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.

Email Dr. Jayne.

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.

Email Dr. Jayne.

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.

Curbside Consult with Dr. Jayne 12/15/14

I wrote last week about a “Forbes Style File” piece that offered fashion tips for women presenting at and attending conferences. The topic has generated more comments and emails than anything I’ve written about in the last year, which in itself is an interesting commentary. Although to be fair, it’s a pretty slow time of the year for healthcare IT news.

I asked for readers who were attending the mHealth Summit to send their thoughts and observations. Cindy Wright, president of Thomas Wright Partners, offers her own take on the event.

MHealth Exhibitor Fashion to Go

I want to thank Dr. Jayne for adding a little additional fun to the mHealth Summit by sharing Forbes’ fashion advice column, written specifically for the mHealth Summit. It made me wonder why in the world Forbes is giving advice on how to build a wardrobe. Just for women, not men? And why this particular conference?

I attended last year and did not see any atrocities that might have provoked such a story, but found myself on high alert for any over the top offensive dress as I attended a number of really informative sessions and presentations. All presenters were very professional, and yes, dressed appropriately. Darn it.

However, being in the business of marketing and communications — which includes public relations — I concern myself with brands and images. Fortunately, I work with adults who mostly have good common sense and know how to dress themselves and even know where to go for help when in doubt of appropriateness. I am not so much concerned with choice of kitten heels or flats, but how you and your company might best reflect your brand.

Being the good marketing professional and huntress that I am, I spent some quality time in the exhibit hall visiting with business owners and hard-working entrepreneurs. Among the large hall of exhibitors, I did find a number of really creative dressers who stood out among the crowd. They were great representatives of their brand. Fun and engaging. Confident in their lively attire. Most importantly, they drew me to them and were engaging. So important, especially if you are new to the arena and maybe even a startup. Oh yeah, and these fashionistas did not follow the rules brought to you by the good people at Forbes.

Men in Kilts traveled "across the pond" from Nugensis to share their "views" that improve patient care. The clan of four offered Scotch whisky and fun demos for takers.

Dapper European Milan Steskal, proud founder and COO of Mentegram, punches up his gray pinstripe suit with a blast of orange, picking up the color palette in company brand. His app helps keep mental health patients connected with professionals and support team and so much more.

Mother and daughter team Glenda and Brittany Gerald, co-founders of MobiDox Health Technologies, not only engage patients in disease management and drug safety, but also engage attendees having fun with coordinated outfits that reflect their business offerings. Where do you find a dress that looks like a keyboard or pharmaceuticals? Not just anyone can pull this off and yet Brittany does while mom plays it cool Chanel style.

Thanks again to Cindy for sharing her thoughts. I hope to spend some time with her stalking the halls at HIMSS. It will be interesting to get a professional opinion on what hits the runway (ahem, trade show floor) in Chicago.

From Met My Match: “So clearly the issue here is inappropriate dress.” Thanks for steering us back to a piece on the larger issue, which is that women speakers are “still few and far between” at conferences. The piece highlights a Rock Health exploration of the gender gap in speaker counts.

One reader commented on the original piece that, “A far more interesting topic is the dynamics of power in professional dress. The trainer can show up in jeans and t-shirts, but the trainees need to present a more polished look. How common is it to have different rules for the executive level? I’m curious how many of you see this power divide or double standard in your organizations.”

With regard to the trainer in jeans and a t-shirt, I think that has a lot more to do with organizational culture than it does with a true power divide. One of the vendors we work with has a very casual culture, which is reflected in its employees’ attire even when they go out to client sites. That’s been a problem for some of our offices and we have had to include a “dress code” request whenever staff comes on site. We don’t need them in suits, but a collared polo-type shirt is the minimum of our brand of business casual.

When we conducted our ambulatory rollout a decade ago, we were worried about members of the team having too much personal variation in dress and also wanted our staff to be easily recognizable when out in the practices. We bought each implementation team member polo shirts with our project logo on them, to be worn with the brown, black, or blue pants of their choice (no jeans). Although not cheap, it was money well spent as we didn’t have to deal with any dress code issues on the team. The biggest problem we had was being made fun of by our trainees, because it turned out that the particular shirts we picked out were also chosen by a local auto parts store.

Even looking at similar organizations, the dress code for similar job roles varies dramatically. While we get away with polos and khakis here, implementers at large medical group I visited in Texas wear dresses and heels every day (they are all women). While that may seem unusual to some, in their corporate culture if they showed up in anything less formal than that brand of business dress, they might lose respect. Who knows what would happen if they tried to show up in scrubs, which is what implementers at our hospital wear? They have a different color than any of the other staff members (who are categorized by color – nurses navy, techs blue, doctors green, etc.). They also wear safety green vests and look like a roadside hazard crew, but they’re definitely easy to find.

Looking at our corporate environment, I think the president of our medical group is perceived as too casual. He often wears open-collared shirts when most of our male physicians wear shirt and tie, if not a jacket also. He’s also not a physician, so it’s hard to tell whether dressing up a bit more would help him be more respected.

Most of the women in our corporate environment wear skirt suits or dresses. I personally prefer pants, and on one rare occasion when I did wear a dress, one of my analysts announced to the team that indeed Dr. J did actually have legs. The old adage about dressing for the job you want rather than the job you have is still out there, and when I see people that are too informally dressed for the situation, it always crosses my mind.

Thinking too much about wardrobe can sometimes backfire. I attended a vendor user group last year and they had decided to put the staff in more casual attire to try to appear more accessible to their clients. It was a calculated move and I felt bad for them when I overheard clients mentioning that they didn’t like it since most of the clients were wearing suits. I’m not sure the power dynamic worked in the right direction. Instead of feeling more powerful, some of the clients felt anxious or annoyed.

We’ve all heard that “clothes make the (wo)man” and one of my favorite Broadway tunes (“My Strongest Suit” from “Aida”) is a great play on that. The number occurs at a point in the story when Princess Amneris realizes that she’s been groomed to focus her efforts on appearance when she has the skills to do more for the people around her.

As the year winds down and people go into a more thoughtful and potentially resolution-making state of mind, I challenge everyone to think about how appearance and dress influence our thoughts. What can we do to focus more on material, meaning, and message? And where can I find that pill-print dress? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/8/14

My favorite fashionista sent me a link other day in advance of this week’s mHealth Summit. Since I spend most of my time worrying about MU, PQRS, VBP, and a host of other acronyms, I wasn’t terribly familiar with the fact that Forbes apparently has a style file. And here I thought they were all about business and investing!

Reading further down her text made me even more curious: “There’s tongue in cheek, and then there’s this….”

“Power Wear: mHealth Summit 2014” starts out innocently enough, providing background on the conference and its attendees. From there, however, the author gets a little silly, stating, “What you wear will visually convey your professional message as well as empower you to fully engage at the conference … my mission is to free you up to concentrate on presentation and participation by making getting dressed easy.”

Seriously? Does she actually think that women who have arrived at the point in their careers where they’re presenting at a national meeting cannot coordinate their own wardrobes?

She goes on to remind us that we need to “appear flattering” and “to opt for clothing that enhances or creates an hourglass shape.” I’m pretty sure I left my corset in the 1890s, where it belonged. When she admonished readers not to be distracted by “a fussy handbag, or fidgeting with your look,” I’m sure my mouth was gaping open. I wonder how many female mHealth professionals even own a fussy handbag, let alone give much consideration to their “look?”

Certainly no one wants to look bad on stage, but most of us prefer to spend our time polishing presentations and ensuring we have time to actually make all the meetings on our schedules rather than fretting about whether our outfits are au courant. Not to mention, serious travelers are more motivated to ensure their entire conference wardrobe fits into a 22-inch roller bag rather than making sure they have multiple handbags with which to accessorize.

She offers three “inspirational style guides” that are (in her words) fashion-forward, professionally-polished, versatile, comfy, and inspirational. Don’t get me wrong, I enjoy a smart suit or a hot shoe. But generally I’m inspired by a person’s words, accomplishments, and how they relate to the audience far more than how they’re dressed.

The second look she pictures reminds me of something out of the Barbie aisle, complete with awkward posture, anatomically-fascinating digital alterations, and optional accessories:

I was torn on thinking whether this piece was really supposed to be serious, so I sent it to some of the most fashion-savvy people I know, all of whom are seasoned conference presenters and attendees. Comments ranged from, “OMG, is this a joke? I’m kind of speechless. And why specifically for mHealth?” to, “After reading the beginning, I was expecting something a little more from the clothing.” One C-level took less exception to the existence of the piece than to the author’s choices: “Seriously, did you look at what she picked out… Good God! But don’t they have similar fashion articles for men?”

Other highlights:

• I am sorry, but I am stunned by this. I would think that this conference would be less Project Runway and a little bit more Davos… the fact that this is probably representative of the wearable market (did Google Glass die yet, because it should), which is ripe with misplaced interest and based on the idea that the sexy dork is a smart one. Sure, I’d love to have years of biometric data in your EHR if I were your patient, but can’t we agree as patient and provider that it would be most valuable if you had all of my previous tests, visits, labs, and data elements in discrete and reportable (and trendable) format inside your EHR first?
• The only trend in healthcare that we should care about is the one that comes from having a true longitudinal and holistic and normalized view of a patient from birth to present. All other trends should be left at the hatters and haberdashers.

My favorite all-around IT guy is married to a physician and summed it up:

Maybe, just maybe, when healthcare leaders start to focus on the meaningful, the trite can be ignored. Providing sartorial suggestions for presenting demonstrates to me that we continue to focus on all that is useless while ignoring the real issues at hand. I am saddened, in a time when female representation at these meetings and panels remains woefully disproportionate to the balance of society at large, let alone employment in healthcare, that there is something important in how a woman is styled that will alter the content of the message, the value of the opinion and/or data, and the attention of the audience.

I am wearing a smart plaid tie over a blue shirt with brown pants, brown belt, brown shoes, and plaid socks with grey in them. No one cares that my socks are poorly chosen and the brown belt and shoes are not the same brown. Nor do people care that I rarely get a close shave. They just don’t. I stand in front of people and present things and they just listen to me and judge me on the content.

My personal advice for presenters is to wear something you’re comfortable in and to make sure that you have somewhere to clip the power pack for your wireless microphone. That in itself effectively rules out the first look, unless you’re traveling with a backstage roadie who is ready to hook it to your bra band or duct tape it to your back under the dress. I saw both of those happening in the green room of the studio where our hospital films its public-access cable show and neither is a technique I’d want to utilize in the 15 minute handoff between speakers at a conference.

I know a good number of HIStalk readers are at the mHealth Summit this week. I’m interested in what you think as well as what you’re seeing in the halls and on the podium. Is the mHealth crowd more fashionable than the HIMSS or Health 2.0 crowds? Is a $177 Tory Burch floral top going to take my presentation from good to great?

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/1/14

As much as some of us complain about our jobs or life in the healthcare IT trenches, most of us have a lot to be thankful for. I experienced that first hand this week with an emergency department shift that was unlike any I’ve ever worked.

I was called to work at the last minute. That should have made me suspicious, but it was a post-holiday shift so I figured it was just poor planning on someone’s part.

To start things off, the entire hospital was on lock-down due to protests across the country and a specific threat of protests near our facility. Unfortunately, there wasn’t any mechanism to communicate that to staff members in advance.

The only entry is through the main lobby. Nurses, patient care techs, and physicians were wandering around the building swiping our badges since we didn’t know what was going on. Once people got to the other side of the building and made their way in, they were late for their shift, which is never a good way to start.

Instead of having clear communication from hospital leadership (not like we all have email addresses or anything), we had to rely on what people had heard through the rumor mill. About 30 minutes into the shift, we finally got a straight story from the charge nurse. It didn’t make any difference to the way we were caring for patients, but it allowed us to mentally prepare for what might be coming our way should we have an actual protest at the hospital or receive casualties from nearby incidents.

Mentally preparing was all we could do since there apparently isn’t a policy and procedure for how to handle civil unrest. The other doctor on shift with me joked that we were ready to handle Ebola, yet had no plan for something that was actually likely to happen given recent events.

I fired up Twitter on my phone and immediately subscribed to the local media, figuring that would be a decent way to keep tabs on the situation. All of the local TV stations had been blocked by IT, but one of the EMS guys pulled up Broadcastify at the nursing station, which let us hear police scanner traffic. Patients were another good source of information since the threat of a protest certainly didn’t keep anyone from coming in.

As a safety-net facility, the staff is used to working under stressful conditions. Most took it in stride. I work at this hospital only a handful of times each year and it always impresses me how well it holds together even though there may be a substantial amount of duct tape and some baling wire involved.

I was running the fast track side of the ED, so I didn’t expect to see any major trauma if things got rough, especially since the hospital lowered their trauma center level a couple of years ago. In the morning, most of my cases were truly primary care – people who had run out of their medications due to the clinics being closed and not having refills, sinus infections, colds and flu, and so on.

I was grateful for the defaults in my EHR that let me document the visits quickly since our volume was picking up. Towards the lunch hour, there was an announcement that protesters were at an intersection about a quarter of a mile from the hospital. We expected things to slow, but they didn’t.

I saw a couple of Thanksgiving-induced casualties (pro tip: if you cut yourself while cooking, you need to have it stitched up within 12 hours or there’s not much we can do) including a woman who had her hand smashed in a shopping center door during the Black Friday madness. What really made me think of Thanksgiving, though, was realizing just how many times I had searched for non-English versions of patient education handouts during the shift. As much as we sometimes complain about EHRs, this time ours performed like a champ.

I looked through my “complete chart” board and realized I had seen patients from Somalia, Ethiopia, Bosnia, Iraq, Guatemala, Mexico, and China. It’s powerful to know that despite its flaws, we live in a country where people are willing to leave their homes and families for a chance at something better.

Ultimately, the protesters never approached the hospital. Other than being one of the busiest shifts I’ve ever worked, it was pretty unremarkable. I feel privileged to be able to care for such a diverse population and am definitely glad the EHR was up to the test.

Have a story about the EHR actually making life easier? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/24/14

I’m getting ready to be a volunteer judge for the local science fair. I’m communicating with not only the school’s science fair coordinator, but with a couple of student ambassadors who have been assigned to make sure the judges know what to expect and have all the materials they need.

It’s been fun seeing the student packet and how they can leverage technology. This year they’re even offering a “virtual science fair” where submissions can be entered via electronic presentations rather than on the time-honored table display.

This is the same school where I’ve spoken at Career Day in the past. It’s always fun to see young people embrace technology when I spend a good chunk of my time helping physicians who are fighting it tooth and nail.

I just hope they’re teaching the students how to use technology responsibly because some of my hospital co-workers seem to be challenged by it. I’m still amazed by the number of people who haven’t yet mastered the art of the blind carbon copy, not to mention restraint where “reply all” is concerned. Those elements are just basic workplace standards, but workplace use of social media is another thing entirely.

Sharing your life with co-workers on Facebook shouldn’t be taken lightly. I’m not a heavy Facebook user, but I do have an account since it’s an easy way to keep up with college and med school friends. It’s tempting to accept friend requests from people at work. Usually I accept them since I don’t have anything to hide and it’s unlikely I’ll be posting any wild and crazy party pictures that could haunt me down the line. Even as a casual user, though, there is a fair amount of content that builds up over a couple of years.

I hadn’t really thought much about it until one of my colleagues started mentioning random things to me. They seemed familiar, but I couldn’t really place them. I have to admit it was a little unnerving since I wasn’t making the connection.

Finally, after a couple of weeks of this, he mentioned seeing something I posted on Facebook. It all made sense. This guy had completely stalked me on Facebook, reading everything I had ever posted and making note of everything I had “liked” for the last several years.

In addition to making me feel completely creeped-out, it made me think a lot about my social media footprint. I don’t accept friend requests from patients, although any patient who tries to friend me will get a friend request from our office’s account instead so that we’re not ignoring them. I have my security settings pretty narrow and I don’t post overly-personal information. Still, one could look at the pattern of comments and likes and end up putting together a profile that really doesn’t fit me at all.

There are also the privacy concerns about companies like Facebook capturing our browsing patterns and selling that data and a host of other scary situations. Their ability to peer into our lives is limited by the power of their algorithms and the data they had to work with.

On the flip side, there are companies that we willingly provide a host of personal data to that can’t seem to present useful information. I receive weekly emails from a couple of job-hunting type sites, and despite my building a fairly decent profile, they still send me junk.

This week one of them found me some interesting positions: System Center Operations Manager; Medical Technologist; Hotel/Resort Sales Recruiter; Business Analyst for Nestle Purina Pet Care; Cardiovascular Pharmaceutical Sales Professional; Infusion Center Nurse; Senior Storage and Back-up Engineer; and Inpatient RN. My favorite was “Intern, software development.”

The only one that remotely fit my profile was for an emergency department locum tenens position. I’m thinking that either their algorithm has gone haywire or it just can’t handle the chaotic scope of keywords a CMIO might have on her resume. It makes me want to think twice about the ways we process big data for patient care and whether we have enough measures in place to flag whether trouble is brewing.

On the other hand, if our HR department uses anything like what this website is using, it might go a long way to help explain why we have such a difficult time finding qualified candidates for some of our open positions.

Do you have concerns about social media or analytics gone wild? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/17/14

Color me less than thrilled that the Institute of Medicine is now asking for EHRs to capture additional social and behavioral data as part of Meaningful Use Stage 3. That’s assuming that Meaningful Use is still viable now that the money is nearly gone and more than half of ONC’s senior leadership has left in recent months. Practice administrators have been dazed and confused trying to figure out if they are better off trying to apply for hardship exceptions, take advantage of the flexibility rule, or throw in the towel altogether.

I recently met a practice administrator who swore up and down her providers were attesting for Stage 2, even though they hadn’t yet installed a patient portal and didn’t have a Direct interface. Then again, she also thought that Patient-Centered Medical Home was some kind of design/construction initiative rather than a practice transformation activity, so I shouldn’t have been surprised.

I understand that the Institute of Medicine sees EHRs as a great place to mine data for research, but patients are already weary of having their privacy invaded. Anyone remember the Florida legislation to control whether providers could ask about firearms in the home? My vendor actually had to code in a setting where a practice could hide the firearms questions to avoid running afoul of the law.

Although we’re pushing patients to be more engaged and it’s nice to work with them when they are, at least in my world the majority of patients don’t care about engagement. They just want to be treated and get back to work, their kids, or whatever else was going on in their lives before they got sick. They’re not interested in proactively managing their health when they’re living paycheck to paycheck and think that even questions about alcohol and tobacco use (which are clearly linked to major health outcomes with most people understanding their significance) are over the line.

When we had to start asking about race and ethnicity, we spent on average two to three minutes per patient explaining why we needed that information and helping patients figure out how to answer the question. Many patients thought they were interchangeable, so we were at the front desk educating them on the vagaries of demographic data rather than collecting their co-pay and speeding them back to see the doctor. At least those particular pieces of demographic information don’t change over the life of the patient, so you only have to ask them once.

Now the academic crowd is going to push us to ask about factors that could change at every visit, including depression, education, intimate partner violence, financial resource strain, physical activity, social connections/isolation, and stress. I can tell you without gathering data or an exhaustive chart review that most of my patients would require discussion of the last four.

As a good primary care physician, I should be asking about these things anyway, but I want to ask about them at an appropriate time during an appropriate visit, after I have built a relationship with the patient. I don’t want them turned into screeners that my staff has to administer to every single patient so we can avoid being penalized.

Will providers be judged on the percentage of patients who follow advice to manage these issues, like we’re currently judged on the number of patients we can convince to go for colonoscopies or mammograms? That’s not what I signed up for as a physician. I should do my best to encourage my patients, but didn’t I spend a lot of time in medical ethics learning about patient autonomy and how the paternalistic model of healthcare delivery has to go? We’re just asking for more cherry-picking by providers as they dismiss non-compliant patients from their panels to improve their numbers.

Most patients don’t understand that their data is already being used for research by health plans and other payers without their specific understanding or consent. Sure, it’s probably in the fine print somewhere and it’s either aggregated or de-identified, but if you asked them whether they understand where their data goes or what it’s used for, they would say no. When people think their information might be used in a way they don’t want it to be used (or to be out of their control), they’re going to lie.

Mr. H’s recent poll showed that nearly half of HIStalk readers have withheld medical information from a provider due to privacy concerns. I’m one of them, I admit. Parents are lying on the California home language survey  because they don’t want their children labeled as “English learners” for fear they will miss out on other educational opportunities. The old medical school adage of “take the amount of alcohol the patient says he uses and double it” reminds us this is not a new phenomenon.

How about let’s actually get people to use the EHRs they already have and use them well rather than pushing more minutiae on overburdened end users? A friend of mine has an EHR with a great onboard reporting tool, yet hasn’t leveraged it at all for actual clinical care. They’re so busy trying to get their patient portal enrollment numbers up and micromanaging the rest of their “all or none” Meaningful Use metrics that they’ve lost their ability to do cancer prevention outreach, immunization campaigns, or other interventions that have been actually proven to save money as well as improve people’s lives. And that, dear readers, is a shame.

What do you think should be in Meaningful Use Stage 3? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/10/14

Assuming that it doesn’t get delayed yet again, ICD-10 is a little less than 11 months away. For those of us who had been preparing for the most recent and now-postponed transition date, it’s time to dust off our implementation and training plans if we haven’t done so already.

My organization had already done a fair amount of informational outreach to physicians and other providers, so most people know what it is and that eventually they will have to use it. Their actually readiness to do so, however, is variable.

I have to admit that I’m not well versed on our plans for the transition in the hospitals. As our employed physician base has grown, I’ve had to focus more and more of my time on the ambulatory projects. Although I’m still privileged for inpatient medicine, I rarely see patients in that environment.

Even so, the communication from our hospital to rank-and-file admitters has been spotty at best. I think I’ve seen maybe a handful of emails since the last delay. Hopefully they will get on their game soon at least as far as communicating with community providers is concerned.

On the ambulatory front, however, we’re really gearing up. We’ve been on the ICD-10 ready version of our EHR and practice management software for a year. It was helpful that they bundled the ICD-10 functionality in with the 2014 Meaningful Use Stage 2 content so we didn’t have to take multiple upgrades.

Now that they’ve had a little bit of a hiatus with regulatory requirements, our vendor has again turned to coding actual functionality and usability updates, which puts me in the lane again for an upgrade prior to ICD-10.

Timing the need to educate everyone around an upgrade is tricky with ICD-10. We do plan to bring all the ambulatory end users in for some type of formal training for both processes and don’t want them too close together (training fatigue) or too far away from the go-live dates. We also have to remain sensitive to the realities of pulling people out of office.

Although I wrote a few weeks ago that we’re doing computer-based modules for new practice go-lives and for addition of incremental staff, we’re still planning to do classroom training for these two projects. We’ll likely supplement them with on-demand resources as well, but right now I’m planning for traditional training.

We did purchase some external vendor content for ICD-10 for certain high-dollar and complex subspecialties, but I’m responsible for organizing the plan for medicine-based subspecialties and primary care. We had external trainers in last year to train our core team (physician leaders, compliance officers, auditors, training staff, etc.) but I’m sure most of us have forgotten the nuances. We’re going to have them back after the first of the year to deliver a refresher.

In addition to the classroom training planned for closer to October 1, we’re scheduling monthly lunch and learn sessions to re-familiarize people with the concepts of ICD-10 and prepare them for more intense documentation. During the decade we’ve been on EHR, many of our providers have developed an affinity for voice recognition-based narrative documentation. Since they’re not using the discrete elements of the EHR as much as they used to, their ability to leverage discrete data to suggest appropriate ICD codes will be limited.

We anticipate that those who are afraid of learning a new coding system may want to rely more heavily on the EHR’s computer-assisted coding features, which will require retraining on the template-based workflows for those providers. Being able to identify those individuals early will be good, especially since we didn’t exactly budget for basic EHR retraining as part of our ICD-10 transition. I’m hoping we can leverage super users in the practices and our regional physician champions to assist, but I want to make sure all the bases are covered.

Although some of our providers complain about the restrictions of being employed, ICD-10 is a prime example of why physicians are willing to give up a degree of autonomy in exchange for corporate management structures. I’m working with two other people to put together our strategy and it will be rolled out to all of our practices. If those sites were independent, they’d be on their own to find a consultant, develop a program, or potentially try to just wing it.

Of course, those organizations that aren’t even on their ICD-10 ready software yet have additional work cut out for them. I don’t envy the upcoming months for them. With the estimated cost of the transition ranging from $50K for small practices to millions of dollars for the rest of us, there’s a lot at stake.

Are you ready for ICD-10? What’s your strategy? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/3/14

I’ve taken a few clinical informaticists under my wing over the last couple of years. I shouldn’t be surprised, but I am still baffled that organizations expect someone to take a lead role with clinical software but don’t give them any training or support. I’m not talking about software training (although that may be a factor) but rather assistance with the skill set needed to manage the things that are about to come their way.

Clinical informaticists come in all shapes and sizes and with all kinds of titles and varying levels of experience. That’s the first thing I tell them – to forget about what their title might be and figure out what their duties actually are. The second thing to do is to figure out whether they have the skills to tackle their given areas of responsibility and to put together a plan to prepare for them.

Organizations tend to be penny-wise and pound foolish in this regard. They expect physicians to learn many of these things on the job, but sometimes forget to tell teams they’re responsible for helping to build that provider. That can create fiction among the teams and is often a challenge when providers are not comfortable with exposing a lack of knowledge and need for assistance.

In my first CMIO-type job, I was responsible for managing clinical content for a good-sized outpatient medical group. There was a team of young-ish (well, at least younger than me after umpteen years of training and medical practice) analysts that held the keys to the system as far as modifications were concerned. I was overwhelmed in my role (trying to do the job in four hours a week) and trusted that they were being straight with me.

They weren’t too keen on trying to help me learn the back side of the EHR. The IT team didn’t budget any time for me to go to training other than what I had as an end user. I decided to dig in with the system’s user manual and, believe it or not, read it cover to cover.

That experience was a serious eye-opener. First, I learned that the system had many more capabilities than I knew of. Second, I learned that my team had been snowing me as far as how challenging various configurations and customizations really would be if we wanted to perform them.

The trick was figuring out how to leverage my new knowledge without letting the team know I had discovered the mismatch between their work capacity and the product delivered. In hindsight, the portable putting green and disc golf equipment in their part of the office should have been a clue.

Although I tell them to try to forget about the title, it can be important especially if the title indicates the level of respect or support a clinical informaticist will have in the broader organization. My first stab at this was as a medical director. The CMIO title wasn’t even an option, as there had never been one and the CIO stated he didn’t feel it was necessary to have a CMIO. In itself, that gave me significant insight as to what I was signing up for. However, the only other titled physician leader was also a medical director and that was reassuring.

Regardless of the title, the ambulatory arm of the organization positioned me well and publicly explained my role and responsibilities as far as approving clinical content and working with providers to optimize the EHR implementation and ongoing use. This was important when physicians pushed back in areas that were clearly in my realm because I knew I could count on leadership to back me.

Unfortunately, some of my new colleagues are facing less than optimal situations. One is already chief of service in his procedural subspecialty at the hospital (with all the committee meetings and responsibilities that go with that) and yet is charged with leading a rollout for a largely ambulatory medical group. Although he’s very interested in clinical informatics and has done some coursework, the deck is already somewhat stacked against him.

The odds are also not in his favor regarding how the leadership positions him. Although they’re publicly telling physicians he is going to “run” the application team and “lead” implementations, the staff actually reports in a different vertical whose top leader is openly hostile to the idea of physician leadership. He’s gone on record as saying that CMIOs are “useless” and it does not appear anything has been done to modify the behavior or to ensure public support of the new physician leader.

I’ve seen that before firsthand, when IT and operational teams had difficulty working together. In one organization where I worked, the project’s executive sponsor forced the IT director and the operations director to have regular breakfast meetings with a report out of the issues they were working on to build their relationship and ability to collaborate. No one likes being “forced” to play nice, but sometimes that type of structured intervention is helpful (and often necessary).

In addition to title and responsibilities, the other thing newly minted clinical informaticists need to address up front is compensation. There are still organizations out there that think the job can be done under the “other duties as assigned” clause of the job description. Unless a clinician is only expected to manage a narrow window of content or functionality, it’s just not realistic.

I’m a full-time CMIO (my clinical practice is all on the side, outside of my primary employer’s control) and trying to manage user needs, application limitations, regulatory requirements, accountable and value-based care, and everything else requires coordination with multiple teams and resources. Compensation needs to be appropriate for the level of work being done as well as the responsibility involved and the overall impact to the organization.

Compensation should also include a budget for continuing education in informatics as well as the calendar protection needed to attend sessions and spend time gathering new skills. In my first medical director position, I actually lost my continuing education budget because our bylaws decreed that only full-time clinical physicians received CME funding. It took me 18 months to get training courses approved through our IT staff development budget, which specifically excluded CME courses. Talk about a Catch-22.

Being a CMIO, medical director, director of medical informatics, or clinical champion — or in my case, Jayne of All Trades — can be a rewarding experience. It’s even more so when organizations are committed to setting us up for success, although that’s not always the case.

Have a CMIO horror story? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/27/14

In this week’s Monday Morning Update, Mr. H mentioned the UberHEALTH promotion where customers could use the Uber app to summon a nurse to administer a flu shot. The idea came from John Brownstein, a Harvard epidemiologist who saw the mismatch between importance and convenience of getting a flu shot. After the success of the program, he feels it might be a possible delivery model for basic preventive care as well.

Given the ebb and flow of my happiness as a CMIO of late, I decided to run the math and see what it would look like to take to the road.

Although as an Uber promotion the nurses had a driver, I could certainly drive myself. That would cut costs right there. I’d be seeing fewer patients each day, which would actually lower my professional liability insurance premiums. I wouldn’t be paying rent or utilities either.

I have a friend who has a retainer-based practice and does only house calls, so I know that I’d have to trick out a decent-sized vehicle that could handle vaccine and specimen storage, various equipment, and more, but it would still be cheaper than paying for office space.

EHR costs would be about the same, although if I ran it as a cash practice they would be significantly less due to the savings in billing services, audits, etc. I went back and forth thinking about a cash practice. Looking at the percentage of cash-pay patients I see at a local urgent care, it may be more realistic than one would think. There are increasing numbers of patients with high-deductible health plans, which may make a reasonably-priced cash practice very attractive.

Having limited equipment would actually help to keep costs down. There’s no temptation to order x-rays because it’s convenient if you don’t have a machine.

Several countries in Europe offer house calls as part of standard medical care. One of my medical school classmates who lives in Germany recently had a baby and was telling me about her benefits. Rather than cutting services as payers do here, plans offer generous coverage and even things we wouldn’t think about. She was able to get “homemaker” services to perform light housework while she recovered from her delivery and had home visits from a lactation specialist and a pediatrician with very little out-of-pocket cost.

Her family physician actually takes “first call” at night, alternating with other physicians, rather than screening the calls through an answering service. My friend asked her family doc how he liked that. He said the patients are respectful because they know they’re waking the doctor up and they only call if it’s an emergency. Because he’s the one on the phone with them, it’s easier to negotiate an office visit the next day or even a house call, rather than potentially just sending everyone to the emergency department.

It’s certainly not inexpensive to deliver care this way. Coverage is funded by a flat percentage of each worker’s income that is paid to a non-profit coverage fund. It’s mandatory, but due to the flat percentage, it varies by income, with higher wage earners paying more. Although most Americans would balk at paying 8-10 percent of our gross income individually for healthcare, when you do the math and look at what employers are paying, the cost of individual insurance, and the level of service, it seems like a contender.

Although she’s a physician, my friend isn’t licensed in Germany and works part-time as a medical editor. She did mention that highly compensated employees can opt out of the requirement and purchase “private” coverage from a for-profit plan, but she doesn’t personally know anyone who has.

My friend isn’t an expert on healthcare finance, but that model of care brings up some interesting concepts. She didn’t have a lot of feedback about EHR use among physicians other than to say that they’re significantly less stressed out about it than most of her friends in the States.

I’d love to hear from readers that have deeper knowledge on those topics or who have experienced that type of health system first hand. I’d also love to hear from providers in the US who have incorporated health IT into either mobile or direct/cash primary care practices.

In the mean time, I’m going to start shopping for a vehicle worthy of a diamond-plate accessorized vaccine refrigerator.

Got a sweet ride for patient care? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/20/14

One of my friends from residency contacted me last week for advice on converting from one EHR to another. She’s a medical oncologist. Her organization is bucking the single-vendor system trend by allowing its oncology practice to move onto a specialty-specific EHR. They’re planning to use a private HIE to tie it all together for patient care and data integrity.

She wanted to know what kind of skills would be involved in supervising a data extract and migration since she had been asked to be the physician champion.

I started explaining that there are multiple dependencies involved – from how willing the “old” vendor is to participate in an extraction, to what kind of data is moved, to how ready the “new” vendor is to handle a conversion or data insert.

As we talked through demographic conversions, what to do with scanned documents, and various strategies to handle discrete data, it became apparent that no one had been discussing this process with the physicians at her organization.

She told me a little about the vendor they had selected — how great the demos were and how much better they think it’s going to be than their single-vendor platform. We talked about her current workflows and how they might change in the new system.

It sounded like they are heavily dependent on voice recognition technology at present, so I asked how the new vendor proposed to handle that. She wasn’t sure, so I asked if there were questions around that topic in the RFP. I was quite surprised to hear that they had just started working on it.

I asked if she even knew what RFP meant and she didn’t. I told her it was a Request for Proposal and explained that the RFP isn’t just something you send to the vendor for response. Ideally, creation of the RFP involves a thoughtful review of your current state and your desired future state. It’s your way of letting a vendor know what your organization looks like as well as learning what their organization looks like.

She interrupted me part-way through my informatics lecture. “But we’ve already had three demos with them and we really liked it. Why do we need to go through all that?”

I explained that the fact that she has been tagged as the physician champion for this system yet she has no idea whether the system can handle their current preferred method of documentation is a big problem. I brought up other key features that she should be knowledgeable about that would be largely covered in the response to the RFP: MU certification status and track record, eRx capabilities and intermediaries, Direct messaging capability and provider, support, etc. Then I dug into how they should be requesting information on how the vendor plans to support the transition, etc.

Since they’re coming off an existing EHR, those questions should have been included in the RFP rather than being posed to an old friend halfway across the country.

We talked about the requirements analysis that should have been done before they even looked at other systems. Did they actually document how they thought their other system was failing them, or what they wanted to have different? Who was involved in the discussions? Do they know who the decision-makers really are? What is the budget? What will they do if they can’t take their legacy data with them into the new system? Will they keep their current practice management system or transition completely to a new platform? Do they need a vendor who is willing to interface?

It never occurred to her that some EHR vendors will not interface with a third-party practice management system. I explained this is why the RFP process is important and not just to receive the vendor’s response, but to even know what business problems you’re trying to solve. We also talked about how proposals should be obtained from multiple vendors, not just the one you’ve pre-selected. In my organization (which has a strong and highly-regimented RFP process) we’ve had situations where one vendor’s answer to a question lead to additional questions for the other vendors as we hadn’t thought of a particular angle or process.

We also talked about the fact that her organization is a highly visible non-profit that receives a lot of state and federal funding, meaning if they don’t have multiple vendors competing for the contract, that might be a serious problem. Realizing that if they neglected to complete a proper RFP process they were probably cutting corners elsewhere, I had some additional questions for her. Did you check the vendor’s financials? Do you think they’re at risk to be acquired or to have financial difficulties? Do they have a chief medical officer and what are his/her credentials? Who has input into product development? Did you do any reference calls with current clients? Did you do any site visits?

As the call unfolded, she realized that being a physician champion (and thereby putting her stamp of the approval) was going to be a little more involved than she originally thought. I told her I’d send her some reading material and had my assistant drop my dog-eared copy of Jerome Carter’s EHR textbook in the mail. It’s not the current edition, but it will help her prepare for what’s ahead and figure out whether she even wants to be involved given the way her organization is operating.

It never ceases to amaze me that organizations are willing to put themselves at risk by failing to follow basic business processes. Even in her single-specialty situation, there are millions of dollars at stake. Not only the purchase, implementation, conversion, and support fees, but the potential loss of revenue if they don’t get this right.

Does your organization put the cart before the horse? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/13/14

We are in the process of adding a variety of self-directed learning options to our EHR training. Up until now, we have had formal classroom training for clinical support staff and practice-based group training for providers.

Although we’ve had good outcomes from training, our paradigm is fairly resource-intensive. Additionally, providers complain about the time they spend in training sessions since it often cuts into their office hours even though we offer sessions before and after typical practice schedules.

One of the advantages of a resource-intensive training program is that it is the resources are intensely involved. When we train in small groups, we can provide individualized attention and can monitor who is catching on and who might be struggling. We can also ensure immediate follow up if attendees don’t pass our competency exam.

In turn, our learners can provide feedback on the effectiveness of our curriculum and presentation style so that we can modify it if needed. This is important when we bring new specialties live that our trainers might not be as familiar with as they are with other specialties.

We’ve had online refresher training for the last several years. It’s largely in the form of recorded web presentations, although we have a number of clips that were done with Adobe Captivate. They’re tied to our learning management system so we can see how many times each piece has been viewed and whether a particular employee is taking advantage of the resources. Managers can access a report of their employees’ activities, but the sessions are not required.

Our goal was to create some 5-10 minute segments that people could watch if they were having difficulty with a particular functionality or a new feature. Feedback has been good.

Given the budgetary pressures facing healthcare organizations, we’ve been asked to enhance our online offerings with a goal of reducing classroom training time. Staff will now be required to view a core set of e-learning offerings and managers will be responsible for tracking compliance.

I’m in favor of e-learning because it can be completed at the employee’s preferred time and location. However, I’m concerned that since reduced training time is the goal, that employees will be shortchanged. I can’t see some of our managers carving out protected training time for new employees. In particular, I know some of them will expect employees to jump right into patient care and learn the EHR on the fly.

Those same managers are likely to expect employees to complete the sessions on their own time even though that’s a violation of company policy. Staff working on uncompensated time might rush the training, or worse, multitask their way through it, diminishing mastery. We have a plan to gather data on whether the new strategy is effective, but based on the number and frequency of new hires, it will likely be six months or more before we know if it’s equivalent to our current platform.

I don’t like the idea of experimenting with our practices. We’ve worked hard to have a successful program and our practices get up to speed very quickly with only rare exceptions. Although we pull new hires out of the office for several days of training, when they return to the practice, they’re able to hit the ground running.

I guess my biggest concern is that there’s really no way to shortcut the material. A trainer — whether in person, recorded, or as part of an e-learning platform — can only impart information so fast. In turn, learners can only absorb so much in a given amount of time.

If this was an experimental drug, we’d first have to experiment on healthy subjects (or those who didn’t really need the training) to make sure it was safe. If it passed those tests, we’d have to experiment on more subjects to determine if it was more effective than placebo. Finally, we’d have to have a limited head-to-head trial against current training standards to determine if we should switch to it or not. Only if it passed certain statistical tests would we use it to replace our current training platform.

Since this is mostly about saving money, you can bet we didn’t have the opportunity to really study the new approach, let alone have an actual pilot or trial. We are being forced to switch everyone over without proof that it’s not going to lead to problems. As normally happens in healthcare IT, we were given a short deadline and limited budget to get it ready.

We’ve been in the business of delivering the impossible for a long time, however, so we’re up to the challenge. As for outcomes, only time will tell.

Have you been able to pare down training and maintain quality? Have great ideas? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/6/14

Given the recent events at Texas Health Presbyterian Hospital Dallas, the Ebola virus is all our hospital can talk about. We’ve been combing through our infectious disease protocols and scheduling education sessions to ensure people have access to all the resources available.

It’s daunting to think of what might happen should the disease get a toehold in the US. Many of our hospitals are already taxed with the usual communicable diseases. During flu season last year, one of the local pediatric hospitals had to put a M*A*S*H style tent in the parking lot to handle all the cases coming in.

Although Ebola is statistically less infectious than other diseases (including HIV, SARS, mumps, and measles), the lack of available treatments and high mortality rate frighten the average person. NPR had a great graphic that we’re using to help educate staff and patients about the need to ensure we have appropriate precautions in place to treat all communicable diseases, not just the most worrisome ones.

We have measles outbreaks in our community every couple of years due to some concentrated populations who do not vaccinate. Measles has a fatality rate of around 25 percent in underdeveloped nations, compared with an average fatality rate of 50 percent with Ebola (although specific outbreaks have ranged from 25 percent to 90 percent). For readers who don’t have a clinical background, the World Health Organization fact sheet provides good information about what your clinical co-workers are contemplating.

According to WHO, single travelers have spread the disease to countries including Nigeria and Senegal, which adds to the worry around a traveler bringing it to the US. Unfortunately, the early phases look a lot like other viral illnesses – fever, fatigue, muscle aches, and headache.

I probably saw 10 patients with those symptoms in the emergency department during my last shift. If we had treated each one like a potential carrier, it would have brought our patient flow to a screeching halt. From an epidemiology standpoint, IT resources are going to be critical for surveillance and identification of potential cases in the US.

I’m glad Texas Health Resources released a clarification on their earlier statement that cited a “flaw” in the EHR as contributing to the release of the patient at his initial presentation. Ultimately, it’s up to the physician to take a detailed history and physical. We all know that even with the best nursing protocols, patients will occasionally add details when a second (or third) interviewer talks with them.

It used to drive me crazy as a student when a patient would tell the resident (or worse, the attending) a detail that they had omitted even when I asked specifically about it. It may be the time between evaluations that makes the patient think about other details, or maybe one feels more empowered and able to formulate thoughts after telling the story previously.

My initial response to their statement about a flawed EHR was to take offense on behalf of their physicians. It was almost like saying their physicians aren’t responsible for thinking about elements not prompted by the EHR, or that they’ve totally given themselves over to cookbook medicine. I reached out to a friend on staff there who shared my opinion. Whether there was pressure from Epic to update the press release or whether it was from the medical staff, it was the right thing to do.

Now I’d like to see their root cause analysis on why the history was not taken fully into account and whether the presence of scribes was contributory. I’d also like to know what kind of providers saw the patient and whether there were other circumstances at play, such as shift change, a full patient board, staff who called out sick, etc. Those factors have led to mistakes at my institution and they’re much harder to place solutions around than making sure the EHR fires alerts and that personal protective equipment and isolation rooms are readily available.

I’m curious as to what other institutions are doing to prepare themselves for a potential outbreak. Are you modifying your EHR workflows? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/29/14

As a CMIO, I often feel my attention is all over the place. I’m dealing with clinical documentation needs for various constituencies while trying to ensure compliance with a host of federal, state, and other quasi-regulatory standards bodies. I’m also trying to implement tools to measure patient, physician, and employee satisfaction while maintaining my sanity in what seems like an upside-down healthcare world.

Given that background, you can’t imagine the serendipity I found when Dr. Andy’s recent CMIO Rant coincided with my weekend project to review E&M coding.

Due to some discrepancies in coding volumes after a recent ambulatory EHR upgrade, our compliance officers asked for a thorough review of the system’s E&M calculation tools. There are quite a few nuances to how the system codes and we’ve also had some recent coding education outside of the EHR, so I wasn’t convinced we weren’t dealing with another variable.

Our system is flexible and allows physicians to choose either 1995 or 1997 guidelines for each encounter. What if the recent coding class had physicians making different choices than they did previously? What if they were scared by the gloom-and-doom predictions of a RAC audit and undervalued their documentation?

I had been sitting for several hours with my trusty-rusty paper coding review forms, scoring visit documentation based on the guidance from our coding and compliance team. Once a visit was scored, I compared the results to the EHR’s calculations. Our EHR breaks down its coding suggestions parallel to E&M guidelines, so it is fairly easy to compare the bullets it counted vs. what I counted on paper.

Fortunately, our system does not advise on the level of Medical Decision Making, but rather requires providers to select that coding component. I can’t imagine how controversial the review would be if the EHR was prompting it.

There’s so much going on with HIStalk I tend to get behind from time to time. When I couldn’t handle any more bullet-counting, I took a break to catch up on HIStalk Connect and HIStalk Practice. Imagine my delight when I found Dr. Andy’s response to the AMA’s comments on EHR design. His first counter-request for the AMA is for them to help us fight “regulations that require overly detailed physician documentation, like the CMS E&M coding guidelines, which really set a floor of complexity below which we cannot sink.”

I laughed out loud, as I do every time I receive an email from CMS advocating their brand of “administrative simplification,” which has to be the biggest oxymoron ever. Just that morsel would have been enough to make my day, but then he covered their seemingly contradictory request for EHRs to lower cognitive workload while requiring them to enable dozens more tasks than we ever handled on paper. “Massive cognitive workflow” were the words he chose. Having had a 40+ patient clinic day this week, I can attest to the massive nature of the volume of information I had to process to care for them.

Note that I didn’t say data. Data implies the information is in the EHR or another accessible system that I could theoretically review. The reality is that physicians have to handle information on a much broader scale – the patient’s history, family members’ version of the same events, stories about what the patient read on Google, the physical exam itself, in-office testing, and more – on top of the actual electronic data available. Add to that mountain of information the fact that we’re now caring for patients in the office that would have been cared for in the hospital five years ago and it would be easy to become buried.

Reflecting on this massive cognitive workload inspired my new and improved “guidelines” for E&M coding. I didn’t have enough time (or martini fixings) to flesh out the entire scheme, so let’s confine our thoughts to established patient office visits.

Traditional E&M coding poses five levels of service – 99211, 99212, 99213, 99214, and 99215. The value of the visit (and thus the payments) increase as the level of service increases. Typically 99211 and 99212 are not used to bill actually physician services, so I threw them out. Talk about administrative simplification – I just slashed the number of things I have to think about by 40 percent.

Looking at the rest of the codes and what you have to have to justify documentation in the traditional coding construct, I identified some sample visits that were reflective of the codes even by conservative standards. They fell into nice groupings based on the amount of information the physician had to interact with during the visit. I’m not just talking about information that one would have to review, but also information one might have to deliver. Out of ten charts reviewed for each level of coding, I had a 90-100 percent concordance when using the “information burden” scheme to value my efforts.

Here’s how it works.

99213 – Now called “Mild Information Burden”

• Patient has fewer than three issues he/she wants to be seen for today.
• Patient has been seen at fewer than three healthcare facilities/providers in the last three months.
• None of today’s issues will cause death or serious consequences if left untreated.
• Determination of proper treatment requires review of fewer than three data sources (EHR, clinical data warehouse, HIE, antibiogram, CDC bulletin, guidelines website, Sanford guide, discussion with colleague, etc.)
• Treatment requires fewer than three instructions, outside orders, or documents (patient education handouts, prescription, therapy order, referral, prior-auth, FMLA papers, etc.)
• Visit requires less than 15 minutes for documentation.

99214 – Now called “Moderate Information Burden”

• Patient has more than three issues he/she wants to be seen for today.
• Patient has been seen at three or more healthcare facilities/providers in the last three months.
• At least one of today’s issues will cause death or serious consequences if left untreated.
• Determination of proper treatment requires review of three or more data sources.
• Treatment requires three or more instructions, outside orders, or documents.
• Visit requires more than 15 minutes for completion, including documentation.

At this point, based on my “rules of three” and the two levels of coding, you could quit. However, neither category covers what I had to manage for several patients seen in this week’s clinic. I decided to reserve the highest coding level for those special circumstances, but in keeping with the rules of three:

99215 – Now called “Severe Information Burden”

• There are three or more non-office personnel in the exam room (patient, family members, children, interpreter, etc.)
• Patient has been seen by facilities/providers that are members of three or more ACOs.
• At least one of today’s issues will lead to hospitalization in the next three months.
• There are three or more possible ways to treat one of today’s issues, depending on the patient’s insurance status and/or ability to pay for non-covered services.
• More than three separate logins and passwords are required to access the data needed to care for the patient.
• Visit takes long enough that it requires cutting three or more subsequent appointments short in order to catch up.

Maybe it’s just me, but those rules would be much easier to follow than what we currently have. I’d rather use my cognitive skills to deliver quality care and build relationships with patients than to remember whether I’m supposed to be documenting by organ systems or body areas. What does “expanded problem focused” mean anyway? Or “detailed”? I like to think that all my visits are detailed, if not comprehensive. Current E&M coding turns those perfectly good words into something incomprehensible.

Give it a shot – pull a couple of visits and see whether my proposed coding system holds up under the stress of your clinic day.

Do you dream of a world without E&M coding? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/22/14

A couple of weeks ago, we performed a major upgrade on our ambulatory system. Officially we’re now ready for both Meaningful Use Stage 2 and ICD-10, with all the bells and whistles installed. As upgrades go, this wasn’t my first rodeo. It went smoothly with only one minor IT concern and no significant incidents for the end users.

Since no good deed should go unpunished, management is now looking to cut our personnel resources for the next one. They can’t seem to understand why several hundred hours of work went into the upgrade because clearly it was “no big deal.” Mind you, these are not old-school IT managers, but members of our ambulatory operations team who want to avoid having super users out of the office.

We rely on the participation of super users, not only from the ambulatory practices, but also from our central business office, central scheduling department, and central referrals department. No one knows end user workflows like the super users who work with them day in and day out. We have detailed test scripts for our internal testing, but we need real-world expertise to tease out the smallest bugs. Like any organization, our users have some creative workflows that we don’t train, and if we don’t have their participation, we won’t find those issues until go-live.

We’ve been using the same upgrade methodology for half a decade, which is usually goes off without a hitch. It’s a belt-and-suspenders approach, with some duct tape and baling wire thrown in for good measure. We do a dry-run upgrade just prior to the super user testing so that we can get our timing down pat for the main event. The upgrade weekend playbook has some elements timed to the minute and there is a single upgrade commander responsible for ensuring every step is completed and communicated.

Because of the need to involve a couple of third-party vendors to handle some data migrations that we wanted to perform while we had the system down, timing for this one was even more critical. There were numerous handoffs among DBAs, access management, application analysts, build analysts, internal testers, and end-user smoke testers in addition to the third parties. Although we don’t make everyone sit on a bridge line and talk through their work and the hand-offs, we do require people to notify the team when they complete a step or if they’re running behind so that we can adjust if necessary.

The lead analyst that usually quarterbacks our upgrades had an unexpected medical issue a handful of hours before we were due to take the system down, so I ended up co-managing it with one of our analysts. This meant being on call overnight for issues, which doesn’t bother me. Once you’ve been on trauma call or managed an ICU full of patients overnight, being on upgrade call doesn’t seem very scary. Still, you never want to hear that phone ring in the middle of the night. Shortly after midnight, I decided to grab some sleep since we weren’t expecting a handoff until early morning.

When the phone rang at 3 a.m., my heart was pounding. The tone in the tech’s voice wasn’t reassuring as she apologized for calling. Apparently the upgrade was running nearly three hours ahead and she wasn’t sure if she should wake someone up to tell them or not. I have to say, seeing an upgrade run ahead, especially by that much, isn’t something you see every day. I shuffled out of bed and we walked through the checklists to make sure nothing had been missed. I cruised the error logs as well. Nothing was amiss, so we had to chalk it up to the production server being faster than our test platform.

We must have our share of either insomniacs or nervous Nellies on our team because a couple of people were showing available on our instant messenger service. They were happy to launch the next few steps early. Despite the call being a non-issue, once your adrenaline is flowing, it’s hard to get back to sleep. I curled up on the sofa with some journal articles, which thankfully did the job. By our 8 a.m. status call, I was rested up and eager for the build and testing teams to get to work.

Even though everyone has remote capabilities, we require the regression testers and analysts to be on site. We’ve learned the hard way that people are sometimes less attentive when working remote on the weekends. Sometimes it’s just better to have two sets of eyes looking at the same screen together (without a WebEx lag or dogs barking in the background) for troubleshooting. It’s a sacrifice for the team to come in, but we try to make it as fun as possible. The kind of team-building you get from an event like this is often priceless. It’s also important for the end user and analyst teams to work closely together and build mutual respect.

In response to the questions about why we spend so many hours preparing and delivering an upgrade, I’m going back through the last couple of months and highlighting some key milestones that may have been riskier with a leaner team. We have multiple people trained to do each task, which was clearly helpful when our quarterback unexpectedly sat out the game. I’m also working to quantify the intangible benefits of having disparate teams work together.

We ended up being able to re-launch the system two and a half hours early, which meant less downtime procedural re-work for the patient care sites that are open on weekends. Due to the diligent prep, we also had fewer phone calls Monday morning than we’ve ever had. That’s got to be worth something as well. The question is whether the Administralians will agree with our analysis. If they don’t, maybe we can let them run the next one and see what happens. We’ve already documented our lessons learned and updated the project plan, so it’s ready to ride.

Ever jumped in when someone said “Cowboy up?” Email me.

Email Dr. Jayne.