Curbside Consult with Dr. Jayne 4/14/14

I wrote last month about our health system purchasing another physician group in a bid to strengthen its primary care base for Accountable Care activities. The IT team is always brought into the acquisition phase too late, which is a shame. Our ability to identify potential issues and prepare for a smooth transition is always forgotten until we’re later asked to deliver a miracle after the ink is already dry. That was the beginning of my “pastry therapy” sessions, which have progressed significantly.

At the time, my biggest worry was figuring out how to get them through the EHR upgrades needed to get their first-timers ready to attest for Meaningful Use. My team was tasked with preparing for the upgrades, which is a standard duty for us. In reviewing what they had done to the EHR, I was entirely unprepared for the volume of customizations they have put in place. I was also unprepared for how ridiculous some of them are.

They have a robust EHR that allows creation of custom workflows even though the out-of-the-box workflows are pretty solid. This is good for customers who have specialties the EHR doesn’t cover, but not good for customers that use the EHR as a means of managing physician behavior.

After several weeks of reviewing their content and consulting with our development, training, and support teams, I was ready to meet with the combined medical leadership of our two organizations with a plan to gradually bring their workflows to our standard so that eventually we can convert them onto our database. (Initially the Powers That Be wanted an immediate conversion, but I was able to convince them we couldn’t do it on the timeline we have.)

Allowing for a slow retirement of their customizations would allow us to make two smaller steps rather than one giant leap, which I felt would be better for physician adoption and user acceptance. The first move would happen with their upgrade to the EHR version certified for 2014 and would involve addressing customizations that either impaired MU data-gathering (such as creating custom fields rather than using existing vendor fields that feed canned reports) or didn’t make sense (extra navigation buttons that cluttered up the screen and distracted from important clinical data.) The first step would also allow them to get used to our training style and expectations so that next time we can just use our proven franchise model with them.

The second step would be the true move onto our content, although we’d keep them on their own database until the dust settled. The final step would be to perform a relatively quiet migration a few months later.

Although the overall plan would take more than a year, we felt it would adequately balance the need to keep the volume of change manageable with the fact that we aren’t getting very many additional resources or dollars to pull this off. Although we’re going to assimilate their IT and training teams, we quickly discovered that they only had a rudimentary knowledge of the software since they had referred nearly all their changes out to consultants and contractors. We’ll have to retrain them not only on the product, but also add some discipline and critical thinking to the mix if they’re going to stay with us.

Our meeting with the medical leadership started out well with them nodding at all the right places as we presented the high-level plan. They agreed in principle, but it started turning ugly when they began asking about which specific customizations we planned to retire in the first phase.

My ever-OCD development manager quickly produced a spreadsheet. Her team had carefully catalogued every customization on a template by template basis with helpful information including why we recommend retiring it and what the proposed replacement workflow would be. They also attempted to gather information on why the changes were made in the first place, but for the vast majority, there was no compelling business case that any of the analysts could remember.

I was proud of my team for pulling this together in such detail on a tight timeline, especially when they had absolutely no documentation to work from. They literally had to do a visual inspection of each part of the workflow because our new partners apparently had never heard of a build specification document, let alone an approval tracker or anything else.

We began to work through the spreadsheet and were immediately stopped by our new colleagues. For every item we proposed retiring (even if it was actually contrary to the stated goals of meeting Meaningful Use, being an ACO, and providing quality care) they had an excuse why we needed to keep it. Many of the excuses took the form of, “This is something Dr. Jones really needs,” but they couldn’t provide any concrete reasons to back their statements.

After a dozen or so of these exchanges, it became apparent that rather than only modifying the EHR when it was deficient, they had been using EHR design changes as a way to appease cranky providers.

I’m all for modifying the EHR when it’s needed – if it’s truly deficient, if the workflow is inadequate, or if you are trying to document a specialty that’s not available from your vendor. Our group has been at this nearly a decade and all our customizations have a robust business case and have been vetted through a formal review process. We have design standards that keep pace with our vendor, so even when we customize, it appears seamless to our users.

We also log every single customization with our vendor so they know there’s a deficiency, defect, or workflow need. We can’t fault them for not designing to meet our needs if we haven’t told them what our needs are. Often we find that in the process of logging an enhancement request, the vendor is already coding what we want in their next version. We can make our customization look like what they’re doing so that when we upgrade, it is truly seamless.

I finished my mini-lecture on rational customization. The folks on the other side of the table just sat there with blank stares. They clearly either weren’t buying what I was selling or simply didn’t care.

Pulling out my best behavioral health “motivational interviewing” skills, I tried to get them to at least acknowledge a need to change even if they didn’t like it. It became obvious that they are scared to death of having to actually deal with their peers, let alone actually manage employed physicians.

Our trainers are pretty tough, but if management is not going to help us lead the physicians through a meaningful change process, we are never going to be successful. What makes me the angriest, however, is that we’ve been through this. We know what needs to be done to achieve success. We were in the same place many years ago. We have a proven track record of not only bringing practices live, but actually achieving clinical transformation and improved outcomes. We also have been able to do this without a significant change in practice revenue or any loss of clinical quality.

Unfortunately, we’re now being faced with providers who have been coddled and apparently don’t know the meaning of being an employee. Rumor has it that some of them are so politically charged that they’re being paid above fair market value just to keep them from leaving.

With those kinds of forces at play, the idea of achieving standardization seems impossible. If we can’t get them to agree on EHR workflows, how are we going to get them to agree on clinical content such as order sets or care protocols for chronic disease management? Looking at the impassive faces across from me, it was clear that we’re going to have to bring some bigger guns to support us. I’ve scheduled a follow-up meeting with our CIO and CFO as backup, but I’m not optimistic.

There’s nothing in medical school or informatics training that prepares you for this. I’d love to be able to turn to some of my CMIO pals for advice, but the idea of admitting this level of dysfunction — even to my closest confidantes — makes me squirm. It’s good, then, that I can turn to my virtual colleagues for advice. Leave a comment if you have some words of wisdom.

For those of you who just want some pastry therapy, that was Martha Stewart’s Chocolate, Banana, and Graham Cracker Icebox Cake. I didn’t have any milk chocolate, so I pulverized and melted several dark chocolate Easter rabbits, which was therapeutic in its own right. I also left off the whipped cream topping that Martha recommended – it was a little too over the top for my primary care brain.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/7/14

I renewed my battle today with Big University Medical Center in trying to get my information corrected on its patient portal. Unfortunately, my efforts were derailed by a much more sinister problem – basic office chaos.

Luckily I’m a nice, stable patient so I only have to visit Big University’s outpatient clinic once a year. They run chronically late. I’ve learned to always schedule the first appointment of the morning so I can have a chance to make it to my own office before noon. I make sure to arrive on time if not early because they tend to triple (if not quadruple) book appointments and I want to be the first of the cohort to be roomed. I also bring plenty of reading material so I don’t go out of my mind when I inevitably end up waiting.

I shared the elevator with a member of the office staff who was reviewing a printed patient appointment schedule (including names, appointment reasons, and dates of birth.) I’m not sure why anyone would need to take home a printed schedule since they have a big-time EHR system with remote access and plenty of redundancy and they definitely shouldn’t have been reviewing it openly in the elevator.

I hit the floor 15 minutes early (as instructed by my appointment reminder that came through the patient portal) only to find the doors locked and six patients standing in the hallway. The weather was decent, so bad roads or traffic weren’t a viable excuse. They finally opened the doors just a few minutes before my appointment time and all the patients hustled to the check-in desk.

Since the office doesn’t use sign-in sheets (purportedly for HIPAA purposes) they told everyone to sit down and they would call us up in appointment order. Most of the patients were retirees and began grumbling. While we were waiting, we were treated (via the open floor plan check-in desk) to one of the receptionists chatting about some birthday party she was invited to.

By now, it was past the first appointment time and we got to watch her start up her computer, stow her personal items, then walk away. 

My process improvement brain had engaged. I decided to do an impromptu time and motion study. She was gone four minutes and came back with an open cup of coffee. I know there are no OSHA requirements about coffee at a desk, but there ought to be some rules about open liquids and eating around computers. Not to mention that slurping coffee in front of patients is unprofessional. 

The first receptionist had checked in two patients and had called me up before the second one was ready to start working. The receptionist apologized about my wait. I mentioned that their reminders tell everyone to come early. She said she knew it was a problem and they’ve asked to have the message modified several times because they don’t open early. They didn’t have a printed patient information form to verify, but rather read all our demographics aloud and asked for verbal verification.

I felt bad asking her about my patient portal problem and spared her the long story. I simply asked if they had a help desk number I could try before I left the office since all the demographics are correct at the practices where I’m seen but are wrong on the portal. The only advice she could offer was to try the help feature from within the portal.

By this time, they had four patients checked in. It was 15 minutes after the first appointment time (assuming I was actually in the first slot as I had requested) and not a single patient had been called back by the clinical staff.

I was placed in an exam room with the door left open. While waiting for the patient care technician to start my visit, I was treated to conversations about other patients coming later in the day, various people walking back and forth chatting about their weekend activities, and a physician who normally doesn’t work at the satellite location who didn’t know what exam rooms he should work from or who his assistant would be. Not exactly a vote of confidence for patient privacy or engagement.

Last year my physician had used a scribe to document my visit in the EHR. I figured at least once they would try to blame the EHR for the delays. As they started my visit, I realized they wouldn’t be scapegoating the EHR – the office had gone back to paper. The tech started documenting my visit on a photocopied paper template. She did reference the electronic allergies documented in the EHR and re-documented them on paper, so score one for patient safety. She also reviewed the previous note input by the scribe as well as a “backup” paper note that apparently was documented during my last visit.

I let her know I wanted to talk about a new concern that popped up in the three months I waited for my appointment. She responded by letting me know my physician was no longer caring for “routine follow up” patients and I would have to find a new doctor if the new concern didn’t turn out to be anything serious. I’ve already been handed off multiple times within this practice, so I’m no stranger to starting over, but I thought the timing was poor.

I finally saw the physician 45 minutes after my scheduled appointment. She remembered that I’m a member of the community teaching faculty for Big University and offered to keep me as a patient even though my new concern turned out to be nothing. I should probably feel grateful to not have to change physicians again, but I think I’m going to anyway. Their office is a mess and I get aggravated every time I go. Simple things like a) cutting the personal chatter while there are multiple patients waiting; b) being vigilant about behavior when the practice has an open floor plan; and c) manifesting obvious “hustle” when you know you’re late opening would go a long way towards reducing that aggravation.

Now they’re not using EHR any more, so my data isn’t available to share with other physicians. There’s not an advantage of staying there vs. finding a physician at one of the other institutions in town. If my records are going to be in silos, it doesn’t really matter if the silos are 20 miles apart or right next door. The clinic always posts a loss and blames it on the number of Medicaid and charity patients they see, but after several years of this routine, I’m fairly convinced that poor management has as much to do with it as patient mix.

I’ve never received a patient satisfaction survey from this location, but hope I get one today. I’ve got some choice recommendations to share with them, although I don’t think it will make much of a difference. It doesn’t matter how much we spend on IT or whether the systems have outstanding usability if we can’t get back to the basics and actually manage our offices, whether they’re academic clinics, private practices, or hospital outpatient departments.

Making sure that IT functions support our mission by synchronizing automated reminder messages with actual office practice, having help desk support for patient-facing systems, and ensuring staff come in early enough to turn their computers on before they start assisting patients are a must as well. There are numerous stressors on all our healthcare systems and personnel. We have to come up with ways to fix them.

Have any creative ideas? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/31/14

I wrote earlier this month about our hospital nickel and diming staff who wanted an actual paper card to confirm their life support certification. There was an outpouring of reader correspondence about hospital policies that are designed to cut costs but that seem to have backfired.

Many of us are pinching pennies to buy larger more powerful servers because we’ve outgrown our current ones faster than anticipated or are juggling implementation budgets to ensure providers get the go-live support they need. With that focus, we tend to forget how much our organizations spend on day-to-day operational costs. We’re not the only ones who have to keep an eye on the bottom line. One reader knows acutely just how deep the budget slashing has gone.

Dr. Jayne, I enjoyed your column about penny wise and pound foolish. Our hospital replaced a fairly decent paper towel with a very cheap brown one. These towels don’t absorb much, so you end up using five times the paper towels that you did with the previous rolls. Our department runs out of paper towels frequently and I have to run down to housekeeping to pick up more rolls. As it happens, housekeeping has trouble keeping paper towels in stock (maybe because the whole hospital is using the cheaper rolls much faster – go figure).

Many times I am unable to pick up paper towels the first time I run down to the supply department. When I pointed out the inefficiency of the paper towel situation (particularly with the FTEs spent running around trying to keep them in stock) in a cost savings committee meeting, the environmental services rep said, “You wouldn’t believe how cheap they are.” Hello? Did anybody hear me? It’s been a couple of years. We still have the same blasted paper towels. And let’s not forget – it takes FOREVER to dry your hands, but they want to encourage hand washing.

We’ve had a similar situation in the office building where our ambulatory EHR office is located. To save money, instead of having housekeeping staff check the bathrooms multiple times each day, they only service ours once a day. We don’t have rolled towels but those old-school folded ones. In order to keep the towels from running out, the housekeepers cram as many towels as possible into the dispensers. They’re packed so tightly that if you try to pull a single towel, it rips, so there are constantly scraps of paper on the floor.

The only way to get towels out is to hook them on the end and pull a big stack of them out. This leads to dozens of towels being dumped in the trash. Another tactic is for the housekeepers to leave a stack of towels on top of the dispenser, which leads to either all of them falling into the trash (or on the floor) or being ruined when someone drips wet hands on the stack. Ditto with leaving a pile of spare towels on the sink.

Additionally, because after-hours housekeeping is more expensive than having it done on the day shift, our floor is now serviced during the noon hour when lots of people are trying to get in and out. Some housekeepers will work around the staff’s needs, but a few of them barricade the door. In the best-case scenario, our staff wastes a little bit of time going to another floor. In the worst-case scenario they stand around and wait for the housekeeper to finish.

I’m pretty sure the productivity cost from either scenario would cover the shift differential so our facilities could be serviced before or after office hours. Either way the staff is left with the feeling that saving money is more important than their needs, which isn’t exactly a morale builder.

Another reader recently relocated and finally landed a position with a health system after a lot of looking. It was more of an entry-level position than he had when he worked for a large vendor. He expressed concern at the waste he’s seeing from a personnel standpoint:

I’ve worked with hospitals, but never for one directly. I didn’t want to miss out on ICD-10 and Meaningful Use 2 and there aren’t many vendors out here. I was blown away by the size of the IT department. There are more manager-types than doers. Everyone is a consultant and no one gives a hoot. There is a ton of turnover and no accountability. The consultants are riding out the sunset of their careers and take it out on the energetic ones. The SMEs have skills that no one wants and the six tiers of management exist solely to waste time and overcomplicate things. People vanish for hours a day and the place is empty by 3:15. What do I do now that I’ve taken a job and am surrounded by such inefficiency and waste when I really wanted to DO something?

Unfortunately, I don’t have good advice for him other than encouraging him to stick with it long enough to either move up or find something better in his new home town. I’ve worked with a handful of analysts that think it’s OK to arrive at the office late, Facebook all day (pausing only for a long lunch), and duck out early. I suspect that with that many layers of management they may not have a handle on what’s going on right under their noses.

With all the regulatory events on the horizon, though, most organizations have more work to go around than anyone can handle. Our analysts work their tails off, and if they have a spare moment of time, they’re looking ahead trying to anticipate ways that they can make processes more efficient or help our users. They’re a self-policing team and if there was a slacker in their midst, they’d make his life miserable. Unfortunately if the entire team has those tendencies, it’s much trickier.

Have any advice for this reader? Any other great stories of cost cutting that saves dimes at the expense of dollars? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/24/14

Mr. H posted some comments from the annual reader survey last week and one of the areas that people wanted to read more about was the patient experience of IT. As he mentioned, it’s difficult to get patients involved since they probably don’t read HIStalk, but the good thing is that all of us on the team are patients ourselves. I’ve had several recent adventures in patient engagement involving IT over the last few weeks.

Fail #1: I had mentioned before my ongoing issues with a large academic center and their patient portal. It’s a solid product, but I don’t think it’s being implemented or managed particularly well. I had an issue right after I signed up to use it where my last name was spelled wrong. It had been correct on the patient information sheet at the office, but was wrong on the portal. When I inquired about it via secure email, I was told I had “aliases” in the system and it couldn’t be corrected. A few weeks ago I made an appointment for my annual eye exam, and when the appointment confirmation came, I noticed my name was now spelled wrong in two different ways. Additionally, there is incorrect allergy information now posted.

There’s no way for me to fix it from within the patient record at the moment. However, it’s unclear if the product will allow that and they don’t have that functionality live or whether the product is that way by design. I called about getting it corrected and was told again that there are multiple “alias” accounts for me and that they can’t correct it. I have a serious problem with there being multiple accounts, especially since I’m only seen in one practice at the health system. Did someone create a duplicate chart? What’s going on? And why can’t they be merged if it’s a simple duplicate issue?

I brought up the fact that now I have incorrect health information present and specifically used the phrase “patient safety risk” multiple times. I asked them what the process is to correct the erroneous records and the answer from the portal team was “talk to your doctor.” I called the physician office and confirmed that my records are accurate in the source system. How can the physician be expected to clean up an erroneous allergy that she can’t even see?

I called the portal team back and told them that the source chart is accurate and asked them again for a process to correct it. They confirmed they have none. I then asked if I could withdraw consent for participation in the portal because I don’t want the erroneous information (how much else is there that I might not be able to see?) associated with my records or populated to another physician I might see in the future. Of course they have no way of closing my account. At this point it’s more an exercise in frustration rather than engagement. I don’t have hours to spend pursuing it, so I guess I will just let it go and continue to make sure the charts my physicians are using are accurate.

The bottom line is that systems (both the actual software and the policy/procedure associated with it) need mechanisms to handle issues like duplicate patient accounts, demographic errors, and especially medical errors. I’m floored that a major institution would be so clueless. After all, they have wait time billboards for the emergency department and sponsor the local sports teams, so they must be good, right?

Fail #2: This one is wrong on multiple levels. I went to a new physician for a fairly uncomplicated skin condition last December. Although I could have treated it myself, I’m not comfortable with calling out my own scripts and figured it would be good to establish myself as a patient in case I ever really need to be seen. This was in December. Last week I got a bill from the reference lab for the same date of service as my visit but for a surgical pathology charge. I called the ordering physician’s office and explained the bill and had them look in the chart.

Sure enough, there were results on my chart, but no record that I had been notified. Had they bothered to inform me of the results attributed to me, I could have told them that there had been an error. The staffer informed me that “it was benign, so we don’t call” and I let her know that “no news is good news” went out decades ago. She went on to look through the chart and saw that the lab had faxed (who still faxes these days?) a name discrepancy report. Apparently the name on the barcoded sample and the name on the electronic order the lab received were different, but the office corrected it incorrectly. I requested a call back from the physician, which I’m still waiting for.

I don’t want to get sent to collections for a bill I shouldn’t have received, so I called the lab. While on hold for 40 minutes, I had plenty of time to think not only about the potential source of the error (human error NOS, multiple episodes, probably staff had two patient charts open at the same time) but also about why it took 90 days to get the claim adjudicated and a bill to the patient. If we had real-time adjudication at the point of care, I could have handled the entire problem at the check-out desk and the sample would have gone out correctly. When a person finally took my call, I told them that I didn’t have a skin biopsy and wasn’t going to pay for it. They were nice about it and said they’d place a call to the ordering physician and get it taken care of.

My hospital is self-insured, although we do have a benefit administrator who processes the claims. I’m sensitive to the fact that the physician compensation model (small-business “eat what you kill”) has providers directly paying for the insurance premiums of their office staff because I used to pay those premiums myself. I wasn’t about to let $300 in erroneous payments go by, so I called the benefit administrator. The representative I spoke to told me that the physician performed a biopsy on me during my visit and I must just not have been aware.

Seriously? I guess I not only slept through the biopsy, but also the informed consent process and the actual consent form itself. It took me a full five minutes to convince her that I did not have a biopsy. I also told her that the office was aware of the problem and had admitted it, that I was just letting the insurance team know so they could recoup the payment since we’re self-insured and with the rising cost of health care, etc. She then helpfully let me know that they actually paid over $600 because there was another claim for a second biopsy I wasn’t aware of. Since it was paid in full, I didn’t receive a bill.

She admitted there would be no way to know it wasn’t accurate since it was the same date of service as my actual visit. I told her that’s why I was calling, to make sure that the payment was disputed so that the money would go back into the insurance pool because otherwise they’d be unaware of the problem. That’s when it got even more ridiculous. She told me that basically it was my word against the physician’s claim, and that unless I wanted to pursue written documentation of the error, there wasn’t anything they could do. She couldn’t provide a form or documentation of the actual information she needed – she was basically saying that there is no way for a patient to easily dispute a claim.

I reminded her (since she works for the benefit administrator and probably isn’t aware) that we are self-insured and I was trying to do the right thing getting the money rightfully returned. I let her know that the lab had already reversed my portion of the charge and at this point the easiest thing for me to do as the patient was to walk away. After all, it’s not MY $600 that was paid out (although at some level it is) and I had already spent over an hour trying to pursue this and now she was asking me to pursue undefined documentation that they’d probably reject anyway. I asked if there was any mechanism for them to reach out to the physician (after all the insurance fund was the one that was wronged) and she said I’d have to provide the phone number and she’d try to call if she could. I was surprised by that (they should have the phone number since the provider is in network) and interpreted it as her attempt to just get the patient off the phone and move on. I doubt she’ll ever call.

What’s my point here? The patient experience still stinks and it’s not all due to technology. Although my first tale of woe has a distinct odor of an IT nature, people are unwilling to address it. Heck, they didn’t even try to play a “known issue with the vendor, blah blah blah” card — they just said there was no way to fix it. The second scenario is strictly human error. The office put the wrong name on the requisition and filled out the name discrepancy form incorrectly. But because all the technology components were met (CPT, ICD, DOB, MRN, insurance information) the failure wasn’t detected.

It could have been mitigated by IT, however, with the use of real-time claim adjudication and the immediate collection of the patient balance. On the other hand it could have also been mitigated by a direct pay method of funding healthcare, where I would have been presented with a bill to review at checkout and then either paid it or disputed it rather than sending it to insurance. That’s the way medicine used to work.

To put the onus on the patient to correct either of these errors is wrong. We should be bending over backward to make sure patient information is correct and that there are processes to handle incidents like these. We’re all patients, and someday that could be us on the other end of the phone. There are other elements here, too. What if that biopsy was melanoma? Then that information would be in my claims data and that would be another nightmare entirely to try to correct.

At the end of the day, patients want physicians and other health professionals to be accessible. They want them to listen. They want the office staff, hospital employees, and anyone else they have to interface with (insurance, lab, etc.) to take care of their needs without acting like they’re in a hurry or pushing back. They want to be treated fairly and have accurate records. All the technology and the bells and whistles are nice, but they’re secondary for the most part. Many of us would trade it all for a physician who had more than six minutes of time to address our needs and an office staff that was pushing for us rather than pushing paper or the electronic equivalent.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/17/14

There was a great response to last week’s Curbside Consult and my mention of the therapeutic powers of baking. Despite everything going on at the office, it ended up being a fairly low-key week, so the only things coming out of my kitchen were a pan of brownies and a batch of banana bread.

(I admit I played a little bit of the Mad Scientist game with the banana bread. Although it was good, it wasn’t significantly better than the original recipe, so maybe I’ll stop trying to mess with perfection.)

We made a fair amount of progress in our due diligence efforts around bringing the patient records from the practice we acquired onto our system. Although some people might find it boring, I actually enjoy rolling up my sleeves and digging in. It’s predictable work in some regards.

Our DBAs started looking at their system’s data structure to identify how many custom fields they are using compared to a vanilla version of the software. Some of our EHR analysts started looking at the actual user screens to identify custom fields from that perspective as well as to begin diagramming the workflow they’ve built in the EHR.

We’ll send people on site and work with their training team to determine whether the EHR workflow matches how they operate in the practices or if this is an opportunity to retire any custom elements that aren’t actually working in the field. I’ve seen plenty of instances where physicians have customized their systems to the point where efficiencies are lost. This tends to happen more when users don’t have adequate training or don’t agree with the design intent of the software.

Where there are customizations in the workflow, we’ll also do some statistical analysis to look at how many times custom fields are actually used. Just because they were built doesn’t mean anyone uses them regularly.

Our medical group has grown substantially over the last few years. Given the number of physicians who currently use an EHR, we’ve had to do a fair number of conversions. Some of them are simple, especially when the source EHR is fairly primitive or doesn’t have a robust data structure. In those situations, we might convert the patient notes to PDF files and bring them in as if they were scanned documents. It doesn’t give us a lot of discrete data, but in some regards it may be safer than trying to map imprecise data.

I’ve seen systems that don’t use any kind of formatting on data fields (such as restricting blood pressure entries to numbers only) that lead to garbage in the record. In those situations, I typically sit down with the physician and explain the choices: we can either bring the data as images (akin to scanning a paper chart as far as patient safety is concerned) or we can spend a lot of time and money trying to map it. In the latter scenario, they will need to sign off on any corrections.

Most physicians who hear about the time commitment for mapping data run shrieking out of my office and I never hear from them again until I see their signature on the checklist approving the test extract that’s been pulled into the imaging system. Those who aren’t scared off by the time commitment are usually scared off by the budget, which our medical group usually isn’t very keen on funding.

I’m surprised (at least at some level) but the number of physicians who realize they have dirty data but don’t do anything about it. They see the typo’d letters in the BP fields and authenticate their notes anyway rather than talking with their staff about data accuracy. Very few have thought to talk to their vendors about why the system even allows typing of letters into a BP field.

I guess I shouldn’t be that surprised, because I’ve seen even wackier things in the paper world, such as subspecialists who had their staff stamp consult letters with nonsense like, “Dictated but not read; signed by secretary to expedite.” Someone who is OK with that probably doesn’t care about potentially erroneous data in their notes.

So far, the potential conversion doesn’t look that bad from a technical perspective. Although there is a fair amount of customization, it’s not being used extensively. In fact, overall use of the EHR is pretty light. From a change management perspective, though, that’s pretty ominous, especially since our group requires significant commitment to documentation via discrete data. We’ll have our work cut out for us in helping them truly adopt EHR as well as in helping them adapt to our culture.

I almost wish the technical aspects of the conversion were more daunting because I could use that to buy more time with the powers that be. Our analysts still have a bit of digging to do and the workflow teams will find plenty of issues when they go on site, but I’m not sure we’ll have as much time to formulate an effective plan as I’d like. We’ll have to see how things unfold.

Regardless of what we find, I know we won’t have anywhere near as much budget as we need to do our best. We’re pretty good at delivering the impossible, though, so I’m hopeful. And when all hope is gone, there will always be pastry.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/10/14

This week was the beginning of what I suspect will be a long and painful project at work. If I wanted to deal with mergers and acquisitions, I would have gone to business school. Instead, I went into medical school, but nevertheless here I am.

Like so many other health systems across the US, mine has been in growth mode. We were accelerating the growth of our employed medical group going back as far as 2008. The push towards more tightly integrated delivery systems has only added fuel to the fire.

We had previously been purchasing groups in the three- to 10-physician practice space, with a couple of outliers that had 15 or so physicians. Now we’ve gone and purchased a 75-physician group. I’m sure it looked great to the hospitals as a way to further consolidate their referral bases. It was also a grab for the revenue that the new group’s imaging division was bringing in on the side.

I had the opportunity to speak with a few of their physician leaders in a couple of weeks ago. My ears perked up when they mentioned one upside of being part of our health system as “better support with IT projects including Meaningful Use and PQRS.”

Red lights started flashing in my head and alarms were going off. Thinking that PQRS or Meaningful Use are “IT projects” is like thinking that a heart/lung transplant is a “plumbing project.”

I immediately scheduled a series of meetings with their leadership and IT teams and our counterparts to figure out what had been promised by the C-suite and how we were going to deliver it. It’s bad enough to have to deal with a culture shift, but when technology and millions of dollars in incentives are involved, the problem is magnified. Our C-suite has a track record of promising technology projects that they can’t deliver (such as a complete EHR conversion in 30 days) so we quickly formed a betting pool to entertain just how bad this might get.

One of the reasons they get us into these kinds of binds is they’re afraid to involve too many people in the acquisitions. They fear that other physicians will get word of them and become demanding or that there will be a loss of bargaining power if it’s public too early. I understand that, but I also understand the need to do due diligence around merging or converting IT systems before the promises are made and the papers are signed.

Every once in a while, one of the VPs will ask someone from IT to “look under the hood” at an acquisition target, but it’s usually more along the lines of valuing their hardware, calculating their maintenance, and figuring out how to connect them to the hospital backbone than it is to assessing the quality of their data and how well their workflows and care gel with our existing best practices.

Unfortunately, the ink was already dry before I knew about it. Our group president made some assumptions that since our target was on the same EHR as we are that it should be fairly easy to just “throw them on our system and have them attest with our docs.” Oh, so much easier said then done, my friend. When I started throwing out reasons why it doesn’t really work that way, he actually referred to me as Debbie Downer and reminded me that we have to make it work because we already said we would.

I can’t believe that’s what passes for leadership these days, but our health system seems to love this guy. He’s personable and kind of a teddy bear, but he’s generally all fluff and no stuff, which leaves the rest of us to scramble around behind him to try to make things work.

This week began the series of meetings to try to figure out how to deliver the impossible. We now have two installations of the EHR to deal with. Their group has a lot of primary care docs that refer to our specialists. Given the number of common patients between the platforms, I’m not confident of being able to do a clean conversion without a lot of data integrity issues and a substantial commitment for clinical cleanup even if we had a nice long time interval. That’s problem number one.

Problem number two is that both installations have to take a major upgrade before we start the attestation period for Meaningful Use on July 1. Leadership assumed we could combine the systems quickly and do a single upgrade, but in addition to the patient issue, we also have a fair amount of customization and client-specific configuration on each system that will have to be evaluated. We can’t just throw it all away and assume physicians will be immediately facile on a plain vanilla system.

We also have the issue that at least 40 of their providers are going to be attesting for MU the first time. That means that not only do we have to get their upgrade live early enough prior to July 1 that the users have enough time to burn in the new workflows and make sure they’re entering quality data, but we need to plan to have our MU and auditing teams work around the clock at the end of the quarter so we can attest for them by the deadline. Problem number three.

Let’s see, the end of that quarter also puts us at October 1, which is ICD-10 go-time. That makes problem number four.

Let’s back up a little, though. If they’re such a solid, established group, I wonder why more than half of them are just now going after MU Stage 1? That was the topic of Wednesday’s half-day working session, when I really dug into the fact that they think MU, PQRS, and other quality initiatives are IT projects. That’s when I came up with problem number five, which unfortunately is the biggest one of all. The reason they haven’t attested yet is they’ve been attempting to have IT lead all these projects without adequate operational and clinical support.

They seriously think that there is some kind of magical IT wand that will be waved around and the physicians will do what they are asked along with all the support staff. They have zero physician alignment strategy. Physicians have no financial skin in the game for MU or any of the other incentive programs. They don’t even have a standard physician contract. All the physicians have been able to negotiate their own deals even those in the same physical location. That makes it a little tricky when partners are able to earn the same income seeing dramatically different numbers of patients per month.

The IT team listed off more than a dozen resentful bitter physician disagreements without even taking a breath. At least all of our physicians were migrated to a common contract in tandem with our EHR project more than half a decade ago because we realized only money would align them with our goals. These folks (including the one operations person that bothered to show up at the meeting) acted like they have never heard such a thing.

Their staffing ratios are also a mess. Everyone has the same number of support staff regardless of specialty, productivity, or how they run their offices. There is no common scheduling methodology across their locations, which adds another worry of how we’ll do an appointment conversion if we decide to do one when we move them to our database. No wonder they were ripe for the picking — they were undoubtedly losing money with how they were running. By the end of the meeting, I was scarfing down Advil like they were the green M&Ms in Inga’s Quipstar dressing room at HIMSS.

I spent most of Friday with my trusted lieutenants trying to figure out how we’re going to do this and still preserve our sanity and keep our team intact. After looking at all the pros and cons, I think I’m going to be lucky to make it through the next two quarters without losing my own mind or quitting my job. My liver can’t take as many martinis as I think I’ll need to get through the inevitable goat rodeo this will become, so I figured it was time to find a less-harmful way to self-medicate.

My drug of choice: pastry. This week’s offering is pictured at top. I’m a big fan of doing things old-school so I can let out my stress cutting the butter into the flour by hand as I pursue the perfect crust. I can release my creative energies by trying different fillings. If I really need to escape, I can do decorative top crusts or make little designs with dough cutouts.

I may not be able to make this project work, but I’m armed and dangerous where an egg wash is concerned. I’m going to go all Martha Stewart in my free time, just without the insider trading or the prison term.

Got a recommendation for pastry therapy? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/3/14

HIMSS Wrap Up

Every year at HIMSS there’s too much going on and not enough time to write about it. We try to hit as many booths as possible while attempting to attend some educational sessions as well, but there just aren’t enough hours to do it all. I had several sheets of notes in my bag, so please bear with my somewhat rambling wrap up.

Someone reached out to me over the weekend to follow up and share photos of the Verisk Health service project benefitting the Second Harvest Food Bank. I had mentioned last week about seeing the  woman in the carrot costume at the Phytel booth and didn’t realize that Verisk Health was the main sponsor. They ended up with over 250 HIMSS participants who prepared 4,100 food packs for kids. Thanks to those who turned out to help. They are planning to host similar events at AHIP and NHCAA, so if you’re attending either of those events, keep an eye out for the location and time. Thanks to Verisk Health for sponsoring HIStalk as well – I hope they keep me posted on future events so I can alert our  readers.

Several vendors were showing off their “big data” but weren’t ready to address the “big questions” that come with it. Having dealt with numerous EHR conversions, I’m keenly aware of the sheer magnitude of bad data out there. Those aggregating it tend to assume that the data they’re getting is good. I really pushed one of the major national vendors on how they handle data integrity and the answers were less than satisfactory. I could tell they understood the problem because they provided the example of allergy data where one vendor has separate fields for the allergy and the reaction and another vendor combines them. The rep wasn’t able to explain how they’re handling it even though they were displaying a patient chart that showed allergy data from both sources. I asked for a follow up contact, but I’m not holding my breath.

CHADIS (Child Health & Development Interactive System) is a vendor I wish I’d come across earlier. We have struggled with implementing our patient portal for pediatric patients due to privacy issues, and ultimately our health system placed it on hold. Their product is tailored to the pediatric population with online screening that covers all the Bright Future requirements. They also somehow managed to obtain permission to use most of the popular pediatric developmental screeners. That doesn’t sound like a big deal, but knowing that my vendor has struggled for years to try to obtain permission to use one particular screener, it’s pretty exciting to those of us that see children in practice. CHADIS includes a research database and is interoperable with many EHRs, so I’ll be checking them out in more detail.

After Mr. H mentioned he was having difficulty finding note pads, I had my eye out for them. I spotted a handy notebook at the Accretive Health booth. The gentlemen manning the booth (which was on the fringes of the exhibit hall) at the end of the day were very engaging. One of them was leadership development author Ken Jennings, who was happy to chat about his book The Greater Goal and send me home with a copy as well. I noticed his Air Force Academy ring and we talked about the difference between a military education and a civilian one. The teenager who mows my lawn wants to attend the Academy and he was kind enough to offer himself as a resource. Those little moments where we can connect as people (and not just as vendor/prospect), especially after a long day, are one of the things I look forward to at meetings.

There were several people I wanted to connect with and missed, including Jonathan Handler, CMIO at MModal. Since he was in the board review course I attended, I was planning to ask his thoughts on what the vendor space thinks about the Clinical Informatics certification. My employer refused to pay for me to take the exam (they barely gave me the day off to sit for it) and I wonder if vendors are more generous. If they have certified informaticists on board and are using that for marketing purposes, they ought to!

I wanted to mention a little more about the educational session I attended on Monday: “Converting Your Legal Medical Record – It’s Both Technology and Process.” I’m glad I arrived early because I had some time to look through the printed HIMSS pocket guide to figure out the lay of the land and do some last-minute exhibit hall planning. I was looking for the location of the press room and noted that HIMSS had a designated “Nursing Room.” I thought that was pretty progressive until I noticed it was in the same location as the designated “Prayer Room.” What were they thinking?

Back to the educational session, the presenters were from Main Line Health (which was converting their hospital system) and Leidos Health, which assisted in the effort. They did a great job with the presentation despite some technical difficulties and had a good sense of humor about it. Having lived through multiple conversion projects, I can say that their advice was spot-on. They admitted they wish they could have started earlier and spent more time documenting the current state and figuring out how that was going to impact the new system.

They talked about building their clinical crosswalk and how they planned to handle the audit trails once the legacy system was decommissioned. They had a great statement about organizational resistance: during early meetings, they spent 50 percent of the time mourning the loss of the old system and the remainder doing actual work. I’ve been to a lot of meetings like that. If only the attendees realized that no amount of begging or pleading is going to bring an old system back once it’s been marked for death, we could be so much more productive.

They shared great examples of what to look out for in system conversions. The legacy system changed physician ID numbers, which created problems with providers showing up as “unknown physician” after the test extraction. Scope creep was a major issue, but many of the expanding requirements involved patient safety or risk elements which had to be considered at some level. They also emphasized the need to have two willing vendors and lamented the lack of an industry best practice in how to approach these projects. They interviewed a variety of consultants prior to the project and received many opinions on the best way to proceed.

One aspect of their conversion is (thankfully) something I haven’t had to experience yet. They found that when the conversion was announced, many of the staff responsible for the legacy system pursued employment elsewhere. There was a tremendous loss of institutional knowledge around the legacy system and they had to add retention bonuses to keep them on board through the knowledge transfer. I can’t imagine what my last two conversions would have been like if I lost key staffers. They also got lucky when their go-live was delayed by another project, which resulted in an extra six months for converting data. They’re still extracting as we speak, but I’m sure that gave them a bit of a cushion. They plan to go live with six years’ worth of hospital data, which is a tremendous amount.

I snuck out during the question and answer period so I could make it to my next meeting (the fact that the audience didn’t want to come to the microphone to ask their questions was definitely a contributing factor) and get the the exhibit hall when it opened. The rest of HIMSS was a blur and I’m still trying to get caught up. I found this politically incorrect squeezy stress thing in my bag when I got back. I saw them at the Hitachi booth but didn’t pick one up, so I suspect one of the folks I was roaming the hall with was trying to be funny. I’m sure if I put it on my desk at work I’d be summoned to HR before you can say “harassment.”

I did have one nice surprise this weekend – my Clinical Informatics certificate has arrived! All my certificates are in matching frames (courtesy of my first employer who actually had a budget for that sort of thing) so I hope I can find something that is close or at least complimentary. On the other hand, maybe I’ll go completely wild and frame it in animal print or something unusual. That would definitely start some conversations when people weave their way through Finance and Compliance to make it to my office.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/17/14

Across medical specialties, there’s a little bit of an “us vs. them” mentality when you look at physicians who use their minds more than their hands. We refer to it as cognitive specialties vs. procedural specialties. 

If you guessed that the proceduralists make more money, you’re right. Those of us on the cognitive side of the equation, which includes primary care, worry about keeping our minds sharp as much as surgeons worry about their hands.

Like cognitive physicians, many of us in health IT make a living with our brains and are under a great deal of stress. Sometimes it feels like we’re losing our minds when we have to try to figure out how to accomplish everything that needs to be done on limited budgets.

In doing psychiatry and neurology rotations, I always wondered whether people who are having brain disorders know that something is going wrong or whether things seem OK to them. When I feel unfocused, can’t sleep, and can’t concentrate, I wonder if something sinister is going on or if it’s just stress. I wonder too how many people realize I’m not on my “A Game” when that happens.

I’m excited about the potential for genomics and personalized medicine to be able to predict future illness on an individual basis. The idea of being able to prevent disease at the molecular level or to design targeted treatments after it already occurs is appealing. On the other hand, I’m not sure I’d want to know about conditions that might not be curable. It’s a double-edged sword.

It turns out that Big Data might be able to provide some advance warning at least for those of us who are writers. NPR recently re-ran a story from 2010 about an English professor at the University of Toronto who came up with an interesting way to bring literature and medicine together.

Ian Lancashire has been gathering Big Data on authors, looking at the number of words in their texts and the volume of usage. He tries to identify patterns that help him understand the author’s thought process.

Recently, he took on the work of Agatha Christie. He used computer analysis to review 16 books written over half a decade. He found that in one of her later novels, her word usage changed. The number of unique words decreased by 20 percent. Certain types of words increased in number. His conclusion: Alzheimer’s may have been responsible for the change.

He worked with others (including linguists, pathologists, and statistical experts) to review the work before publication. Although she was never diagnosed, she may have exhibited signs and symptoms of dementia by report. Interestingly, the book where the changes were noted is called Elephants Can Remember and is about a novelist experiencing memory loss.

According to the NPR piece, other Alzheimer’s research also indicates that patterns in writing can help identify those that may develop the disease. A study done with the School Sisters of Notre Dame looked at memory and aging. The sisters also allowed pathology review of brain samples after death. Researcher David Snowdon found writing samples (the sisters’ essays written when they joined the community) and analyzed them.

Those samples with higher “idea density” seemed to be less predictive of dementia than those with lower idea density. It certainly doesn’t prove a cause and effect relationship, but only an association. I wonder what it would look like if we did an analysis of the writings of the HIStalk team? How concordant would our “day job” work be with that written by our HIStalk personas? Would researchers be able to pick out those weeks when our real-world IT departments were crashing and burning around us? Could they identify the pieces we secretly wrote from the beach or other points unknown?

Some of the discussion after the broadcast centered on the large volume of digital communications that we now create each day. Could our employers mine our emails and instant messages to determine whether we are exhibiting symptoms of mental instability? Are we more depressed by failed projects and untenable initiatives than we should be? Does the level of anxiety among analysts predict whether one go live will be more successful than another?

Looking at my Sent Items folder, I’d be scared to have my work analyzed. It’s likely to show symptoms of multiple personality disorder as I have to play games with various providers to get them to comply with organizational initiatives. Throw in some crisis of identity with all the different hats I have to wear (often at the same time) and it could get really interesting.

What do you think your writing says about you? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/10/14

I’ve made some really good friends in health IT over the last couple of years. One of them shared a great story from a recent get-together he hosted. It made me chuckle enough to want to share it.

We had another family over for a the Super Bowl last week, which was really just a kid-friendly play date and some chatting as the game was awful and the adults were slap-happy from being snowed in with their kids for the last several days. 

“So I am thinking about interviewing for for the new chief medical information officer job at the hospital" said one of the docs, who is a hospital-based physician.

"You mean informatics, right?" said the pernicious techie, cringing at yet another sentence starting with “so.”

"Yeah, sure. So that would be exciting. I am just afraid of being the complaint desk for all Vendor issues. Do you think there is a way to integrate Vendor A and Vendor B?" he said, looking at me, even though the two other adults (which makes three out of four) are employed physicians at the same hospital.

"You can integrate any two things, but the question I would ask is, ‘What things do you feel need to be concatenated for the benefit of patient care and physician happiness?’ since just combining data recklessly can be worse than what you currently have," said the now aghast techie, who wonders whether current employees are being paid to interview for positions they are unqualified for.

"Well, it is a part-time job and I think it would be cool to help improve workflow at the hospital," said the hospitalist.

"Sure, I mean, great. It is really progressive for the hospital to go after a CMIO position. I mean, for them, this is big stuff. I have some friends who are CMIOs that maybe you can speak to. One even finished her sub-specialty Boards recently. The other is an ER doc, but he also has a degree in computer science."

My friend concluded that there is a significant gap between what needs to happen in clinical informatics and what will likely happen. I see this more often than I would like.

I recently helped a local hospital craft a job description for a CMIO-type position. Like many others, they refuse to call it what it is, and instead are hiring for a “Medical Director of Informatics – Ambulatory.” The job description looked good and they posted it. I was shocked when they immediately narrowed the field down to two in-house candidates, both of whom are hospitalists with virtually no ambulatory experience.

Only one had any formal informatics training and that was a three-day continuing education course focusing on public health informatics. The hospital has over 150 employed ambulatory physicians and I was surprised that none of them made the short list. They have been on EHR for half a decade and have a handful of strong physician champions who would have been great in the role. I’m sure there are other political factors at play, but I can’t imagine what they would be that the organization would risk going with an unproven commodity with minimal experience.

My friend had the same sentiment about his party guest. “Why would a hospital that has invested over $20 million in the past five years in inpatient and outpatient technology, keeps buying up practices, and is undergoing a shift to PCMH & ACO across the board leave its CMIO position up to people who have absolutely no idea what they could do, should do, or can do in that role? When do we accept that the needle won’t be moved very far in improving any of the triple-aim’s intended targets?”

Since it was Super Bowl Sunday, he drew the analogy that it is similar to thinking that a baseball player is also a good ping-pong player because they are both sports. I agree with his conclusion that this is a problem for physicians who lack real representation in technology and for administrators who are clueless to the practical requirements of IT in their environments.

I’ve seen a couple of articles recently on the importance of developing effective leadership in healthcare organizations. Leaders need to not only be confident and inspiring, but they also need to know the material at hand. That’s difficult to do when you’ve never practiced in the environment you’re trying to lead. I’m not saying you can’t learn it, but starting in a position where the deck is stacked against you is a challenge.

Let’s suppose my local hospital chooses to hire one of the hospitalist candidates. He is being set up to fail, as the employed physicians will immediately claim that his lack of ambulatory experience makes him unqualified. Even as a practicing outpatient physician, my first physician champion role led to claims I was inadequate because I didn’t see as many patients as my peers or my patients weren’t as sick as theirs. I can’t imagine what it would be like to be thrust on the scene as a hospitalist.

My initial advice for this physician who thinks that part-time informatics work might be “cool” would be to dig deeper into the job description and determine areas of strength and weakness. Even though this physician would be just beginning his informatics career and therefore would not be eligible to sit for the Clinical Informatics board exam, I would encourage him to attend the AMIA board review course, as it is does a great job illustrating the breadth of material that falls into our realm. He could also choose one of their 10×10 courses to dig further into areas where his employer wants him to focus.

Should he actually be offered the job, I would recommend pushing to have these kinds of courses paid for as part of the informatics role, as well as dedicated time for continuing medical education (CME). When I took my first informatics post (part-time), I was able to use standard physician continuing ed hours and funds to accomplish this. However, when I went full time, that week of CME time and the money that went with it vanished in their initial offer and had to be negotiated back into the agreement.

It was good catching up with my friend. I usually see him at HIMSS but he’ll miss it this year unfortunately. He did have some good advice for me, however, in response to my recent question about how administrative physicians decide whether it’s time to give up practice:

You asked if you should give up treating patients recently. My advice: no, you should not stop treating patients. You should instead redefine who your patients are. No longer should you spend time with booboos and flu shots and diabetes. You should now look at the sick hospitals, clinics, and IPNs (there are still some out there) that really need a checkup, a care plan, and an intervention. Your patients are out there and your patients are very ill. They may even compensate you, and like the great feeling you get when you catch appendicitis early, you will change the health of your patients in ways we will benefit from for years to come.

I really appreciate the pep talk and have to say it came just at the right time. Listening to his story, I remember what it was like being a fledgling informaticist. It makes me want to go out and win one for the Gipper.

Have a health IT pep talk to share? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/3/14

News is always pretty slow leading up to HIMSS, but I’m pleased to see things are picking up a little. We learned over the past couple of days that Apple leadership met with the Food and Drug Administration to talk about mobile medical apps. Rumor has it that Apple is working on a health-monitoring smart watch. Insiders are debating whether this was a fact-finding mission or a mission to try to push an existing application through the process.

Neither Apple nor the FDA have responded to comments as far as I can tell, but the news just broke on Friday, so there’s still time. We’ve heard the iWatch rumor before from a couple of different angles. Reports last year covered the announcement by Corning Glass Technologies that it had created bendable glass. Other companies have developed Bluetooth watches. Most speculate that the watch will link to an iPhone and will run iOS. Some sources have the number of product developers working on the project at more than 100.

Apple better get it in gear because the recent patent agreement between Google and Samsung might make Android devices more competitive. There are already several on the market. Having the companies play together nicely rather than litigate each other to death will put an interesting spin on things. Samsung also struck a licensing deal with Ericsson that addresses patent issues with GSM, UMTS, and LTE standards for both networks and devices.

As I’ve mentioned before, I’m interested in wearables, but they have to look good. After years on the wards and in the emergency department, I finally gave up my waterproof dive watch for something more grown up looking. Even if it was cool, I don’t think I’d want to wear something that looks like I’ve strapped an iPod Nano to my wrist. I don’t want to look like an old Dick Tracy cartoon. Most of the current offerings fall into that category.

Hot news this week, though, is that there will be new offerings for Google Glass including prescription-ready frames and detachable sunglasses. They’ve also partnered with eye health insurer VSP to train eye care providers how to fit the device and attach it to frames. I might consider trying if it I could get it mounted on my own sassy frames rather than the relatively sci-fi looking standard Google Glass platform.

Speaking of less-fashionable tech, it may not look glamorous but I’m intrigued by Fin, which is a ring-like accessory worn on the thumb to capture gestures meant to control phones, radios, TVs, and other Bluetooth-enabled devices. It reminds me of vintage Bakelite jewelry. I’m not opposed to wearing something a little more towards the geeky side if it’s not intended to replace a “normal” accessory.

A photo on the Fin site showed a child wearing it as a substitute for a gaming joystick. That got me interested in the potential for wearables for children. One interesting device that was shown at the Consumer Electronics Show was Sensible Baby’s SmartOne real-time sleep monitor, which can relay information on a baby’s temperature, sleep position, and movement to a smartphone or tablet. Alerts can be customized for the infant’s developmental stage. Unfortunately, the product’s blog features a photo of a man watching a baby sleeping on his stomach, which flies in the face of current medical advice that babies should be put to sleep on their backs.

I think my favorite wearable tech of the week is June, a monitor for ultraviolet exposure. It can be worn on a bracelet or attached to clothes or other accessories. It ties to a smartphone app and alerts the wearer when a particular UV exposure threshold is reached. I’ve been devoted to my SPF 70 for years because I have a fine line between being ghostly pale and turning into a lobster. If it’s released before summer, I’d consider giving it a try.

What’s your favorite wearable tech? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/27/14

To practice or not to practice, that is the question. Among the other CMIOs I talk with regularly, it’s a nearly 50-50 split as to whether they continue to actively practice medicine or not.

For some of them, the decision was made based on factors related to medical specialty. Others gave up licensure when they pursued administrative work and found it too difficult to go back. Some chose informatics as a way to escape patient care. But it’s not always straightforward. It seems that those of us who are earlier in our careers are more apt to try to continue seeing patients, with those in the primary care disciplines hanging on longer than others.

I’ve been lucky because my EHR background has given me experience with multiple vendor systems. This allows me to work as a locum tenens physician and fill in for a week here or there in a traditional family medicine practice. Seeing how different practices function is interesting and I often get ideas for performance improvement projects or bring back tips and tricks that can help my providers.

I’ve also worked for the last several years in various emergency departments and urgent cares. Although I do a fair amount of “real” emergency medicine, it’s mostly the same kind of conditions that I’m used to handling in the family medicine office.

I try to work consistently, but it has been more and more difficult to find opportunities that will work with my ever-expanding CMIO work. My “day job” is full time and my hospital doesn’t provide much accommodation for my clinical work. Now that we’re in the throes of Meaningful Use and preparation for ICD-10, it seems like there isn’t enough time to do anything else.

During the last six to eight months, one of the hospitals where I worked has closed their fast track area in the emergency department. Another replaced all the part-time physicians with nurse practitioners and physician assistants. I took some time off while I was preparing for informatics boards and that impacted my seniority on the scheduling board at my remaining facility, which has made it harder to get back in the rotation.

Continuing clinical work doesn’t yield a lot of income compared to the cost of being an independent contractor. Although I don’t pay for professional liability insurance, there are many other costs: board recertification, maintenance of certification, state licensure, Drug Enforcement Agency registration, state drug enforcement registration, hospital medical staff dues, hospital recredentialing fees, and more. There’s also the cost of professional society memberships and continuing medical education.

Continuing education has been a thorn in my side the last couple of months. For emergency department work, I have to maintain certifications in basic, pediatric, advanced cardiac, and advanced trauma life support. They’re all due this spring, and trying to work them in with everything else that is going on has been enough to make me think twice about seeing patients. Thank goodness I finally got to stop maintaining the obstetric life support credential because I’m not entirely sure I’d be able to fit it in.

For most of the classes, I’ve been able to find programs that offer at least part of the course online, although all of them require a practical component. Some are sponsored by national organizations and others are modules that have been purchased by one hospital or another. I figured doing them online would give me more flexibility but I’m not sure it’s doing much good. The differences in quality are tremendous. When I compare it to what we’ve been trying to achieve with e-Learning for our EHR program, it’s even more striking. Some of the “e-Learning” is little more than written textbook sections punctuated by the occasional embedded video.

They vary greatly in the length of the modules and whether users can pause at any time or only at pre-defined points in the course. One of them was so restrictive that I might have been better off using a vacation day and attending an all-day course rather than trying to fit it in as time permitted. The cost of the courses is the same as what I have paid in the past for in-person courses except for the basic life support. It used to be free when our hospital education department offered it, but now that it’s offered online by a third party, we have to pay for it.

Despite being an attending physician, I couldn’t even register for the class until my check cleared. Rumor has it that employees have to sign up months in advance so a purchase order can be processed and a check delivered. Another negative is the lack of interaction with colleagues. I enjoyed meeting nurses, patient care techs, therapists, and other colleagues during the classes even if it was just for some chit-chat over lunch or a break. I know the hospital is saving money with the online classes because they require staff to complete them during non-working hours; previously, hourly staff members were paid for attending class.

I’m starting to feel like this might be the last time I do this. Although I enjoy seeing patients, it’s getting harder to manage. There are many things competing for what’s left of my free time after I leave the office. I’m thinking about exploring volunteer opportunities where I could use my healthcare skills but where there would be less overhead than I currently have trying to maintain half a dozen certifications.

I’d be interested to hear from other CMIOs whether they’ve hit this point in their careers and what they decided. Is there a right time to hang up the white coat? How do you know? Have any creative ideas for trying to do it all? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/20/14

Last week, Mr. H polled his HIStalk Advisory Panel regarding their top priorities and concerns for 2014. I laughed out loud at the response above. Not only is it extremely direct, but in the case of my hospital, it’s entirely true.

Like many facilities, we spend a lot of time going through various exercises to define the various projects we need to work on during the year. We also expend a great deal of effort reviewing our personnel and their capabilities while we determine the overall capacity for work.

I looked back at our timekeeping system, and during 2013, I spent nearly 100 hours in various project evaluation and prioritization efforts. That doesn’t include the time spent looking at team members and whether or not they can take on additional projects. At most of those meetings, there were between six and 12 attendees, so that means we spent close to half a person-year trying to figure out what we need to work on and in what order.

We have over 100 prioritized projects on our ‘to do’ list. Being “prioritized” means that a project fits certain business criteria. For example, it might be in support of our Accountable Care or patient outreach efforts. It might be a process improvement project which requires modification of existing systems or addition of a new system. It might even be something that enhances the user experience or the overall usability of an application. Bring prioritized, however, does not mean that a project is funded.

There are a lot of things on the list that the requestors believe we need to do, but are not willing to commit funds to actually accomplishing. They want us to find funding out of some nebulous IT pot of gold which simply doesn’t exist. Because these projects aren’t funded it means they languish on the prioritization list, which adds to everyone’s frustration. The IT department feels like it can’t ever move things off the list and our departmental customers feel like the IT department doesn’t do anything.

When a project is actually funded, we can knock them out pretty quickly. For example, one of our outreach clinics recently applied for and received grant money for a very specific clinical reporting project. The requested a suite of reports and a dashboard for monitoring. We created a proposal and they approved it. The IT chargeback item was opened and the scope document created and finalized. We had their dashboard live in beta in under 30 days and in production a week or two after that. We probably could have done it faster, but there were some delays with accounting and paperwork and we’ve learned the hard way not to start anything until all the paperwork is in place.

Looking at the actual IT discretionary budget that we have to work with, it’s going to be nearly impossible for us to do anything that isn’t MU-2 or ICD-10 related. If it’s not regulatory, it’s not going to happen unless D.B. Cooper drops a mysterious bag of cash from the sky. We have enough in the budget to handle various hardware and infrastructure upgrades so we can stay ahead of the vendor requirements game.

Like many other hospitals, we’re struggling with the fact that our vendors aren’t delivering the MU-2 and ICD-10 software as quickly as we want it. I hope what we ultimately receive is high quality because we can’t afford endless rounds of testing or delays when what we receive requires patch upon patch. We need to get the MU software in so we can free up the environments for ICD-10 testing. If there are delays, we can’t afford to stand up extra testing environments to handle what the vendors should have taken care of during beta testing.

At least our ambulatory vendor has delivered its software package, which includes both MU-2 and ICD-10. We’ve got it in testing and it looks pretty solid, but there are a couple of fixes we’re waiting for that are fairly specific to our environment. We should have them in the next week and then the real fun will begin. Our physicians are very nervous about the ICD-10 transition and we’re using a third-party vendor to augment the mapping provided by our vendor, but that’s one more thing we’ll have to test.

We’re only a couple of weeks into the year, but I already need a vacation. We plan to attest for MU-2 in the third quarter so we can coast towards ICD-10, but I doubt it will be a smooth ride. In the mean time, we’ll be on-boarding new practices and adding several dozen physicians to existing practices. I think I’m going to need roller skates. If you’re a CMIO what are your priorities for the year? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/13/14

This is the last of a three-part response to a reader’s comments on EHRs (Part 1, Part 2.)

What is meaningful for the government is not meaningful for the patient. We sacrifice good care so the government can collect statistical data for free.

I’ve written on this topic before. It’s easy to play armchair quarterback and to dissect things through the retrospectoscope. Surely parts of the program might be different if the creators had it to do over again. I personally don’t like to be penalized for poor outcomes. It doesn’t matter how motivationally I interview, how well I design care plans, how well my team works with the patient, etc. – sometimes patients simply don’t want to do the right things for their health. Sometimes they are genetically doomed regardless of what we do. Sometimes they can’t afford to do the things we recommend, or choose to prioritize other needs or wants.

Most physicians are genuinely motivated to help people live longer, healthier lives (sometimes to the detriment of quality of life, but that’s another topic for another day) and are personally burdened when we can’t make someone better. Adding financial penalties for things which are not entirely under our control is offensive to those of us who work our tails off trying to do the right thing.

You want to ding me for failing to put someone with proteinuria on an ACE inhibitor or an angiotensin receptor blocker? Fine, I deserve it. You want me paid less because I write bad prescriptions that no one can read? Great. But don’t penalize me because Uncle Sal won’t get a colonoscopy despite a decade of counseling, discussion, debate, and downright begging. I’ve done all I can do.

As far as the “free” factor, technically we’re being compensated for our data through the various quality reporting initiatives, as well as through MU, so saying we’re giving it away for free may not be entirely accurate. Most of the clinical quality metrics revolve around good care, so it’s hard to argue that quality is sacrificed. But I respect the comment.

I’m generally not a fan of the conspiracy theories, but I wonder if the government wants to slow us down so they pay for less visits and care? We’ll never know the truth, but what better way to slow us down than Meaningful Use?

I admit I’ve had this thought before. Nationally, many physicians are refusing to accept Medicare, refusing new patients, or limiting their panel sizes, but it depends on your market. We have a lot of people that limit Medicare in our region because other insurers pay better and there’s plenty of demand, but that’s not the case everywhere. There are plenty of markets where Medicare is the top payer and physicians can’t afford to stop participating. The same applies to Medicaid. Several of my blogger friends hypothesize that it’s a ploy to get rid of primary care physicians and replace us with midlevel providers who are cheaper.

On the other hand, in our organization (and many others) we’ve figured out ways to comply with Meaningful Use and not slow down. This involves some extra clinical staff (funded by increased office visits and clinical quality payments as well as crafty negotiations with payers to embed care managers in our group) and a ton of additional training, but we’re generally still seeing the same number of office visits as we have. There have been fluctuations due to the recession when you look at our five-year vs. 10-year data, but most providers still have capacity to expand and we’re still hiring physicians.

I love computers and believe in the EHR concept, but it has to be done right. I’ve yet to see a good EHR. Computers are not smart machines. They are very fast and very loyal to the programmer. The main problem with EHR design sits in the knowledge and experience of the designers, who are:

a) Programmers without medical knowledge

b) Physicians without programming knowledge

c) Reputable professors with lots of published papers without ward clinical experience

d) Physicians who have graduated medical informatics programs but without clinical knowledge

e) Physicians who have clinical experience and some programming knowledge

f) Good physicians with good programming knowledge, which is ideal, but I don’t know if there are any involved in EHR design at this time

I saved this comment for last because it’s my favorite and the most near and dear to me. Although the gulf is closing, there are still significant gaps between clinical needs and programmers. It’s a challenge for vendors to hire people who can translate a physician business case into something the programmers can address, and to translate the limitations of the product into something to which users can respond.

Although there are some good physicians out there who have formal informatics training but minimal clinical experience, I’m always leery of them. When I meet one who didn’t complete an internship and never had a license, that’s a red flag for me. Whether justified or not, I feel that completing an internship and having had an actual medical license at least once in your career is essential. It’s even more essential when you’re going to be in a role where you tell other physicians how to behave.

Having been board certified at least once is nice too. You don’t have to keep your license forever and I don’t care if you maintain your board certification, but I want you to have gone through what the rest of us have gone through just as a point of understanding.

I’d also add another element – product management teams that respond to sales feedback preferentially over the feedback of existing users. Those who haven’t purchased an EHR don’t know what they don’t know, where current users definitely know what bites them on the posterior every day. I’ve seen good products decline when prospects demand functionality that although sexy isn’t built for the long haul.

As a farm girl, I think about it like I think about buying a truck. Although the quad cab with heated and air conditioned leather seats and a bus-load of chrome looks really good to someone who’s not a farmer, it’s kind of silly when you think about the fact that you’re going to be climbing into it with mud on your jeans and manure on your boots. When the motor on the power window dies, I’m going to be wishing I had a crank because I’ll be roasting to death driving while the younger cousins throw hay bales on the trailer.

Regarding the lack of good physicians with programming knowledge being involved in EHR design – as recently as three to five years ago I would have said the same thing. It’s still true at some vendors, but thank goodness ours have seen the light. Both our ambulatory and acute vendors have significant physician participation in design with both employees and clients involved. The staff physicians have substantial clinical experience and programming knowledge and work to translate user needs to the developers and to make sure what is coded actually works. Existing customers are becoming more savvy and vendors have to respond. It’s embarrassing to have physician users who know the product better than the vendor does, but I’ve seen it. A smart vendor will hire those physicians to be on their development teams if they can lure them away from practice, but it’s rare.

I’ve seen more vendors doing formal usability work throughout the design process, but it’s still not enough. What I’d really love to see is a vendor create a “model practice” that it can use for its development test bed. It should be a medium-sized multi-specialty practice. 

For starters, they could learn what practices have to go through even before they think about EHR including licensing, credentialing, professional liability, OSHA, CLIA, and the rest of the alphabet soup it takes to get the doors open. They can fully understand the staff dynamics of a medical practice (which seem different from many other industries) and what it’s like to be responsible for people’s lives and livelihoods. They can feel what happens when payers are slow and see how well their system does managing all the insane scenarios we deal with on a daily basis. And only when those physicians sign off on the content and usability should it ever be allowed to proceed to even a beta installation at a paying client.

I’ve not heard of a vendor doing this but if you have please, let me know. I’d love to get a dialogue going with my vendor about why that makes sense. I might even be crazy enough to volunteer for it. And if you’re a vendor, I’d enjoy hearing from you about how you use physicians in development. It would make a great topic for a future Curbside Consult. I’ll run your comments openly or anonymously if needed. Got docs? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/6/14

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I wrote in Monday’s Curbside Consult about a reader’s comments to my recent EPtalk piece. His comments were similar to those shared by many physicians I meet, so I’m responding to some of them. As background, my organization is seven years into its ambulatory EHR journey (many more on the hospital side) so we’re definitely not new to this game.

There is no infrastructure for EHR outside of big groups. CMS subsidized us to buy Ferraris and then we have to drive them in a corn field. A bike would be much faster in a corn field. Meaningful Use should have required EHR vendors to provide infrastructure to connect all the computers involved in a patient’s care. Our EHR doesn’t talk to our hospital and the vendor wants $100,000 to write an interface for a single clinic. Who can afford this?

It’s great that MU requires interoperability, but the infrastructure is still a challenge for many, especially independent groups. We’ve been struggling with this for years as we’ve watched RHIOs go bankrupt, competing HIEs squabble within the same state, and more. My own state was one of the last to have an immunization registry.

Other competing factions make interoperability more difficult even if the infrastructure is in place. Our health system gave away access to our HIE and we still struggled with physicians reluctant to participate due to privacy concerns. Patients are eager to participate, but don’t get me started on the complexity of the whole patient identity problem and data integrity. I’m pretty sure it has taken years off my life.

Some of our rural clinics are still regularly taken down by well-meaning guys with backhoes. A cut T1 line doesn’t help patient care at all, and that’s assuming you can even get a line there in the first place. One site took nearly six months to get an appropriate line installed.

Trying to get all the vendors to work together is an adventure. More money earmarked specifically for physician connectivity would be helpful. I think there were a lot of physicians out there that thought $44,000 in MU money would actually pay for their EHRs. The true cost of doing an EHR (and doing it right) is far more than that, and considering maintenance, the expanding burden of Meaningful Use requirements, and other costs, I don’t see a long-term ROI over paper. Depending on how much you leverage the system you purchased and how much potential it has, you might be neutral at best.

I like your “bike in a corn field” analogy, especially being a farm girl. I may have a good story involving a broken leg and trying to take a motorbike across a corn field, but it will cost you a martini to hear it. Providers were lured into purchasing EHRs with more bells and whistles than they can understand, let alone use.

The late adopters are at a huge disadvantage because vendors now have thousands of customers to get ready for MU Stage 2. There’s not enough time to do phased implementations like we used to do. Everyone is rushing towards October 1.

As for that charge for an interface (knowing the vendors in question, although keeping their names out of it since I can’t confirm it) that’s exorbitant. Look outside the box for other strategies, like exchanging CCDs or doing a daily extract. You could hire contractors to double-key the information in both systems for several years and still be revenue neutral.

Our EHR is ranked near the top, so I wonder what kind of disasters the rest of the EHRs are? When I read about people who use them and say how good they are, I wonder what is behind their enthusiasm? Is it bribes or just pure ignorance and/or ego of the ones who refuse to see the truth?

There are plenty of disasters out there from all vendors, and plenty of good installations as well. I’m a user of five vendors at the moment (on staff at three different hospitals plus one system I use in the office and one ER I work at makes me use two different systems.) Two of the hospitals use the same system and one works well, yet the other drives me batty. Those kind of situations make it hard for me to understand tarring and feathering any vendor based on anecdotal reports.

As far as enthusiasm, I can understand where a lot of groups are coming from. When you have a good system and it’s running well, it can make a tremendous on patient care, especially where population health is concerned. On the other hand, I’ve been a user of one of those “disasters,” and when it happens to you, it’s not pretty. My previous EHR vaporized parts of nearly six months’ of chart notes because it wasn’t set up properly and there were some database issues that kept the problem from being detected.

Before someone asks how many people might have been harmed from faulty charts, I’ll say it’s far less than the number who might have been harmed had I lost all my paper charts in a fire, flood, or tornado. I’m grateful for EHR because unless it’s a cataclysm that takes out our two data centers 35 miles apart plus the offsite backup vault in South Dakota, we’re OK.

I lived through a year of hell after that while we went through the entire purchase process again. I’m convinced that clinical conversion and reconstructing parts of all those charts took years off my life. I use those experiences to motivate me as I help other users and provide feedback to vendors in the hopes that no client will ever have to go through something like that again. I’m pretty much my vendor’s QA nightmare. If it’s broken I’ll find it. They actually include some of my real-life patient scenarios in their testing process now. It’s much easier than having me yell at them if I find defects later.

As for the results, however, we’re not delusional. We’ve had great clinical outcomes (data proven) but we’ve worked really hard to get there and it hasn’t been easy. For us the key has been emphasizing people and process much more than the technology, which needs to be seen as the tool that it is. Too many groups view the technology as the be-all, end-all and that can be detrimental to their success. Vendors don’t help this perception and need to be spending more time helping customers work through policy / procedure and workflow issues before they implement rather than dealing with train wrecks after.

As to your last comment. there certainly are some egos out there. Our ambulatory vendor once brought a client with a failed implementation to visit our organization. We went through our standard site visit presentation, basically gave away thousands of dollars in free consulting on how to be a success, gave them our implementation plan, etc. and showed them how we did it.

Their CMIO was one of the most arrogant people I’ve ever met. His response was, “I’m sure that worked for you, but we have our own plan.” I wanted to jump across the table and ask him why he was even there. Why did his team of ten fly hundreds of miles and take up three days of my team’s time? If he was so successful with his own plan, why was he starting his implementation over? I had over 150 live docs at full productivity at the time. He had 10 docs who tried to go live and who were only seeing 60 percent of their desired volume and his vendor was paying other customers to try to help his team save their implementation.

I’ve got one more set of questions I’ll answer next time. Tune in to hear my thoughts on Meaningful Use vs. meaningful patient care. Wouldn’t you like to see that in a steel cage match? We’ll also talk about conspiracy theories and whether real live physicians have anything to do with EHR design.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/30/13

One of my favorite readers shared last week’s EP Talk with one of her struggling physicians. He made a lot of good points and they’re similar to those expressed by many physicians out there, so I thought I’d take a stab at responding to some of them. If you work directly with physicians and end users, they should resonate.

Dr. Jayne makes using the EHR seem like a piece of cake. I would like to see how it is working in her organization.

Actually, lots of people have seen how it works for us. We’re a reference site for several vendors (ambulatory, hospital, hardware) so we have sales prospects come on site to see how our physicians work with the system. We’ve also served as a reference site for existing clients who want a “do over” after failed implementations.

Our model has worked well for us and has been cloned by other clients and even by some who didn’t end up buying from our vendor. Keep in mind, though, that we’re seven years into our EHR journey, but I’d say most of the major kinks were worked out in the first 18 months while we were implementing. Key things that have made us successful compared to our peers:

• Heavy use of piloting for everything we do, whether it was the initial rollout, adding a module, adopting PCMH workflow, etc. You name it, we pilot it first. Would-be pilots have to apply – it’s not a political giveaway and they have to understand what piloting means. It’s not a cakewalk. We use them to break the product and re-engineer the workflows to make it better before mass rollout. Sometimes it’s not pretty. Sometimes they never ask to pilot again, and that’s OK. It’s supposed to be shared learning.
• We heavily incent our physicians to do the desired workflows and gather specific discrete data. We initially hoped for compliance through altruism or desire for quality, but what made the difference was cash. It’s remarkable what tying an annual bonus to EHR use can do to a physician’s attitude. We phased the requirements in over three years for legacy physicians, but new hires are expected to be immediately compliant.
• Strong governance. We’re not afraid to terminate disruptive physicians or to encourage those who can’t meet our standards to leave the organization. Our non-compete is written so that providers can purchase their practices and keep their panels and stay in the same location as long as they don’t go to work for a corporate competitor. This lets those who are not a good fit depart without losing their livelihood. This is rare, but it’s one element of our success.

The quality of EHR progress notes is much worse than it was on paper. You get consults back with 5-6 pages of fluff but lacking the important information. This is only because the truly useful medical data is limited by the data entry speed.

I agree. Some of the notes that I receive are unmitigated garbage. Documentation quality is part of our peer review process as well as our coding review process. We’ve heavily modified the “stock” vendor notes for formatting, font, layout, and overall readability. Chart notes are in the APSO format with Assessment and Plan first rather than traditional SOAP format where the important information is at the bottom. We permit providers to dictate assessment and plan so that it’s readable and data entry speed is not a concern.

We assume wrongly that the doctors can be taught fast typing. The young doctors who learned at a young age will be proficient. And voice recognition sucks at this time, even for physicians without accent.

From experience, I disagree. Many of our more seasoned physicians are proficient with touch typing and with the EHR in general. One of them often reminds me how well he does with his favorite statement: “Young lady, I have been waiting for an electronic medical record since before you were born. I’d go up against any of you young pups with it.” He’s not kidding, either. For those who can’t type, they’re allowed to dictate through voice recognition.

Incidentally our voice recognition also does navigation and complex macros within the EHR templates. It’s truly amazing. I wasn’t specific about this in the EPtalk piece last week. A couple of readers reached out to me about similar systems in their organization and I agree they’re extremely valuable and very helpful for physicians who are challenged by EHR.

The training phase for voice recognition can’t be short cut. Our vendor has worked one-on-one with physicians who are having difficulty. We didn’t struggle so much with accents as we did with what I’ll call “surgical mumblers” who are used to hospital-based transcriptionists who slow down the dictation to listen at molasses speed so they can make out the words. When they complained about the system, I went and shadowed them. Frankly, I couldn’t tell what they were saying, so I wasn’t surprised that the system had problems with it.

Patients aren’t happy that we don’t give them undivided attention during the visit. Some physicians can multitask but others can’t, but the impression on patients is the same.

Again from experience (and also from data), I disagree. We actually surveyed the patients (during pilot phase of rollout) about EHR use by the staff and used it to reshape workflow during the rollout. Before they’re ready to go live, physicians have one-to-one coaching sessions and mock patient visits where they are critiqued on how they use the EHR. I’ve personally taken a Sawzall to office cabinetry when maintenance was taking too long and the exam room layout was a barrier.

If physicians still struggle, we’ll bring them to our residency program practice (which has cameras in the exam rooms) and work with them both in person and with mock patients. It’s not cheap and I don’t know any other organization that does this to the degree that we do, but it has saved a couple of physicians from leaving when they truly wanted to be successful.

Those physicians who did multitask before (such as performing physical exam while talking to the patient) do well on EHR. Those who didn’t multitask before don’t do so well with it. No surprises there.

What we do, though, is help those who don’t multitask by identifying what tasks must absolutely be done in the room (meds, allergies, orders, and patient plan is our policy) and the rest they can do immediately after the patient visit. We don’t force everyone into a cookie cutter workflow. We also include questions about EHR and the visit on our patient satisfaction surveys. Those results factor into physician bonus payments as well.

Looking at patient satisfaction scores before and after EHR, we noted no substantial differences on a per-provider basis. Those who struggled with patient satisfaction continued to do so after EHR, and some worsened. Those who were doing OK continued to do well. A fair number even improved, although most patients indicated patient portal and decreased wait times due to better scheduling as causative reasons rather than bedside manner.

Our product doesn’t work properly in Windows 7, only Windows XP, which is an issue. A good EHR should be multi-platform, should work on Apple computers, Linux, and other operating systems as well.

I absolutely agree with you here. Many vendors have struggled with this issue. I ran across one the other day whose product only runs on Google Chrome. I actually like Chrome, but it’s not exactly the most widely used, and is especially problematic considering that the limitation also applies to their patient portal. Chrome isn’t as popular among the Social Security set who seem wedded to Internet Explorer. I think they’re going to regret that narrow niche and I do wonder what exactly is going on with the programming that it won’t even run correctly on Firefox.

For client-server apps, the popularity of Citrix has helped systems feel more agnostic to end users, although Citrix itself can be a complicating factor in support and maintenance.

There were quite a few more comments, but I’m going to save them for the next EPtalk. What do you think about these issues? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/24/13

I’ve seen this graphic about the interpretation of scientific jargon multiple times. It seems to turn up on Facebook or in an email every now and then. I read a fair amount of scientific literature and thinking of the alternate meanings always makes me smile. You could use it to play a kind of Mad Libs substitution game to liven up whatever article you’re reading.

As a medical informaticist (Now improved! With Board Certification!) I read the literature with a pretty critical eye. That probably goes back to my medical school training when I learned the importance of understanding whether the patient population in a clinical study was similar to the patient in front of me before deciding whether to use its data to alter my treatment plan. I’ve also read far too many studies that lack statistical validity or pursue therapies that although clearly proven are just irrelevant in real-world medicine. I’ve spent most of my medical career in the community rather than in the academic space and know that they can be vastly different environments.

As part of my preparation for taking the American Board of Preventive Medicine Clinical Informatics certification exam, I attended the AMIA Clinical Informatics Board Review Course. Although it was great to actually sit down and discuss informatics with others in the field, it was a little surreal at times. I’m used to working in a bit of a vacuum – most of the time I’m the only clinical informatics professional in any given meeting – so being surrounded by scores of my peers was a bit overwhelming. The fact that several people in the room were the authors of the texts I had been reading to prepare added to the intellectual climate.

By listening to some of the questions asked during the class, one could tell that some of the attendees were significantly more academic than others. I ended up spending most of the breaks off to the side with several attendees who were more community/clinical-based like I am. After the course, AMIA launched a listserv for attendees and being a silent participant has been entertaining. Watching highly-intelligent physicians interact over minute details of one thing or another can either be educational or mind-numbing depending on the topic and the people involved. Since we’re in a fairly new field, the group is very good about bouncing ideas off one another and one recent series of posts revolved around the idea of the environmental scan.

In a nutshell, an environmental scan is a review of the political, environmental, social/cultural, and technical factors around a business, industry, or market. Organizations benefit from doing an environmental scan periodically to understand the factors influencing their business and the challenges they may face now and in the future. One member was looking for evidence demonstrating a clear return on the efforts of doing such a systematic review. Her employer wanted it proven before they agreed to conduct one. Respondents quickly piped up with examples of business practices that may not be evidence-based but are good ideas, such as paying bills on time (which is pretty funny in and of itself) but one response had me laughing so hard I had to physically get up and walk around after reading it.

This particular scholarly work was published in the British Medical Journal and is titled “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials.” Although it’s subscription-only, the abstract is available. The authors set out on a systematic review of randomized controlled trials “to determine whether parachutes are effective in preventing major trauma related to gravitational challenge.” Essentially they did searches of Medline, Embase, the Cochrane Library, and other sources to try to find literature proving parachute use is a good idea. Not surprisingly, they could not find any randomized controlled trials of “parachute intervention.” The conclusions are what pushed me over the edge (somehow the more formal-appearing British spellings make it even more humorous):

As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.

It just goes to show that even those among us who are most academic can still have a sense of humor. It also reminds me (along with the original “show me the money” question about the environmental scan) that there are a lot of administrators and other people out there who still don’t understand what we do or what we can bring to the table as part of this new discipline. I’ve got a couple of people in mind that I’d like to enroll for that parachute trial. Perhaps you know a few candidates?  Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/16/13

The vast majority of ambulatory organizations have either implemented EHRs or in the process. There are different challenges for large organizations and small practices. In talking with a couple of my peers in the physician lounge over the last few weeks, one challenge is the same: determining whether EHR projects should be clinical, operational, or IT initiatives.

When I went live on my first EHR nearly a decade ago, the project was under the IT department. It was run by analysts who knew very little about what happens at a medical practice other than what they had experienced as patients. I was in a solo practice situation at the time, but part of a larger ambulatory group who wanted to use me as a pilot for the EHR system they were planning to roll to everyone else.

The vendor was well known, however, more in the billing space than the EHR space (as was common at the time.) I was busy running my practice and seeing patients, so just went along with what the IT department recommended. At the time, I didn’t know much about project management and lacked the experience to know that things were going very badly.

The vendor sent a trainer who taught us on a different version than what we had installed, and no one caught it before I was in training. There was no training around how to modify office workflow or transform practice. It was merely a parade of templates and how to use them, hour after hour, until our minds were numb.

We struggled with the system for the first six months. It wasn’t just the software, but issues with wireless connectivity, signal interference from the tenant next door, hardware failures, and a lack of a support structure. Eventually we discovered the software had been omitting data during the note-signing process. That was what allowed us to put a nail in its coffin.

I didn’t know at the time how visible the project had been since I was just trying to muddle through while also growing a new practice and seeing patients. When we started the Request for Proposal process for a new vendor, however, it became clear that many eyes had been on the project. Based on the events of the failed pilot, hospital leadership ordered that the next ambulatory EHR initiative would not be IT driven.

The project team that was ultimately assembled had leaders from operational and process excellence disciplines. They quickly hired a physician champion who was in place before the system selection was final. One of the key drivers of the project was clinical transformation rather than just a paperless transition. This required a lot more work than a simple EHR installation. I didn’t understand at the time how important that was, but I certainly do now. By focusing on outcomes from the beginning, we were able to drive adoption in a way that we could not have otherwise.

Our IT resources reported to our project leadership through a charge-back arrangement, but it was clear that they worked for us. They were tasked with supporting the infrastructure and helping us maximize the application and its capabilities. The rest of the team focused on understanding clinical workflow and practice operations. At the same time, they learned the system so that they could pull it all together and identify the best ways to implement various features.

The arrangement served us well and allowed us to deploy the platform to several hundred physicians, but I’m not sure we could make it work in a different organization with different leadership. With that in mind, when people ask me the question about where ownership of EHR projects should sit, my answer has to be, “it depends.” It really does depend on the organization, its goals, its strengths and weaknesses, and the people involved.

Small practices see this acutely, especially those who are trying to implement EHR at this stage of the game. We’re clearly in the realm of the late adopters, and I suspect many of them wouldn’t be doing it at all if not for the Meaningful Use money or the fear of penalties.

I’ve seen a couple of my colleagues fall prey to the idea that these are IT projects and don’t need much operational or clinical involvement. I was recently asked to assist a practice that had signed up for a hosting arrangement which only covered infrastructure. They had a complete lack of understanding of what it takes to maintain a system even if they were using it in a vanilla fashion.

They didn’t understand the difference between an upgrade and a software patch, so needless to say, they hadn’t applied any since going live, yet were baffled when things in the system weren’t up to date. They didn’t attend any of the complimentary training their vendor offered. They have no idea what it takes to attest for Meaningful Use, yet plan to do so in the first quarter of 2014. I hated to break it to them that they didn’t even have all the required components installed, and that based on their continued use of paper telephone messages and dictation of office visits, they are a long way off from being true meaningful users.

I’d like to see EHR vendors perform an “informed consent” process for new EHR clients, especially the late adopters. They should spell out what it takes to be successful and warn clients of the risk if those precepts are not followed. They should explain the need to have involvement from clinical, operational, and technical leaders even if they all happen to be the same people in a small practice.

When clients fail to heed this advice, they should not demand that the vendor move heaven and earth to get them back on track. Although vendors have a vested interest in the success of their clients, practices have to bear a large part of the responsibility for success.

Over time and as our project has gone into maintenance mode, management of our EHR has transitioned to shared ownership between its clinical and operational owners and the IT department. The leadership has matured and learned from its experiences and we’ve all become stronger as a result. It hasn’t been easy, and I have colleagues at different institutions that have had completely different experiences, but I would never trade what we’ve been through together. What do you think of EHR project ownership? Email me.

Email Dr. Jayne.