I’ve had a tremendous amount of feedback on Monday’s Curbside Consult. Based on some of the responses, it looks like the industry might be having a collective mid-life crisis. I haven’t had a chance to respond to everyone but appreciate your support. We always love hearing from readers, so keep the comments coming. I’ll share some of them in my next Curbside. Until then, I’ve got a hot date with a cup of cocoa, a handmade afghan, and some Netflix before I head back to the office.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/19/15

Several readers have sent words of encouragement after reading about my last few weeks in the CMIO trenches. I definitely appreciate all of my virtual colleagues, even those who just write to say they understand and to wish me calmer seas. It sounds like many of us are going through the same trials and tribulations even though some of ours may be a little messier than others.

Our hospital is part of a larger health system that has announced its intent to replace all the clinical systems with a single vendor platform. I’m taking a couple of days off this week to really put my thoughts around whether I want to stick around to watch it happen.

I understand the need to consolidate systems. Our IT department is larger than nearly any other except for nursing. The budget for maintaining this “ultimate best-of-breed nightmare” is exorbitant. Many of our systems feel like they’re held together with duct tape, baling wire, and bubble gum. Some of them are just plain old. And several hospitals are on a platform that is being sunset by the vendor, so their systems simply have to go.

Being part of the larger project to turn this new single-platform vision into a reality is potentially exciting. But it also looks a little bit like a bottomless pit of long hours with not enough staff to work at a pace that would allow us to deliver a quality system without burnout. It’s also difficult to know that the health system has plans for how they plan to handle legacy clinical data that will not make our ambulatory physicians very happy.

Those of us that are “in the know” about the strategy have to keep quiet until it’s formally announced. I’m not used to being told what I can and can’t say to the physicians I serve.

It’s also bittersweet to watch systems be torn out when you’ve spent the better part of your professional career building them. We’ve held our users’ hands while they learned them and while they coped with upgrades. We’ve been at the other end of plenty of angry phone calls, but we’ve also heard the appreciation when we started to provide data to help proactively manage complex patients and to identify gaps in care. Of course our new system will also do this, but it was special to see how physicians reacted the first time they realized it was possible. Now those features have become old hat.

In addition to consolidating systems, our leadership also plans some pretty radical consolidation among hospital leadership and medical executives. We’ve always functioned as a federation, but this is taking us much more towards a centralized clinical and financial model and it’s not entirely welcome. A couple of chief medical officers have already moved on and I suspect a couple of hospital-level CMIOs and CNOs are planning to move as well.

On the non-clinical side, however, mid-level administrators seem to be proliferating. The number of buzzwords in an average hour of meetings has skyrocketed. We have four different consulting companies involved and they’re stepping all over each other with contradictory advice.

I’m not sure I want to leave the provider aspect of the CMIO game. There are definitely opportunities out there, but I really don’t want to relocate unless something pops up in Hawaii, in which case all bets are off – the idea of living in a place where the difference between winter and summer is 10 degrees does have a certain appeal. I just started clinical work with a new group that has a lot of promise and an extremely low chaos factor, which is a welcome change. I also spent the fall doing a ton of work on my garden and can’t imagine walking away.

There are some interesting vendor opportunities that don’t require relocation, but I’m not sure about crossing that bridge. My friends in the vendor space seem less stressed than those of us on the provider side (except during Meaningful User certification testing, in which case I recommend either steering clear or providing copious amounts of wine and moral support). It will be interesting to see if any new opportunities arise as we get closer and closer to Meaningful Use Stage 3.

Consulting is also an option, but I’m not sure I can handle being on the road as much as most of the larger firms expect. I’ve also heard the horror stories about being on the billable hours hamster wheel. I’ve dabbled in consulting over the last several years and would consider going out on my own as long as I have some ongoing clinical work as a financial safety net. I’m not enamored of what clinical practice has become in the last decade, however, so going full-time is not an option.

Today was my day to relax and think about nothing work related, but tomorrow is my day to sit down, run the numbers, and see if I can come up with a business plan that might fly. Wednesday I’m getting together with a couple of colleagues in the same boat, where we can trade ideas and see if anyone else has come up with a better plan. Thursday I’ll be back in the office, and it will be interesting to see how that plays since I’ve pledged not to touch my email or answer my phone while I’m out. Appropriate backup resources are in place, but I know my boss isn’t used to being unable to reach me. He’ll just have to get over it.

Here’s to crunching the numbers and hopefully to some new ideas about my next career move.

If you could do anything you wanted, what would it be? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/12/15

It’s hard to believe that I just started my fifth year as a member of the HIStalk team. Even though I’m more “in the know” than I was before, I still depend on HIStalk as a valuable source of information on all things Health IT. I also enjoy the discussion of technology in general, since it’s hard to separate that from the healthcare part and goodness knows I don’t have time to read Wired magazine or surf tech blogs.

With that in mind, I chuckled when I saw The PACS Designer’s comments about Windows 10 and its new browser.

He mentioned that its code name is “Spartan.” I immediately wondered what attributes of the Spartan culture Microsoft was trying to celebrate. Sternly disciplined? Rigorously simple? Brave? Undaunted?

Certainly those dictionary descriptions seem desirable and noteworthy. For those of us who didn’t sleep through World History, there are some other more colorful Spartan characteristics and I’m wondering if they were considered before the name was chosen.

As a city-state in ancient Greece, Sparta was the dominant military power for several hundred years. That sounds a bit like Microsoft. The Spartans were eventually defeated, but remained independent until the Romans came along. While the overall society focused on excellence in military training, the social classes had rigidly defined roles. Legend has it that the Spartans would take children who were weak or disabled and leave them to die of exposure or alternatively throw them into a chasm.

That certainly sounds like a couple of vendors I’ve worked with, where products with a lot of potential are thrown out if they aren’t thought to be highly profitable. On the flip side, sometimes it feels like products are pushed forward just because they look good, regardless of whether they are truly game-changers or solve an unmet business problem in a compelling way. Marketing teams reign supreme in some organizations and it is increasingly difficult to separate the reality from the hype.

My health system has an enormous development shop since we’re one of the few best-of-breed organizations that haven’t yet succumbed to Epic. Sometimes it feels like they’ve taken the “Innovate or Die” mantra a little too seriously. Clinical end users don’t typically ask for more disruption or sassy new paradigms. They want things to be easy and fast rather than eye-catching and trendy. It’s hard to get developers to understand that when every single physician has a common verbiage for the parts of the patient visit note, we’re not likely to appreciate their capricious use of synonyms to try to make the work we do more fresh, exciting, or new.

I recently dipped my toe into “fresh, exciting, and new” with a foray into the land of the MacBook. Quite a few of my friends and a couple of family members are big advocates. I was a Mac devotee early on, but years in corporate IT have stifled the desire to use anything other than Windows. Although it’s been great for my non-work computing needs, I’ve been relentlessly teased at the office. The jury is still out on whether I’ll be able to make a go of it.

As for the Windows 10 browser, personally I hope they’re calling it Spartan because it’s going to be austere with muscular performance. I don’t need any new shiny objects in my life. I just need things that are easy to use and that work day in and day out. If Windows 10 and Spartan hit those marks, they’ll do well. If not, the user community will abandon them on the windswept edge of oblivion.

What do you think about the future of Microsoft and the debut of Windows 10? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/5/15

For many, the end of the year means time off and relaxation. The end of 2014 brought extra stress for our medical group as our Meaningful Use coordinator took an unexpected medical leave three days before the end of our reporting period. 

After having previous employees leave us in the lurch, we’ve learned to assume that someone could win the lottery and not come into work the next day. We’ve tried hard to make sure that all of our key roles have a backup person designated to step in. We also have strong policies and procedures regarding documentation to ensure that if we have to replace someone, the potential negatives are minimized. This was a good test of our system. So far, things seem to be working well with just some minor glitches. 

Our leadership group had already approved the plans for creating the attestation documentation for Eligible Providers. Those parts of it that could be done in advance were already largely complete. Fortunately, our vendor provided extremely detailed Meaningful Use training with almost ridiculously specific instructions for how to prepare documentation in case of an audit. Although we made fun of it at the time, we’re very grateful for it now because it has allowed us to quickly determine what documentation we have and what we still need for each physician.

Although some people instinctively react to the billions of dollars spent on Meaningful Use and even more specifically to the $44K per Eligible Provider figure as some kind of a windfall for physicians, it doesn’t even begin to cover the amount of money needed to actually install, maintain, and optimize the software needed to qualify. It doesn’t pay for the lost productivity while we check boxes that don’t assist us clinically, either. For our group of several hundred providers, it also requires multiple full-time staff members to train, report, retrain, track, analyze, and educate so that we don’t miss our goals. 

We’ve definitely been hurt by the fact that Meaningful Use is all or none. Last year, we had a couple of providers who were really close, but failed on one or two measures, which results in an unsuccessful attestation. We redoubled our efforts around those providers and it looks like they’re going to be successful this year.

Still, my office is now full of hundreds of individual physician binders, ready to receive the rest of the attestation documentation as it becomes available. I wound up as the lucky repository for it since my office is a converted conference room and I’m in it only rarely. I didn’t think much of it initially, but now that I sit here looking at all the work in progress, I think about how many hundreds of hours of staff and physician time have been taken up trying to chase the MU money and avoid future penalties. I can’t help but think that it hasn’t been worth it.

As employed physicians, most of my colleagues don’t have a choice whether to participate or not. As we continue to acquire practices, it has become more complicated. Some may have attested previously under another employment agreement or as individuals and may not have the data we need. Others are unsure whether they’ve attested or not. 

For those who have been employed at the same place since 2011 when this all started, though, it has been a little less complex. Still, those "complicated" binders take up an entire folding table in my office. At least as independent physicians they received the MU payments directly. However, as employees, the payments are shared between the physicians and the organization.

Our group is one of the only employed groups in the area that actually shares the incentive payments between the employer and the physician. Our competitors absorb the payments as a cost of doing business. It’s all part of the complexity of physician compensation and reimbursement. 

Some health systems "charge" employed physicians for EHR costs and maintenance, while others don’t. Some distribute payments based on overall group performance (so providers might get compensated for MU payments although they would be filtered into the general fund first). Still others have arcane and specific accounting systems that charge or reward physicians on a line item basis. As employees, they could determine whether MU payments were a boost or a bust, but they still wouldn’t be able to do much about it.

The one entity for which MU was definitely not a boost (at least not at my organization) was the environment. We’re printing reams of paper for our attestation documentation binders (aka audit defense). Although we have soft copies as well, providers will be required to maintain the documentation at their primary practice locations and we will also keep a copy at the home office. The amount of paper moving into my office on a daily basis as more reports are delivered and more screenshots are prepared is truly staggering. At least someone had the foresight to buy printer paper that was already binder drilled so we don’t wind up with repetitive motion injuries from the three-hole punch.

I don’t think any of us expected to be in this position a decade ago, where we would be using twice the paper we eliminated with EHR just to keep up with government mandates. Although we’ve streamlined care through interoperability and data sharing (at least in my surrounding community), we’ve created more bureaucracy than we’ve eliminated.

Still, it’s a new year and I remain hopeful. Hopeful that MU Stage 3 will not bring more onerous requirements and that our vendors will have some breathing room to return to coding features we actually want and need rather than what government entities think we want and need. I’m hopeful that patients will continue to take advantage of all the patient engagement opportunities and that those who are not yet doing so begin to manage their health and have preventive services performed as appropriate. I’m less hopeful that physician and staff burnout will decrease, but I’m trying to remain optimistic and instead just hope that it won’t increase.

What are your hopes for the New Year?  Email me.

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Curbside Consult with Dr. Jayne 12/29/14

Whenever something happens with our EHR that physicians don’t immediately like, there is bound to be grumbling. Sometimes it doesn’t even have anything truly to do with the EHR, such as a change in requirements for Patient-Centered Medical Home recognition or with Joint Commission accreditation.

Physicians and clinical staff would have had to comply in the paper world, but they don’t see it that way. They seem to perceive such mandates as uniquely burdensome and EHR related despite our attempts to educate.

We’re going through one of those periods now. Our accountable care team has decided that we need to collect certain information in a specific way that doesn’t fit very well with some of our workflows. That’s the problem in an organization like ours – each hospital has its own CMIO, but we don’t have one over-arching person who can cut through the noise and make decisions that fully take into account the limitations of our various systems and vendors. The accountable care team has good intentions, but I doubt half of them have even seen the workflow of some of our clinical systems.

On the ambulatory side, we’re trying to make it as smooth as possible, even using some programming sleight of hand to get the data into the right format without clinicians having to enter it twice. The problem of non-clinicians dictating data that clinical staff must document certainly isn’t new. It goes back to the creation of ICD codes and E&M coding requirements. Anyone who has ever had to formally diagnose a patient with “Bone and Mineral Disease, NOS” rather than osteopenia simply to get it billed will know what I’m talking about.

In some ways, Meaningful Use has helped with this, allowing us to use SNOMED codes to capture that level of clinical granularity. We do still have to translate them into billing codes, however, resulting in parallel diagnosis lists in the chart. That can have issues as well.

When we first started using SNOMED, we found out there were issues with some of our mappings to ICD-9. As long as the data flowed from SNOMED to ICD, we were fine. But if clinicians tried to pull diagnoses off the billing list and convert them to SNOMED, detail was frequently lost.

Physicians immediately jumped on this as a patient safety issue. The financial team jumped on it because the loss of specificity could lead to decreased reimbursement. Those two forces combined made it easy to get access to resources to fix the problem quickly. One of our most vocal EHR haters used it as a reason to again call for discontinuing use of the EHR because of its many safety flaws.

We hear that chorus all the time. Although there are many valid points about EHR design and patient safety, there are also numerous points where EHR makes our work safer as well as more efficient.

I was thinking about this last night as I worked in the ER. There is a great deal of attention to EHR-related patient safety and people are always crying out for regulation. How much attention is there to financially-driven patient safety risks?

One of the patients I treated was a prime example of what happens as more and more of our decisions are financially driven. The patient was a young woman who came in because she couldn’t reach the on-call nurse covering her case. That’s the first point of failure – that physicians are no longer taking their own call because it’s more cost effective (and burnout reducing) to have a nurse cover your call.

Unfortunately, she has four different specialists involved in her care and didn’t actually have a problem that we could address in the ER. Her condition is complex and still partially undiagnosed. Her visit was more about coming to us as the place of last resort. She thought that if we tried to call her specialists, we’d have some magical ability to get her some answers.

If she had come into the medical system when I was a student, she would have been admitted to the hospital until the full workup was complete and we had a plan of care. Each of her specialists would have seen her daily and seen each other in the halls and at the nursing station. However, it’s cheaper to care for people as outpatients, so money was saved by sending her home. Unfortunately, her care was fragmented by this decision – the second point of failure.

During the course of her care, she developed a serious infection that required weeks of intravenous antibiotics. Her insurance company has a policy that patients under Medicare age be “trained” to administer their own infusions at home to save on the cost of the home health nurse. There is no regulation in my state about this practice, which gives payers the ability to make these determinations.

Apparently the patient either didn’t understand or didn’t receive the information that the antibiotic packets had to be kept refrigerated. When she went to the infectious disease physician’s office each week to have her IV line and dressing checked, it didn’t come up there, either. This resulted in the patient infusing 21 days of non-effective medication, which likely contributed to the recurrence of her infection, which was why she was in the ER — she was worried about whether it was extending.

Failure point number three is assuming that just because it’s statistically likely to be OK to allow a patient to administer their own IV antibiotics, that doesn’t make a clinical treatment plan applicable to all patients.

For each person demanding regulation of EHRs, where is the demand for regulation of situations like this? She did determine five days ago (after talking to the on-call nurse about her IV line) that the medication had to be refrigerated and a new supply was sent out, but the infection isn’t looking any better, which was why she was trying to reach her physician in the first place.

In talking to her, I struggled to figure out the best person to call. The infectious disease specialist was out of the country. His primary nurse had gone into labor and was being covered by a nurse who initially told the patient to call the surgeon and then didn’t return subsequent pages. The surgeon was also out of the country, but the patient didn’t think he was the right person to call since he wasn’t involved in the antibiotics. The primary care physician hadn’t seen her in six months. The other specialist involved is a plastic surgeon, who wouldn’t be of much assistance in this situation.

Failure point number four is lack of ownership of this patient and her complex situation, again in part due to cost-cutting maneuvers. Physicians just aren’t likely to spend hours playing phone tag with various specialists when that time isn’t reimbursed and payments are being cut.

I had the charge nurse put out a couple of pages to different specialists involved in her care, figuring there was an equal chance that whoever called back wouldn’t know anything about her, so might as well cast a broad net. In the mean time, I went back in and looked at the patient’s medication that she had brought with her. Sure enough, nowhere on the labeling did it indicate that it was to be refrigerated. It was from a compounding pharmacy contracted by an infusion company contracted by the insurance company. Many cooks in the kitchen always make for a questionable dish.

Ultimately one of the infectious disease nurses called back and we made a plan for the patient. Since she was clinically stable, fever-free, and had no new symptoms, she was stable to go home and the nurse would see her first thing the next morning. I reassured the patient and explained that our goal in the ER is to take care of any critical issues and make sure that patients are stable and that follow-up has been arranged. I chose my words carefully. Usually I say something about making sure any life-threatening conditions have been addressed. In this situation, there are still multiple factors that may threaten her health (and ultimately her life), but they were completely beyond my scope.

I’ve been thinking about her all day today and wondering how things turned out this morning. That’s the problem with putting a family physician in the ER. I always wonder about the follow up since continuity of care is one of the reasons I wanted to be a physician in the first place.

I’ve also been thinking about the ways that the system failed this patient. I can’t help but draw a parallel to all of the people out there who think that more technology is going to solve all the problems and that regulating the technology is the answer. Dealing with technology is just the tip of the iceberg in healthcare. This case is a prime example of everything out there that also needs to be addressed.

To the people who demand broad regulation of health information technology by the FDA as the solution to patient safety problems, I’ll get on board with that at about the same time the FDA gets oversight of compounding pharmacies, home infusion agencies, and payer executives squeezing the maximum profit out of the system. Based on the 50 patients I saw yesterday, they’re a much greater threat to patient safety than my EHR.

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Curbside Consult with Dr. Jayne 12/22/14

As the year closes out, my hospital’s employed physician group continues to acquire physician practices under the guise of building its accountable care network. At this stage in the game, however, the strong independent practices have either grown to a point where acquisition isn’t a viable option or have banded together as part of IPA groups and aren’t interested in being employed. For the rest, however, it seems there’s no practice too questionable for us to purchase.

I was out of the office last month when the operations leaders did due diligence on a small pediatric practice. I had heard that there were some “interesting” things noted on the site visit, but leadership was bent on purchasing it anyway. The physician is close to retirement and they figure they can just plug a new physician (straight out of residency) in July and absorb the patient volume as the owner steps away into the sunset. In the mean time, my team’s job is to get the EHR live, transform care delivery to bring them up to MU-ready standards, and deal with all the fallout.

I went to the office on Friday for an initial workflow review. One of the implementation team members is fairly new, and although skilled with EHR, has never converted a practice from paper. The team lead who was supposed to be running this one ended up having her first grandbaby arrive, so I stepped in to cover the day of shadowing.

We have a checklist of things to review and we also shadow office staff as they go through their daily activities. Ultimately we’ll create current state workflow maps and use those to derive a future state. We’ll take that back out to the practice and validate it with the physician and office manager, put together a Team Operating Agreement, and then schedule them for implementation.

Often there is a fair amount of clean-up that has to be done with the workflows and addressing that is within the purview of our implementation team. Our operations staff initially fought us on this, but finally conceded that practice roles and responsibilities, patient flow, and EHR workflow are so intertwined that they can’t be addressed separately (especially if you’re trying to bring practices live on a rapid cycle). They also didn’t have the resources to adequately handle process improvement, so it was an easy “poach” when I decided it needed to live on my team.

My initial impression from the waiting room was a good one – freshly remodeled, new furniture, adequate space, and a cool salt water fish tank that the patients were enjoying. The receptionists were friendly and using computers proficiently. The exam rooms were large, with plenty of space to add a computer workstation and not lose the room needed to park strollers and the extra family members who often come to visits with new babies. I liked the way the layout clearly separated the “on stage” patient care areas from the “off stage” staff work areas, which not only helps control clutter, but reduces risk of patients overhearing phone conversations.

Once I stepped into the staff area, a veritable house of horrors awaited me. I wasn’t sure whether they over-spent on the furnishings and remodel and tried to make it up by skimping on the rest of the office or whether they just didn’t care. The back half of the office was just dirty. From the stained butcher block table in the staff lunch room to the piles of trash bags by the back door, I couldn’t believe what I was seeing. They knew we were coming, and if this is how they present the office for an assessment, I couldn’t imagine what it would look like if we showed up unannounced.

The counters and workspaces were crowded, with open drinks and snacks in the lab area, food crumbs in the keyboard of the computer they use to access the state immunization registry, and trash on the floor. Really, trash on the floor. Not the “oops, I dropped the cap to that needle while I was drawing up that injection” kind of trash, but the “I just don’t care and can’t be bothered to walk to the can because it’s on the other side of the room” kind of piles.

The cabinets and walls were covered with so many “don’t forget to do this” or “X insurance requires that” notes and stickies that you couldn’t even see the walls. More than two-thirds of them were obscured and some of them had been there for years based on the dates.

We started the assessment and quickly determined that no staff member had been there more than a year. Most had been there less than six months and two were new that week. That’s a red flag, as was the presence of the owner’s son as office manager.

In the positive column, we knew all the clinical staff would be at least minimally tech savvy because they were using their smart phones constantly, even when work piled up and patients were waiting.

We went through our usual questions about training and on-boarding, how work is divided, patient flow, and so on. I also asked about the remodel of the front half of the office (14 months ago) and how long the son had been managing the practice (18 months).

The timing of the son’s arrival and its association with staff tenure was suspicious, as was the timing of the remodel. Pediatric practices are not exactly centers of profit, especially small solo ones. They’re a labor of love for most physicians, and if not run right, can be more chaotic than other specialties. I wasn’t sure whether the son had been brought in to try to remediate a problem or whether he was the cause. Unfortunately, the latter was confirmed when we had a chance to sit down with the physician later in the day.

I haven’t heard such a sad story in a long time. The owner’s son had gone to college with the goal of being pre-med and eventually taking over the practice. His grades weren’t good enough to get into med school, so Dad financed an MBA at a for-profit university and hired him to manage the office instead. With no understanding of medical practice management or the realities of office cash flow, he embarked on an aggressive campaign to improve the office’s appearance.

Driving them further into debt, he terminated the seasoned staff because they were costly and he assumed they were replaceable. The office spun further and further out of control and for love of family the owner didn’t want to reach out to a consultant or anyone else who could help. Ultimately, they felt they needed to sell to remain viable. He saw the purchase by the medical group as a way to continue doing what he loves and apparently wasn’t aware of the plan to add a physician to the practice in six months.

Having been in this business as long as I have, none of this should be surprising. Still, every time I hear one of these stories, it shocks my sensibilities. First, that there are physicians in this day and age of regulatory complexity that still think a practice can be family run without specific training and administrative support by someone who actually knows what they are doing. Second, that the son was still in the practice even though we had acquired it. Usually we have a pretty good track record of buying out those kinds of situations when we take over. And third, that my own employer actually thought acquiring this practice was a good idea.

Looking at reimbursement rates for general pediatrics, we won’t break even for a decade. It may be the right thing for the community, though, and I hope they acknowledge this and react accordingly when the negative financial statements start documenting what our guts already know. In the past, they haven’t been sensitive to the realities of acquiring damaged goods. Their knee-jerk reaction will likely be to push the physician out, replace him with a younger model, close the office proper, and move the “practice” (aka patient base) to an on-campus office.

In the midst of all this chaos, we’re supposed to deploy EHR and have happy satisfied end users without expending more resources than are budgeted. Good thing the OSHA, CLIA, HR, and regulatory remediation won’t come out of my budget.

We’re going to do our best with this practice. Although I’m not terribly hopeful, we’re in it to win it. As for our operational leadership, however, I’d like to throttle them.

Does your employer make business decisions that leave you shaking your head? Email me.

Email Dr. Jayne.