Curbside Consult with Dr. Jayne 7/21/14

A lot of people are talking about the recent JAMIA article that looked at whether Stage 2 Certified EHRs are ready for prime-time interoperability. It concluded that four key areas need to be addressed to improve CCDA quality. One area is “terminology vetting” for the multiple vocabularies used including SNOMED, LOINC, and RxNorm. Another area is reducing the amount of data that can be “optional” with a product still receiving certification.

I agree with both of those, as well as the paper’s assertion that document quality needs to be assessed in “real-world clinical environments.” However, it’s highly focused on the technical aspects of document exchange rather than the actual intellectual quality of the document being exchanged. I wrote about the quality (or lack thereof) of some physician notes a couple of weeks ago. Unfortunately, there are more elements besides the provider’s narrative and abbreviations that are problematic.

My health system is the ultimate best-of-breed nightmare, so I can attest to the fact that some vendors’ incorporation of the clinical problem list into the CCDA reads like one of those “choose your own adventure” novels. Is it an active problem, chronic problem, recurrent problem, or something that just happened once in the past? With some of our documents, I just cannot tell what it is trying to depict. I often feel like I have chosen a path to nowhere, just like the books.

There are fundamental differences between how physicians and other clinicians are trained to sort information. When I trained at a fairly “classical” medical school, we were taught that all of the patient’s problems were part of the Past Medical History, even those that were not truly past such as chronic hypertension, diabetes, obesity, etc. When I helped bring our organization into the EHR universe more than a decade ago, it took while for providers to get used to the idea of a chronic problem list being different from the PMH because many providers still wanted to include everything in the PMH.

Now we’re at the point where we have to educate them on the SNOMED-codified Problem List and how it differs from the ICD-10 Assessment List, even though there may be two codes that represent a single disease. I have finally gotten over it, but many of our physicians are still struggling with the concept despite having been trained two or three times.

Some of the CCDAs seem to comingle the two. It’s maddening. I’m tired of opening vendor support tickets to try to figure out if they’re functioning as designed or just messy. They must meet the letter of the law to receive certification, but that doesn’t necessarily mean they’re good for patient care or educating the patient on the conditions noted in his or her record.

Whether or not Eligible Providers are meeting the letter of the law or the spirit of the law with Meaningful Use is another hot topic. Lately, my running habit has been taking a toll on my feet, which prompted a trip to my favorite foot specialist. He’s a good friend of mine and part of a husband and wife team practice. They’re fiercely independent and have successfully deployed a Certified EHR over the past couple of years. We always chat about EHRs and where they stand.

I knew they were getting ready for attestation when the rooming technician came in with a wrist blood pressure cuff. In practice, I’ve found those kinds of cuffs to be notoriously unreliable, so I asked him if he wanted me to just self-report some numbers that would be accurate. He declined my offer and proceeded to document the 141/87 that the cuff read out. My blood pressure hasn’t ever been that high, but now it’s in my chart. When my colleague came in, I asked him what he thought about it. He wasn’t thrilled and said it sounded like some coaching was in order.

We talked a little bit about integrated vital signs monitors that would make things easier. He then he admitted that they’re thinking about throwing in the towel on MU. Their vendor has been doing a good job helping them dot the Is and cross the Ts, but the thought of an audit scares them. With all the points that must be perfect for an honest attestation, they are wondering if it’s worth the risk. Right now their patients are happy, their staff is happy, and their practice is running well enough from a business standpoint, so why upset the apple cart?

I don’t disagree with them. At times it doesn’t seem like it’s worth it. A lot of practices are just operating out of fear of future penalties or fear that commercial payers will adopt the CMS standards. Fear isn’t really a healthy way to run a business, however.

Since we’ve been friends for a long time, I offered to do a peer audit for them using my knowledge of MU to see how close to compliance they are. There are plenty of professional consulting firms that will do practice audits and they may want to ultimately do that, but are interested in seeing where they sit from a friendly point of view.

In the olden days (or in a truly free market economy) we could have traded some consulting for a free cortisone shot or something like that, but the insurers would take a dim view of that, I’m sure. Given my CMIO role, I also have to be careful about doing anything that could be interpreted as a donation from the health system so I don’t run afoul of any anti-kickback rules. When all is said and done, it will be interesting to see how many providers end up opting out of MU and what percentage of them are independent physicians.

Are any of your providers opting out of MU? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/14/14

I wrote a few weeks ago about my adventures with the CMS physician portal. Since the reporting of payments and gifts from drug and device manufacturers to physicians is now mandatory, physicians are wise to make sure the information is accurate because it is going to be released to the public.

I had gone on the site and registered for basic portal access in June, but had read that I would have to return in July to register specifically for access to the Open Payments data. Once I went to the Open Payments link (thank goodness the website at least has a decent breadcrumb trail at the top), it asked me to create my profile. It also allows physicians to nominate “authorized representatives” to handle physician information.

It also requires entirely too much other information that CMS should already know about us from our NPI, Medicare, and other applications: NPI, license number, practice type, specialty code, DEA number, etc. The first words that popped into my head (of course in a snarky voice) were “administrative simplification.”

Rather than have the specialty codes on a pick list, I had to launch a 359-page PDF to figure it out. Finally, Page 212 had a link to Appendix C, where the answer was still nowhere to be found; the appendix had a link to the CMS taxonomy crosswalk. I’m not sure why they couldn’t have hooked up the link on the actual application to the crosswalk in the first place.

Even though the crosswalk lists my specialty code as “08” in the column that says “Medicare Specialty Code,” what they actually wanted was the code in the “Provider Taxonomy Code” column. Don’t bother trying to cut and past the 10-digit code into the form because it won’t work right. I was able to finally get through all the steps, only to learn that I won’t be able to do anything else until my profile is “registered” after my identity as a physician is confirmed. I’m surprised they didn’t ask for my blood type.

When I write about my initial experience, I also asked for a good martini recipe to help me get through it. Weird News Andy was happy to oblige with one that plays to my literary passions:

Charles Dickens Martini

1) Make a martini as you see fit

2) Add an olive or twist

I’m still laughing. There are so many Dickens titles that seem appropriate for healthcare IT: Great Expectations, Hard Times, and Bleak House, to name a few. It looks like my attempts to see my Open Payments data are turning into either a serial or a novel.

Have a literary suggestion that meshes with our lives in the IT trenches? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/7/14

I enjoyed some R&R over the holiday weekend. It was good to have a break from the normal routine. As an added bonus, most of our IT staff disappeared the day before the holiday, whether sanctioned or not. I had a grand total of one email after noon on Thursday and it had to do with something administrative.

I know this reprieve will be short-lived since we start implementing practices again tomorrow. At least we’ll be heading into the fray well rested.

Quite a few readers chimed in on last week’s Curbside Consult discussion of poor-quality EHR documentation. Several readers mentioned the purpose of the note as a key concept. While visit notes were traditionally for the benefit of the provider in documenting the patient’s condition, exam, and what was done, they have been co-opted by payers and regulators who equate documentation volume with value.

Notes are increasingly the purview of patients. Our health system does release visit notes directly to the patient through our patient portal. Most of our primary care physicians do a great job with patient documentation because they know the patients might actually be reading it. Our subspecialists who have been on EHR a long time also do fairly well.

The new practices are struggling more than those groups. It’s hard to tell how much they’re struggling with the actual documentation process vs. the concept of being part of an employed medical group and being told what to do.

As to who has the authority to take corrective action against “bad actors,” in our organization, it isn’t the CMIO, but rather the CMO and the president of the physician group. Both of them received formal notification of the specific concerns I found during the special project. I also included a request to authorize a more thorough and comprehensive audit by our internal Compliance department. If some of the documentation is as bad (and potentially fraudulent) as it seems, we’re going to need a better sample size and multiple independent auditors to prepare the documentation ahead of disciplinary maneuvers.

When I created my CMIO role here, I intentionally excluded physician discipline from my purview. To be successful within our culture, I needed to be seen as an advocate rather than someone who could get them in trouble. Additionally, I felt that in the case of EHR misuse, I would be seen as inherently biased towards defending the EHR and the IT group whether or not it was true.

Our leadership agreed. So far, the splitting of authority has worked. I think it will work well in this case also once we have evidence of documentation patterns across the group.

I laughed at SpoonEHR’s suggestion to create a macro “Signed but not read.” It’s unfortunately all too true. Back in the days of in-house transcription, I quit using a consultant whose letters came back “Dictated but not read, signed by transcriptionist to expedite” or some similar nonsense. If I can’t trust someone to read, edit, and sign their notes, I certainly don’t trust them to care for patients.

Reader Zafirex receives similarly ridiculous notes addressed to “Dear Dr: No Referring Doctor.” The paradox here is that the referring physician receives the referral note. Therefore, the practice at least knows how to address the envelope correctly.

I also loved Jedi Knight’s comment that, “We’ve sped up the process of sharing data without considering that the data is no longer worth sharing.” I do hope that the OpenNotes movement and the resulting opportunities for patients to read their notes will spur some providers to clean up their acts. Over the weekend, my dad asked about some information that was in his recent encounter note that didn’t make sense. I hope he calls his doctor on the carpet about it.

The idea that gives me the most hope, though, is Richie’s mention of a “Data Kidney” that can review text for “cleanliness.” In the newspaper world, that would have been the editors and proofreaders. All kinds of imagery comes to mind, including the proverbial red pencil. We’ve got grammar check in our word processing software, so why not for EHR output text?

What gives you hope that documentation will get better? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/30/14

I spent most of this weekend doing a special project. Our coding and compliance officers approached me about how some of our providers’ notes look in EHR. They had seen some notes that were “really awful” and naturally assumed that something was going on with the EHR to cause them to be that way.

Our ambulatory vendor offers checkbox-style documentation templates, so I figured the complaints were about how their documentation was being output now that we’re dealing with SNOMED and other factors.

I asked my team to pull a sampling of notes from each of our specialties so that I could look at them myself. We’ve seen issues where the behind-the-scenes verbiage engine generates some subject/verb disagreements. Additionally, when a large number of positive and negative symptoms are documented, sometimes that can get a little strange.

Since our analysts are not clinical, I know that I can’t exclusively use their review to identify good vs. bad notes. Sometimes the documentation might be technically accurate, but would actually be something a receiving physician would laugh at.

We have a lot of subspecialists who do a lot of procedures, so I had the team pull a variety of those notes as well. They’ve been problematic in the past, especially when multiple procedures are documented. Most of those issues have been easy fixes. Still, considering the variety of specialties and all the different kinds of documentation, I had well over 100 visit notes to review.

By the time I was done, I could barely contain my aggravation. The largest subset of “awful” notes came from our providers who are heavy users of voice recognition. Some of the notes were downright incoherent. The problem however wasn’t with the technology – it was with subspecialists dictating sheer nonsense that normal humans (even those with medical degrees) would have difficulty comprehending.

The next subset of bad notes came from providers who have created their own documentation macros. The idea of providers having their own saved text blocks is generally a good one. We all know that there are some parts of the note that are the same over and over again: “regular rate and rhythm, no murmurs, rubs, or gallops, lungs clear to auscultation bilaterally, abdomen soft non-tender and non-distended with normal active bowel sounds.” From years of dictation it just rolls off the tongue, so it would make sense to save it as a block for EHR.

The problem comes when providers save text that either doesn’t make sense or has gender-specific findings that winds up being reused on the opposite gender. The point of saved text is to be able to quickly add documentation with little work. Some of our providers take the idea of efficiency too far, with so many acronyms and abbreviations it’s impossible to figure out what is going on with the patient.

Even with the subject/verb disagreement and some of the typical template issues, the group that most heavily uses check-box powered documentation did the best. They were easy to sort out due to the way the history blocks format and I was surprised at how much clearer their notes were compared to those done via other methods. Those that used the templates, however, had a much higher propensity to document Review of Systems items that I’m sure they didn’t actually perform.

For your amusement, I’ll share some of the highlights:

• General surgeon sees a patient to remove a skin cyst. She documents a gynecological review of systems with seven negative elements. I confirmed that it wasn’t from a paper form the patient completed and staff keyed in. She also documented the procedure as “EXC TR-EXT B9+MARG 2.1-3cm.” What does that even mean? I could extrapolate “benign” and “margins” from that, but it makes no sense for the type of cyst excised.
• The same surgeon documented a 21(!) point male urinary review of systems for a similar visit. The procedure document was the same except it was 0.6-1cm. At least she’s consistent. And apparently thorough, since she documented that she examined all 12 cranial nerves and the cyst was on the shin.
• Orthopedic surgeon documents a physical exam that includes a normal fundoscopic exam. I’d pretty much bank that the last time an orthopedic surgeon touched the instrument needed to look at the back of the eye, it was in medical school.
• Chief complaint of “bx results” which was saved to a provider custom list. Could we not have spared the extra characters to have it read “biopsy results” so that when the patient receives the note on our patient portal it makes sense?
• Not capitalizing the names of other physicians on the team. Nothing says “thanks for the referral” like addressing the letter to “dear dr jayne.”
• A “follow up back pain” visit with a (no kidding) 91-point review of systems including “changes in shape/size of moles” and “breast lumps.” I can’t wait until that one gets pulled for a CMS audit.
• Detailed discussions of radiologic studies pulled into the note from other practices. I guess in addition to being “one patient, one chart” the EHR also lets us time travel because the same CD with the MRI results that the patient hand-carried from shoulder surgeon was simultaneously imported to the orthopedic consultant’s May visit note and also to the nephrologist’s note with a date stamp two months prior to the visit.

I could go on, but it would just make me frustrated and likely make you angry. More than anything, it just makes me sad, especially since the providers electronically signed all of them and indicated that they were read and reviewed.

You might ask who had the best documentation. Hands-down the most coherent, thorough, and clearly non-padded were the notes done by one cardiology group using a mix of voice recognition for the history and plan and template documentation for the physical exam and review of systems. I didn’t identify any gratuitous documentation and the notes were high quality. It probably takes them longer to document since they’re speaking most of the note vs. clicking. However, their documentation was so pretty I wish I could clone them. But CMS says cloning is bad, right?

Got documentation problems? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/23/14

The pile of medical journals on my desk has been growing steadily over the last several months. It’s hard to keep up with all the reading required for my informatics role (Federal Register, anyone?) let alone make time for clinical reading.

Summer hit full force this weekend and the prospect of going out in 90 percent humidity didn’t sound too enticing, so I decided to play catch up. One of my journals has a dedicated public policy section and of course the IT-related items always grab my attention.

CMS apparently released a mobile app to help physicians track payments and gifts received from drug and device manufacturers. My journal stack must have been older than I thought since the requirement for manufacturers and group purchasing organizations to collect the data kicked in last August. Separate apps were created for physician and industry use. Maybe being behind on one’s journals is a good thing, however, since it would allow me to do a post-live assessment of the app.

Looking at the FAQ for the app (only CMS would release an eight-page document for a smart phone app) it didn’t look that promising, although I liked the feature that would allow physicians to send profile information from the physician app to the industry app. That would have been helpful last year when I had to provide my NPI number after a colleague bought me a drink. He realized as he was signing the bill that as an employee of a medical device manufacturer, he was obligated to report it.

Knowing that I have no idea what my NPI is, I’d rather have bought him a drink as opposed to having to email myself a reminder to dig it up and send it to him. In case you’re interested, the threshold for reporting is $10. The martini in question was $12.50, having been purchased in a hotel bar at HIMSS. Had we both had the app in play, I could have stored my NPI in my profile and simply beamed it over.

Other than that, the apps don’t communicate with anyone. They are designed to make tracking easier, which probably benefits the manufacturers more than it does individual physicians, except for those who habitually mooch off of every vendor rep they encounter. In the interests of full disclosure, I didn’t accept drug samples in my primary care practice and generally don’t attend industry-sponsored events. I would probably have less than a dozen items to track over the course of a year and they would probably all be related to drinks at HIMSS, MGMA, or another trade show.

The physician app (which is also for other professionals subject to the reporting requirements) also features the ability to create or import QR codes to share information with others involved, although separate codes are needed for profile and payment data. A summary of transactions can be downloaded and the app is password protected. The information is stored locally and will auto-erase after multiple failed access attempts.

If you get a new phone, you might be out of luck since there’s not an easy way to transfer the information. Just looking at the FAQs, it seemed like more trouble than it was worth, but I headed off to download it nevertheless. It requires an eight-character password although it didn’t require me to use anything other than lower case. The cheesy stock images of physicians and industry staff were a turn-off however. Data entry was completely manual, so my initial reaction was right. I’d rather email myself the information and auto-route it to a folder in Outlook.

I agree it’s important for physicians to keep track of their data since it will be made public this fall. I decided to visit the CMS website to see what information was available and whether that martini from HIMSS was now visible to the public. Apparently it’s more complicated than I thought. There are two phases of registration. Physicians can register in the CMS Portal, but then they’ll have to come back in July to register in the Open Payments system itself.

The CMS website links to a “Step-by-Step” registration presentation.  Seriously? CMS expects us to demonstrate Meaningful Use in a variety of ways but has to provide a presentation on how to complete a registration to an online repository? No kidding, it was 42 slides long.

I did learn that the registration just started June 1, which seemed somehow validating that maybe procrastinating on my journals wasn’t a bad thing. Had I read about this last August when it was released, I probably would have forgotten by now.

I also learned that I’d have to go through an identity-proofing process that was even more stringent than what I had to go through to be an e-prescriber of controlled substances. I’ll be asked questions about my employment history, mortgage lender, and other “private data” and information from my credit report. The identity-proofing process is being run by Experian, but CMS wants to assure me the information isn’t going to be stored anywhere. The registration process will result in a soft credit inquiry.

By Slide 11, I was ready for a martini even if I had to make it myself. CMS requires the password to be changed every 60 days, so I’m sure I’ll become familiar with the reset process. I’m not familiar with this CMS portal, so I was intrigued by its promise to “present each user with only relevant content and applications” yet “provide ‘one-stop shopping’ capabilities to improve customer experience and satisfaction.”

My satisfaction wasn’t much improved by the popup that appeared when I tried to read the FAQs to see what else I could do on the Portal while I wait for Open Payments registration to open next month. I did find quite a few new acronyms I hadn’t seen before, but left before discovering anything I thought might be of use. I finally figured out that I had to request access to Open Payments specifically. Maybe I should have paid more attention to Slide 28.

At that point, I went through the actual identity proofing, only to be told I need to set up another profile to register to see my data. I got blocked at that point, since the “Physician” option is still inactive. I’ll have to try my luck in July, when I can not only see my data but experience a yet-to-be-determined dispute process should the need arise. At least that will give me plenty of time to find a new martini recipe. Have a good one for summer? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/16/14

I’m sure those of you that follow me on Twitter were wondering what could possibly have happened last week to make it one of the strangest days of my career. In retrospect, it wasn’t just one of the craziest days of my IT career, but of my physician career as well.

My hospital is part of a larger health system. When have to have a representative on some kind of IT-related committee, I am usually tapped to attend.

We’re a decent-sized organization with plenty of employed physicians. One of my CMIO friends in a similar situation has employer-paid medical co-payments to encourage staff to see the physicians in their group. Another offers their “associates” early access to office appointments that aren’t available to other patients. Theoretically, when you’re caring for your own people, it should be like a miniature accountable care organization and might give you insight into the best way to maximize health and lower costs for a defined patient population.

I have to admit I am way behind on my email and didn’t read the agenda for our Emerging Technologies meeting prior to heading uptown for the session. I’m barely keeping my head above water and didn’t think it was a big deal because usually the topics are things I can handle on the fly. This time, however, I was seriously wrong.

The meeting happens over lunch and I was trying to grab a quick bite while scanning the agenda as people arrived. One of my IT colleagues thought he was going to have to perform the Heimlich maneuver after I started choking on my salad.

Apparently our brilliant “ET” group decided to bring in a third-party solution for “advanced access” to physicians. Unfortunately, it’s a telemedicine solution staffed not by our own physicians, but by others in the market. As the meeting started, a glossy marketing slick was passed around. I thought it might be some kind of Friday the 13th prank until I realized they were serious.

Our human resources department wants to roll this out as part of our benefits package in the fall. They wanted to vet it with our group as far as our thoughts on HIPAA and other regulatory issues. The health system would pay a fee to the vendor, which offers “doctor visits anytime, anywhere!”

I’m not opposed to the concept of virtual visits, but I’m truly surprised that we wouldn’t give our own physicians the opportunity to not only serve the employee community, but to maybe make a little extra cash as “advanced access” physician resources. Given the recent draft policy from the Federation of State Medical Boards regarding telemedicine, we would be ideal. We’re licensed in the states where most employees live (and are usually located), so that’s easy. We already have unified medical liability coverage, so that’s easy, too. We also have a vested interest in keeping our collective employees healthy as a means to strengthen the community.

I also like the idea of employees being able to receive care without disrupting work schedules, although the service promises access to physicians “at home, at work, or anywhere you need care.” We have enough issues with staff using cell phones to take care of personal business in patient care areas and don’t want to encourage them to talk about their medical issues in the workplace. There aren’t a lot of private places in most of our ambulatory practices (the physicians don’t even have private offices any more) so I’m not sure that’s a benefit.

What really got me was the assertion that the third-party physicians would become “your doctor.” Are they really advocating conducting a longstanding patient-physician relationship established via smart phone? Are they going to be accessible 24/7 to handle all the health issues that typical patients should be addressing with their personal physicians? What is their plan for continuity of care?

I was trying to see the other side of the equation. Maybe they were worried about patient privacy. Employees might not want to see network physicians because their records would become part of our central database. That’s certainly valid. Maybe they were worried about accessibility and that’s a factor, although more and more of our employed practices are extending their hours and providing walk-in accessibility. Maybe they think offering this will differentiate us as an “employer of choice,” as the HR people like to describe it.

One of the other physicians at the table who wasn’t distracted by lunch managed to access the telemedicine website and find out more about it. Apparently they’re willing to partner with healthcare organizations to involve their own physicians, but our HR department didn’t think that was important. They figured they’d just offer it to our employees with the existing provider network because that would be faster.

I wonder if they seriously considered the public relations and morale repercussions of offering our staff having virtual visits with providers from a competitor health system. I’m sure the various medical executive committees at our hospitals will have a field day with this if it moves forward. That’s likely to happen since HR didn’t seem to understand our objections or find them valid. One of the physicians actually got up and walked out. The rest of us stuck it out, if for nothing else than to gather information to help inform our next steps.

Since we’re a technology committee and we couldn’t find any significant technology objections (I have to admit their setup looks pretty slick), it’s likely to move forward. I’m interested to see what the hospital administrators will think since it will likely have an impact on their bottom line.

I’d be interested to hear from organizations who have done something like this, including whether your providers participated or whether you used an existing or external network. We’re having a discussion with the vendor in a couple of weeks, assuming roadblocks aren’t thrown up in the interim. I’m putting together my list of questions and “what if” scenarios for the meeting.

Got ideas? Or alternatively a potential job with a seaside location? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/9/14

I mentioned that I was planning to start working in an urgent care that documents patient visits on paper. I fell into an opportunity with an independent facility and worked my first shifts this week. A reader asked if I had mentioned during the job interview that I would be blogging about my work and whether I’ve been able to remain anonymous in my various work roles.

The answer to the blogging question is “no.” I enjoy my day jobs and wouldn’t want to jeopardize them. Although I share many stories about my work, there are a great many stories that don’t get told because they might result in specific people or organizations being identified. Some of the best tales will go with me to the grave.

A reader once said that as a CMIO, I’m still a doctor, but my patients are sick hospitals and physician offices. That’s true to a degree and I guard their information as I do with patient information. Often my material reflects events that are so common they could apply to many organizations across the country, so camouflaging the events and players isn’t necessary.

As far as my clinical duties, I do think I’ve been able to remain anonymous. Frankly most clinicians in the trenches are too busy keeping their heads above water to even know that there’s an entire health care IT community out there. They may not know who their own CMIO is or what he or she does, let alone that there are scores of us who know and talk to each other. The idea that there would be blogs talking about EHRs and the people who use them to torment physicians isn’t even remotely something that would cross their minds.

If I use photos from work, it’s often months after they were originally taken or in a slightly different context than where I obtained them. I have a veritable treasure trove of photos I’ll never be able to use because they would be easily identifiable or involve people that I know read HIStalk. I also use photos that have been sent to me by readers when they can help embellish something I’m writing about. Hopefully if anyone recognizes those, the story is different enough from their reality that they don’t make the connection.

Back to the world of paper records. I arrived at the office ready to go. It’s a little different vibe from working the ER. The lack of a metal detector and security guard was refreshing, although I admit after my first procedure, I missed wearing scrubs.

The physician I worked with was quick to show me the processes and systems. Staff does the intake interview, gathers the history, and performs any needed pre-testing based on a written standing order. The clipboard goes in the door with a magnet to indicate which patient should be seen next. Simple and elegant, although low tech.

The physician sees the patient, documents on a paper template (they have a dozen or so templates for their top conditions plus some more generic versions), then comes out and order whatever additional tests are indicated. If there aren’t any, we prepare the discharge instructions and prescriptions, which are done via computer. The prescription ordering system isn’t sophisticated, but it does have hard-coded selections for the most common drugs, sortable by body system and diagnosis. If you can’t find them, there’s a search dialog, and if you get in a real bind, there’s a paper script pad in the drawer.

I have to reiterate that this is obviously not a practice that is trying to achieve Meaningful Use. As an opt-out site, we’re not asking super-detailed questions about smoking history or the types of tobacco used. We’re not asking race and ethnicity. We’re not codifying problems in SNOMED. Since we’re not part of a hospital system or accredited by The Joint Commission, we’re also not spending time assessing suicide risk, nutritional status, or any number of possibly irrelevant scenarios on all our patients. This leaves us time to actually see our patients at a reasonable pace.

Even though the first part of the shift was fairly busy (5-6 patients per physician per hour), the pace didn’t seem extreme. I think mostly it felt like I was able to focus on the patient’s current needs and not feel expected to address unrelated issues just because someone made a regulation that said I needed to.

Once the provider is finished, the nursing staff then takes the discharge instructions and scripts, goes back in the exam room, counsels the patient, and addresses follow-up needs. Then the patient gets to go home. Their plan may not have all their medications printed on it nor their list of historical diagnoses, recent vitals, or a host of other things, but it does have the information they need to care for today’s problem and to follow up with their primary care physician.

Up to this point, I’ve focused on the things that made today easy. Let’s talk about what made it difficult.

The first thing that jumped out at me was the fact that there is no drug or allergy checking when we write prescriptions. Although physicians have used paper scripts for years and there are plenty of people who argue that we were better on paper, I can’t help but think that I’m going to harm someone because I don’t have technology backing me up.

I calculated most of my weight-based pediatric prescriptions two or three times because I didn’t trust myself. I had one pharmacy call-back for prescribing a drug that might have had a mild to moderate interaction with a patient’s current medication. I know it would have flagged in an electronic prescribing system, but I’m wondering if there is a chicken vs. egg phenomenon going on. Did I miss the interaction because my vigilance was weakened by my reliance on technology? Or would I have missed it anyway?

I ended up customizing 80 percent of the patient education materials to include additional precautions or information that I like to provide for my patients. Most EHR systems would allow some level of saved customization. but our discharge system doesn’t. I’ll likely create a text document of common phrases that I can use to populate them in the future and just keep it open on my desktop.

Unlike some chain or pharmacy-related urgent cares, we don’t have an easy way to send information back to the primary care physician. It’s something that definitely merits discussion with my new employer.

Looking at the workflow with a critical eye, there were other inefficiencies. Staff had to transcribe lab data to the chart that might have been interfaced with an EHR. Patient education topics had to be searched manually rather than linked from diagnoses. These inefficiencies were virtually unnoticed, though.

Having done more than one stint as a science fair judge, I can’t say this was a valid experiment of any kind. Comparing this practice (regardless of whether it uses paper or EHR) to any other place I’ve practiced in the last several years would be like comparing apples to unicorns.

One major difference is the ability to focus on the patient’s presenting problem rather than extraneous but required information. Another is the encouragement to rely on support staff for tasks like order entry and diagnosis code lookup. It’s been so long since I was just able to articulate a diagnosis without codifying it that I didn’t know what to do with myself.

Whether it was due to the workflow process, the patient acuity mix, or other factors, I noticed one thing. Even after 12 hours of non-stop work, I felt like I had spent more of my day being an actual physician than in doing other tasks. We’ll have to see if I still feel this way in six months, but right now I’m cautiously optimistic. I’m still going to lobby for e-prescribing, though.

Have a story about going back to the basics? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/2/14

I haven’t been on a job interview in years, so I didn’t really know what to think when I found myself getting ready for one a few weeks ago. Since giving up traditional practice, I’ve worked in a variety of part-time and locum tenens primary care situations. I’ve also done part-time work in several emergency departments. I’ve worked directly for hospitals and also for staffing companies hired to populate the ED. It really doesn’t matter where my paycheck comes from – patients are patients and we care for them the best we can.

Due to a couple of regional shakeups with ED staffing companies and posturing by competing health systems, I recently found myself without a place to hang my clinical hat. My own hospital has decided that unless you are board certified in emergency medicine, you can no longer cover the ED (unless you’re a midlevel provider — then you’re OK to work as many shifts as you can cover.)

I find it ironic that they’d rather have a nurse practitioner straight out of training then a seasoned physician who happens to be certified in a non-emergency specialty. It’s less ironic, though, when you understand the real reason, which is as it always is, the bottom line.

Anyway, to take any kind of leave of absence is a pain. Unless you have an active practice address, you’re expected to surrender your state controlled substance license. They won’t let you just transfer it to your home or to an administrative office. I know this well because I got caught in the trap before and it took months to untangle. We received a 90-day notice that our contracts would be ending, so the race was on to find new positions.

Unfortunately, there were about a dozen other physicians in the hunt. Most were looking for full-time positions, though, so I had a bit of an edge being willing to work the odd shift here and there rather than needing a primary income.

I also have the edge of being sassy and single, which means I don’t mind working holidays or providing late-night coverage. In fact, I like the late nights. Usually the nursing staff has a better sense of humor and there are definitely great stories that come out of the ED after 11 p.m. As long as it doesn’t interfere with my CMIO duties, I’m up for it.

In a turn of serendipitous events, I was cold-called by a recruiter who was given my name by a friend of a friend. He vetted my profile using LinkedIn and thought I might be a reasonable candidate. A local urgent care was preparing to open a second location and needed additional coverage while they recruit full-time staff. Just my speed: low acuity, reasonable patient volume, not a terrible commute, and fair pay. And so it was that I found myself on my way to a job interview.

I explained my situation to the owner – that I have a full-time job but enjoy seeing patients on the side and am looking for a way to continue doing both. He asked me a lot of questions about being a CMIO. We talked about his PACS and the patient education system.

I became a little suspicious when the questions about standalone e-prescribing systems started, so I finally just asked what system they’re using. He kind of laughed and told me not to worry, the learning curve is about 30 seconds. I wish I could have seen my face when he handed me the clipboard.

I haven’t used paper in what seems like forever. Even during downtime I didn’t do formal paper documentation, but rather took a few notes to document in EHR later. I suppose it’s probably like riding a bike, although I think the combination of computerized PACS and discharge system with paper charting might feel a little strange. Part of me decided I wanted to work there just to see what going back in time would be like. At least they use templated paper forms, so it’s not like I’ll be writing SOAP notes from scratch.

I start in a couple of days, picking up a few hours after work one night to get used to the system while they’re fully staffed with other physicians. I’m most worried about getting to know the staff, figuring out the informal processes that aren’t documented anywhere, and trying not to make rookie mistakes.

I admit I’m a little nervous, though, not to have the backup of prescription error checking and clinical decision support, not to mention the convenience of e-prescribing. I had to dig through my storage area to find the leather prescription pad holder I received as a medical school graduation gift. Maybe to go full circle with the old-school vibe I’ll have to get myself a fountain pen.

Here’s to new adventures and hopefully a slow first shift. I’ll let you know how it goes. The monogrammed white coats have already been delivered, so there’s no turning back. I hope everyone stays well, but if you happen to find yourself at an urgent care with a sassy physician carrying a hot pink clipboard, you might want to do a double take.

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Curbside Consult with Dr. Jayne 5/26/14

Several readers emailed about last week’s EPtalk, where I shared my frustration with CMS and the constantly-changing game of Meaningful Use.

Dear Dr. Jayne,

I’m sorry for how you feel about CMS and long for days of old when $5 got you a doctor visit at home. I’m 76 and have been on Medicare for over a decade. From a patient viewpoint, it beats big payers hands down. One little card with a red, white, and blue stripe gets you everything from any healthcare system, any physician, no referrals, no one ever asks a question, and, if you have a gap insurer, you almost never pay a nickel. As I recall, CMS gave every doctor $44,000 to buy an EMR and every hospital a lot more. I’m sure over $50 billion was given to providers and now CMS wants something in return. Sounds reasonable to me and almost rare that the government can’t be accused of a giveaway.

I think a lot of MU requirements are off target as to need and value. Most EMRs are off the mark in architecture, workflow, and value. So, we have the equivalent of a 1.0 standoff, but at least it is a start. Hopefully by 2.0 both the MU and EMR will have both evolved to a better place. This will take at least a decade and the practice of medicine and the technological advancements during this period will make the current systems look like stone age work.

Don’t give up on Medicare and CMS; make it better. The alternatives are much less attractive.

Sincerely,
Spirit of ‘76

Dear Seventy-Sixer,

Speaking as an Eligible Provider, I can confidently state that CMS hasn’t “given” us anything. It’s true that up to $44,000 each was available to eligible providers over a multi-year period. For most providers in my community, however, it cost far more than $44,000 to dot the “I” and cross the “T” of each Meaningful Use requirement. Even in the first iteration of Stage 1, providers had to meet 22 objectives (several of which have multiple subcomponents). For many physicians, this meant overhauling practice operations. Unfortunately, I’ve seen a lot of box-checking at the expense of clinical quality. When providers go to file their attestation, it’s all or none in nature, which creates a great deal of stress on caregivers and staff.

I’m glad you have had such a positive experience with Medicare. Patients in my community aren’t as fortunate, as many physicians have stopped accepting Medicare assignment or are limiting the number of Medicare patients they see. CMS has many coverage and medical necessity rules and my patients are spending a lot more out of pocket than some of them think is fair. We’re still in a recession and quite a few patients have been forced to drop their supplement plans or have chosen barebones coverage that they don’t like. Those who have gone on Medicare Advantage plans hate the narrow networks and further limitations, but like the cost.

Speaking of cost, going back to what it costs to implement an EHR. Looking at HealthIT.gov for numbers, they list the five-year total cost of ownership (estimated average) as $48,000 for an in-office system and $58,000 in a software as a service model. That doesn’t include practice losses during implementation or ongoing loss of efficiency, the need to add additional staff to manage all the metrics, or hiring contractors and attending classes just to make sure one understands all the maze of rules.

I agree with you that necessary change will take a decade. Unfortunately, CMS only gave providers half that time to accomplish ever-changing (and sometimes obscure) goals involving elements beyond their control before the penalties kick in. I hope there are some primary care providers left when the dust settles. I’m seeing my peers retire in droves and there aren’t enough new hires to fill the gaps, increasing patient wait times.

Sincerely,
Jayne

Dear Jayne,

What do I think? Well, I’m glad you asked. I have just spent about four hours reading, digesting, and summarizing in a document I can share internally what this could mean. Then again, it might not mean any of what I have summarized. Theoretically depends on public comments.

This has been such a frustrating process for everyone. I work with providers and healthcare organizations. There was so much confusion with the 2014 CEHRT requirement already. This will undoubtedly make it so much worse. For some EPs, it could be a life preserver – several vendors aren’t CEHRT yet. Maybe the 62-year-old provider I met with last week (whose EHR vendor wants him to sign a 10-year contract for their patient portal) will be able to delay and shop some more. Perhaps another client I work with won’t be forced to purchase a CQM module and sign a three-year contract by June 1 or be faced with missing MU Stage 2 this year because the vendor won’t have them upgraded in time.

Waiting the 60 days for public comment, however, will be like trying to fly stand-by the Wednesday before Thanksgiving. If you get the flight, all will be well and you’ll spend the day smiling and toasting your good fortunes. If you don’t, you had better be scrambling to figure out how to thaw a turkey overnight. MU and a turkey – it’s a good analogy!

Sincerely,
Apple Pie Fan

Dear Pie Fan,

Thanks for writing. Your thoughts reflect those of many people I’ve spoken with this week. The potential delay doesn’t mean anything if it doesn’t go through. If you wait for the final rule and you didn’t guess right about its content, you’re going to be caught short. In the mean time, everyone has to push forward as if there will be no delay.

I really like your turkey analogy. In contrast to CMS, however, Butterball has a turkey hotline you can call for actual answers.

Sincerely,
Jayne

I’m not sure how many readers we will have given the Memorial Day observance. I hope you were able to spend time with loved ones and took the opportunity to remember those in the armed forces that made the ultimate sacrifice. If you’re wondering about today’s picture, it’s courtesy of Smithsonian.com and was taken at the site of the Battle of the Somme. There are several other haunting images that show the scars that remain even after 100 years.

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Curbside Consult with Dr. Jayne 5/19/14

Outside of healthcare, very few people understand what a CMIO does. Usually when I meet new people I explain that I’m a doctor, but I work in the information technology world. If I get a totally blank stare, I might go on to say I work on the electronic records systems that hospitals and physician offices use.

Some will ask why I’d want to give up the money and excitement of being a physician. I suspect they don’t have any idea of what being a primary care physician actually looks like. Occasionally someone will ask me if I can help them with some home networking problem, which I find pretty funny that people assume that everyone “in IT” knows how to do desktop and network support.

Inside the hospital, I’m not sure that many physicians actually understand what we do either. They know we’re the people to call when they have complaints and that we’re usually the figurehead telling them they have to do something for Meaningful Use or CMS audit purposes. Physicians may not understand the role we play as their advocate or the depth of the battles that we fight on their behalf.

I’m not sure our role is always fully understood by the IT teams either. Some analysts think we’re just super-nerdy physicians or that we had to leave full time practice for some reason. Others are afraid that having a physician on the team means that we’re going to try to call the shots or be the boss all the time. Frankly there are some days that I’m not even sure what I do. Teams work more effectively when they understand where the various members are coming from. In that spirit, here’s a week in the life of a CMIO.

I started Monday with a half-day of teach-back training for a couple of our new implementation team members. Our organization is a stickler for making sure that training is consistent and reproducible so that no one can complain that he or she didn’t have every opportunity to learn the material. As part of that process, I deliver train-the-trainer sessions for the team.

Some of our team members come from non-clinical backgrounds. It’s important that they understand the training scenarios and clinical pearls we incorporate for our end users. Having that knowledge helps them build credibility and trust with the end users. They’ll also shadow other members of the training team so they can see various presentation styles before it’s time for them to start deliver their own sessions independently.

Over lunch, I returned a couple of phone calls from cranky colleagues who don’t understand why we won’t customize the system for their individual needs. Although our EHR is template-rich, it lacks content for some of our subspecialty physicians. They all have access to voice recognition so they can dictate narrative as part of their notes, but some are insistent on wanting click-the-box type templates.

From experience, we can build them whatever they ask for and they still won’t like it, so our bent has been to steer them to using dictation, but creating macros and templates to make it even faster. One of them agreed to try our standard approach but the other was more skeptical, so I convinced him to shadow one of his colleagues and see how well it can work. I’m cautiously optimistic.

The afternoon was filled with a mountain of email that had built up from taking Friday off. I make it a habit to not work on the weekends unless it’s an upgrade situation or a critical outage. I hope setting that example for our team means something, but I still see entirely too much correspondence originating during the off hours. Maybe it’s time for another work-life balance discussion with a couple of them.

Tuesday began early with the hospital credentialing committee, which is always somewhat of a snoozer. I appreciate the need to have medical staff committees, but they can be pretty dry. In a world where I preach the gospel of working to the top of the license, it’s hard to justify having 10 physicians sit in a room and make decisions that would be quite amenable to the committee equivalent of a refill algorithm or a standing order.

After that, I had a meeting with one of our physicians who is interested in our open associate medical director of informatics positions. He’s qualified, but reluctant to give up any of his current duties to make it a reality. Somehow he thinks he can just fit it in, and that’s not going to be the case. I keep trying to explain that we’re not going to put someone in a position where they’re destined to fail, but he isn’t getting the message. I’d really like to add him to the team, but you can’t just squeeze 16 hours a week of informatics work in between patient appointments.

I met in the afternoon with our project team to run through the presentation we’d be doing for our bi-monthly steering committee meeting on Wednesday. The budget numbers looked a little funny, so we had to dig into the reports and the time-tracking system, which is never fun. It turned out to be some operating expenditures that should have been capitalized, but it took forever to find the discrepancy.

In between meetings, there is a steady stream of email, requests to visit practices, and occasionally help desk tickets that providers want escalated directly to “a real doctor who will understand.” Most of the time those end up being user error or training issues, but they take a lot of time to explain, reassure, and arrange for retraining when needed.

Wednesday can only be described as Meet-a-Palooza. We started with the steering committee. One of our hospital VPs must be reading some kind of leadership book because he was all over asking hard questions just for the sake of asking hard questions. Although no one of them stumped us, it drives me crazy when people use meetings to try to make a name for themselves. Following that was our regular project leadership team meeting, followed by an implementation team meeting, which I usually sit in on so I can stay on top of any practices that are having difficulty with EHR.

I hid in my office with the door closed during lunch because one of our junior analysts has decided he wants to go to medical school and is driving me crazy. I think he’s watched too many episodes of “Grey’s Anatomy” and his expectations are completely unrealistic, but he’s persistent. Unfortunately he didn’t like biology or chemistry in school, and although he has a masters in health information management, his undergraduate major was political science. He’s not willing to concede that he’ll have to go back and take all the science 101 classes, so until he does, I’m avoiding him.

The afternoon’s scintillating meetings included: monthly clinical quality measures review; MU status review; new provider on-boarding; and a red-hot discussion of whether or not we should pay our providers to attend training (we don’t, but they always ask us to).

Thursday is my work from home day, which is the only day I can get anything done. I had a couple of presentations to prep – one on change leadership that I’m submitting to present at a conference, the other for a local residency program on the business of healthcare. I was able to get them mostly done, but I like to let them rest for a week or so then revise, so I’ll be back at them again. In the afternoon I worked on performance reviews. Although I don’t have any direct reports, our organization believes in a 360-degree evaluation, so I end up doing reviews of most of the implementation team and support analysts. I can only do a couple at a time before my brain shuts off, so I punctuated them with some gardening, which was pretty therapeutic.

Friday I met with our testing coordinator to review the test plan for a new specialty we’re bringing up. She’s going on maternity leave soon and I suspect she won’t be coming back, so we’ve been spending time making sure we document the process we use to evaluate new content, build scripts, and ultimately test new content. Although that will make on-boarding her replacement easier, I hate to see her go. We’ve had too much turnover in that position and I’d like to find someone who will stay for the duration.

Next it was on to our monthly ICD-10 update for senior leadership. The delay has taken the wind out of our sails. I wish someone would just cancel the meeting for a couple of months and then we can pick it up full steam, but instead it languishes on the calendar and doesn’t have a real purpose. It’s not my meeting, though, so all I can do is suggest a different path, and when we run out of agenda items, be the one to recommend we adjourn early.

Friday afternoon I came full circle with the implementation team, this time being the student instead of the teacher. I have to say I was impressed with how quickly they were able to pick up the material and how well they did. We cleared them both to go out into the field and work with seasoned trainers. They’ll initially just shadow and assist with the hands-on portions, but over the next month they’ll start teaching parts of the new employee sessions until they’re eventually teaching the entire course with another trainer as backup. By mid-June they’ll be out of the nest and on their own.

I always end Friday by looking over my calendar for the next two weeks. It gives me an idea what I need to focus on for the coming week and lets me see any conflicts or major issues in the one that follows. Sometimes our administrative assistants get a little cavalier with our schedules, so if we want to be able to breathe or eat during the day, it pays to be proactive. I realize they’re trying to squeeze every minute out of the day and respect what they do, but ultimately I’m the one who looks bad when I’m absent or late due to an overcommitted schedule.

Some weeks are different, but many are the same but with just different meetings and different cranky colleagues. When we’re close to a major upgrade, it looks completely different, with much more focus on the new version but with all the same standing meetings continuing. It can be quite the juggling act at times. Nevertheless, I enjoy doing what I do. But sometimes it’s just easier to be “the doctor who works in IT.”

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/12/14

Mr. H recently asked the HIStalk Advisory Panel to weigh in on how the ICD-10 delay will impact their organizations. My organization had asked me to put together an impact statement, but I was waiting a few weeks to see if CMS issued a final date. Now that we know it will be October 1, 2015, we can start quantifying the costs. Some of them are fairly straightforward, but others are a bit more nebulous.

Like many of the Advisory Panel respondents, we will have a fairly significant cost for retraining physicians. We had already started many of our employees through a training program. Although initially it was informational and high level, we were set to accelerate rapidly into the summer. At this point, we have placed all training on hold and will plan to start from scratch again next January.

One of our training strategies included interactive Web sessions which are invoiced monthly based on our number of licensed providers. I was pleased to find out that our legal department had inserted a clause that addresses any delay of ICD-10, so we won’t be losing much on that contract. We’ll see if the vendor tries to renegotiate, however.

We had planned to have additional last-minute training sessions provided by contractors in September. We won’t lose much on those, either. The vendor involved doesn’t charge for cancellations that occur with at least 60 days’ notice. Given the fact that we’re going to have a longer training window, I doubt we’ll need those resources for the next go-round.

One of our major costs, however, will be the training that we’ve already put into our existing coding staff. Although the majority of our ambulatory physicians are expected to do their own coding, there are some subspecialties (particularly surgical) where coding staff are deeply involved. Additionally, we have our internal compliance and audit teams. We had already sent those teams through specialized training and they may need a refresher. Due to their specialized training and knowledge of our organization, we had provided retention bonuses for several of them to stay at least through November. Given the fact that many organizations will be retraining, I suspect their value will continue to increase and we’ll likely be extending those retention payments.

We will also have increased upgrade and testing costs. Our upgrade plan was pretty straightforward since our ambulatory vendor’s ICD-10 version is also their Meaningful Use 2014 version — we were planning to kill two proverbial birds with one stone. We had already done the majority of the testing and the code is already in production, so we thought we were home free. Now we’re going to have to take at least one if not two updates prior to ICD-10, which means more testing. Worst-case scenario, there could be more updates, because it seems like every time CMS issues a new FAQ or refines an existing answer, our vendor has to create a hotfix.

I feel bad for our vendor. As a high-visibility client, I have come to know many of the senior development team members personally. I know they have agonized over the hours they put into meeting certification and regulatory requirements and the fact that those projects have cut into clinical and usability issues. Even though they’re a vendor, I know they don’t have an endless pot of money or endless resources. Hard choices had to be made. There were a few times in the past few years where I sat on focus groups with other clients to discuss various development initiatives and rank potential work, so I know directly how much consideration went into those decisions.

That opportunity cost will play forward to our providers as lost functionality. I know our vendor has plans to use this honeymoon period to shift back to usability enhancements and adding functionality. Although this is a good thing, I would bet that due to the increased regulatory and certification complexity, they will take more time to deliver new features. We’ll be playing a game of chicken to decide which updates to take based on existing vs. future features and the testing timeline as we approach October 2015.

In my mind, though, one of the more significant issues isn’t really quantifiable. I’m not sure how much of an impact it will be. Many of our providers now assume we are on a slippery slope towards skipping ICD-10 altogether. I had forgotten everything I learned in middle school about voice votes vs. roll call votes, but the nuances of how the actual legislative timeline unfolded on this one have been an interesting read. I’m not sure if Congress used this as a deliberate jab to undermine the very clear statements by CMS on there being no delay or if they were just oblivious to the nuances of the ICD-10 portion of the bill. Who is to say that some crafty legislators won’t sneak something in later?

The only good news I’ve heard out of Washington recently is the reopening of the Washington Monument after being damaged by the 2011 earthquake. I’m a big fan of our National Parks and had visited shortly before it was closed. I hadn’t been aware that half of the $15 million restoration was funded by a private contribution and was pleased to learn it was completed on time and on budget. Maybe something inside the beltway can be done right, after all.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/5/14

It’s time for another update in my ongoing saga about the physician group that our health system purchased. We’re in the process of preparing them to upgrade to the 2014-certified version of their EHR software. Initially, they balked at any suggestion of retiring their custom content. Our team has been diligently working on them and has convinced them to agree to approximately half of our recommendations.

At this point and given their resistance, I can get on board with half. It’s certainly more than none. Through discussion of their actual needs and observing their workflow, we’ve even identified a handful of customizations that we’re going to advocate that our vendor incorporate into the product out of the box. Ultimately, what allowed us to get the agreement we achieved was the idea they will be piloting the changes for a couple of months after the upgrade and then we’ll revisit them.

We added the pilot approach when we sensed they were stuck in analysis paralysis. The reluctance of the identified physician champions to make decisions was palpable. They feared backlash from their colleagues and claimed to be unable to reach consensus.

I’ve been through this enough times to know what kinds of darts their colleagues might start throwing, so I was happy to offer myself as a virtual human shield. If using the larger health system as the scapegoat for required change is what it takes to move them ahead, so be it.

Now that the decisions are made, it’s time to get their build underway and start preparations for testing and training sessions. I’m grateful the build will be fairly easy. Although large in number, most of the customizations are very easy. If we get in a bind on the timeline, we can always bring in contractors to knock it out quickly. As for the testing requirements, though, I think we’re going to be in for another fight.

Typically we bring in key end users to help us with testing. That way we can ensure that any unusual workflows they’ve come up with get put through their paces using the new software. Over time, we’ve aggregated many of these scenarios for our physicians into test scripts that our analysts can use to replicate their workflows.

The new group is a little bit of a mystery. though. I’m sure there are plenty of aberrant workflows we’ve yet to discover, so having access to their actual staff will be essential.

As we suspected, they didn’t want to let us pull anyone out of the offices or create a situation where overtime might be needed, so we had to get a little creative. I was able to pull together data from our previous go-lives and upgrades and convince them that if they let us leverage the users now, they will need less training right before the upgrade.

It still seems somewhat contrived that we have to produce data to convince them of a proven solution. I just have to keep reminding myself that they’ve come under our umbrella under circumstances that were less than willing.

I know there will be culture shock when they experience our training program as well. We require not only attendance, but participation in our sessions. Users are expected to demonstrate competency before they are signed off.

We use both written and practical evaluations for non-provider users. Providers are expected to demonstrate mastery by replicating 15-20 past patient encounters in the new system. Ideally I’d like to get them to do more, but we’ve found that’s about all we can get them to agree to.

We find that when users have completed a certain number of scenarios, they are able to get back up to speed more quickly in the days following the upgrade. It’s not rocket science – it’s a simple matter of practice.

Nevertheless, we often have physicians who fight us about the need to practice. It’s difficult to help them understand that documenting quickly and accurately in EHR while preserving the integrity of the patient visit is a skill, just like anything else they do. They wouldn’t try a new procedure on a patient without supervised practice.

Some of them try to tell us that they didn’t need any special training to document on paper. Although I’d agree that they didn’t need “special” training, they did need training. As medical students, we wrote hundreds if not thousands of patient notes, notes that were critiqued by our interns, residents, and attendings. Those of us in employed practice models had our notes further critiqued by coding and compliance auditors as well.

We plan to have our first testing and training event in a few weeks. We’re bringing in the non-physician staff first and will do our best to make the sessions not only educational, but fun and interactive. By winning their hearts and minds, it should make for an easier battle when it’s time to address the physicians.

I always like to bring homemade goodies to user events and this won’t be any exception. Right now this quick bread (made with an insane amount of butter, sugar, and sour cream) is a leading contender. Despite the calorie count, I can at least pretend it’s a health food. After all, it’s got bananas — how can it not be?

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Curbside Consult with Dr. Jayne 4/28/14

Death of a Practice

I wanted to be a physician from a very young age. Most people find that interesting because no one in my family is a physician or even in the healthcare field.

Going into junior high school, my best friend (who eventually became a nurse) and I became candy stripers, starting our healthcare careers. My first memory of a physician who didn’t make me cry was the kindly general practitioner my parents took me to after our pediatrician retired. He was the kind of doctor who kept his patient records on index cards (they were 4×6 inches) and wore a reflector on his head – old school.

Flash forward to second year of residency, when most primary care trainees start looking for a job. I had a potential offer from the medical group affiliated with the hospital where I was training. I had seen too much from the inside, though, to really want to work for them, so I decided to investigate whether that hospital where I first started was hiring any physicians.

In a stroke of luck, they were looking for someone interested in solo practice. I was offered a start-up in the small town where I grew up.

Their deal looked pretty good. Although technically employed during the first couple of years, the group allowed their sites to run like private practices and the physicians were on a largely eat-what-you-kill model. They were allowed autonomy over their practice except for certain office processes, which were paid for through a management fee taken off the top. Compared to hiring separate billing, compliance, OSHA, legal, HR, and other services, the management fee was extremely competitive.

I had rotated in one of their practices as a student and had seen first-hand how things ran. Two trainees ahead of me had taken jobs with them and everything was on the up-and-up. The non-compete was such that physicians could actually buy their practices and go private, staying in the same location, once they got off the ground. Coupled with the fact that they were willing to install an EHR at no cost to me and the fact that as a solo doc I wouldn’t have to deal with anyone else’s baggage, it was a done deal.

I had a lot of input on the office itself since construction had just started in a local strip mall. It was built for electronic health records from the beginning and was large enough to eventually house three physicians. The sponsoring hospital had done its homework and knew there was primary care demand in the community. We had people trying to make appointments more than a month before we were set to open.

I completed residency at the end of June, sat for the Board exam two weeks later, and opened the practice the following Monday. I saw nine patients that first day and never looked back.

I was proud to be part of the community. I had my own branding, Most people didn’t realize we were affiliated with the hospital. That was a big draw for some and gave us a certain pride of ownership I don’t think we would have had if we were visibly under the hospital umbrella.

Patients loved us being in the strip mall near a high-traffic intersection, glad they could park 20 feet from the door rather than having to use a parking garage or large lot at one of the hospital-based practices. I threw candy from a float in the Founders’ Day parade. It many ways, it was a dream come true.

My little office grew by leaps and bounds (“local girl comes home” is a powerful marketing statement.) Before long, I was ready to add another physician and eventually a nurse practitioner. The hospital sponsored several other start-up primary care practices, hiring a couple of my residency colleagues to help them build a troop of primary care docs to stay ahead of the community’s needs.

As for my site, since we were piloting the EHR system that the hospital’s parent health system planned to implement for all owned practices, I became pretty visible as an EHR champion. Eventually I was hired as part-time medical director for ambulatory EHR. One half-day a week at the IT office became two, then four, to the point where several years later I was only in the practice one day a week.

Eventually, patients’ lack of access to me became the topic of every office visit. Realizing it wasn’t good for the practice or my morale, one of our IT directors figured out a way for the hospital and IT to buy me out. It was a bittersweet decision to leave my little start-up, which wasn’t so little any more. We never turned an enormous profit, but we did break even and I had the opportunity to recruit my own replacement. It seemed like things were in good hands, so off I went to the land of IT.

The practice thrived until the recession started, the auto industry failed, and other heavy industry went to states with cheaper costs of labor. I had moved on career-wise, but still had enough connections to hear the updates on “my” practice. The staff was a little less busy, the bad debt write-offs grew, and the finances moved into the red.

The hospital president believed in primary care, though, and continued to subsidize the practice, knowing there was a need in the community (I’m not naïve — he also knew how many million dollars in ancillaries the average primary care doc drives to his or her preferred hospital.) And so the office stayed open.

Fast forward, and the hospital (now a major part of the regional safety-net rather than a community resource that drew patients through innovation and excellence) posted several major losses, sending its president to greener pastures elsewhere. Then one of the providers left for a higher salary, followed by another who took a maternity leave and never came back.

The hospital had a hard time finding a physician who wanted to care for patients with difficult socioeconomic challenges, especially when affluent practices with richer payer mixes beckoned. They weren’t willing to guarantee a salary that would have convinced someone to stay. I had last heard the practice was running with a single nurse practitioner who was supervised by a physician 20 miles away.

I found out today that the office is closing. Once I stood on the sidewalk with the mayor of our small town, cutting the “Grand Opening” ribbon with his giant gold-painted scissors. Now that sidewalk will lead people to yet another vacant quasi-retail space.

The provider who remains is being “consolidated” into a shared office on the hospital grounds, where physicians seem to land when they can’t get along with their partners or their practice loses too much money. Any trace of the office we worked so hard to build will soon be gone.

The economic reality is that no one wants to own small primary care practices any more. The work is hard, the hours are long, and the pay is less than other specialties. Hospitals stepped in hoping to lure primary care docs to their communities and solidify their slices of the revenue pie. Once they stop making money, though (which is often the reality of primary care in our current model,) it’s the beginning of the end.

Perhaps new payment models could have saved my little practice, but we will never know. Rather than having a family physician down the street or around the corner, patients will drive half an hour and navigate the maze of the hospital campus. They’ll probably be subject to a facility fee now, as I’m sure the remaining provider will be set up as a hospital outpatient department to try to eke out as much revenue as possible.

Even though I haven’t practiced there in years, I feel bad about it. I’m sorry that primary care doesn’t get the respect or compensation it deserves. I’m sorry that the hospital is no longer willing or able to subsidize valuable community services.

But most of all, I’m sorry for the patients. I’m grateful, though, for the time we had together, for the times I was able to help, and most of all, for the memories.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/21/14

Next weekend is my medical school reunion. Although I can’t make it, the fact that it is happening spurred me to try to re-connect with old friends and colleagues. Some are from med school, others are from residency, and a few are friends I made when I was a young solo practice doc trying to figure out how to fit into the medical establishment.

I had a nice chat with a friend of mine who is a pediatrician. It was interesting to catch up because her practice is different from what I see every day. Hers is a traditional group private practice, but they only take commercial payers – no state or federal programs. As such, they’re not on the Meaningful Use treadmill. They document in paper charts that are filed by family rather than individual – totally old school as far as most health information management folks are concerned.

I had talked to her several years ago when they were trying to implement the same EHR that we were rolling out to our employed physicians. They had purchased their system through a local reseller, hoping to get good service from people close to home rather than buying directly from our vendor who is headquartered halfway across the country.

Unfortunately that local reseller was purchased by another reseller who didn’t have the greatest track record for customer service and most of their local resources were let go or quit. Because of that situation (coupled with turnover in their practice leadership), they had halted their implementation after bringing the billing system live.

They were heavy admitters to one of our hospitals, so I did a courtesy consultation to provide some advice on how to proceed. I talked to them about working with their reseller to come up with a phased implementation plan that would help them transition slowly since they weren’t in a huge hurry and had multiple older physicians who would need convincing and a lot of hand-holding.

We had run into each other in the newborn nursery almost a year after that, so I knew they continued to struggle with the system and ultimately went back to paper, although they were doing well with the billing system.

When I caught up with her a few weeks ago, I learned that they had made the decision to replace their entire system. They never got the EHR off the ground, largely because the older physicians perceived the software as too complicated and too clicky. They had not taken any upgrades since their initial installation in 2009, so I can see why they thought that – early versions of the software were indeed clicky and it wasn’t easy to save physician-specific defaults and preferences.

The practice had tried to re-implement on that version even though our vendor had since rolled out a redesigned user interface that vastly improved the workflow. She said that due to a lack of confidence in the reseller coupled with the physician resistance, they were afraid to take any upgrades.

They decided to go with a specialty-specific product, rolling out the practice management system first without any kind of conversion from their previous system. For a busy practice with nearly a dozen physicians, that surprised me – not even a demographic conversion. They went live on April 1 and every patient had to be re-registered, whether they were presenting for an appointment or calling in.

They made no adjustments to the schedule to accommodate the change because the providers refused to risk a revenue loss. As a result, they are running hours behind by the end of every day. Talk about an April Fool’s Day joke! Needless to say, no one is happy – the providers, the staff, or the patients.

Patients are complaining about the registration process because they have to provide information they didn’t previously, specifically race, ethnicity, and preferred method of contact for patient reminders. Sounds familiar! I asked her why they’re doing that since they’re not attesting for MU, don’t participate in any research or quality programs where those fields are needed, don’t do email or texting, and it’s not required by payers in our area (yet). The answer: those fields are required in the system and can’t be turned off.

I asked her how the system handles other information that may be needed for MU but not for the way the practice currently delivers care. She has no idea. I wouldn’t be surprised if there are plenty of other required fields that they’re not going to be happy about once they start implementing EHR.

I asked what their plans are for that. She didn’t really know whether they plan to implement EHR in 60 days, 90 days, or a year. There’s no burning platform, but I would expect a partner to at least have some kind of understanding of the group’s strategic plan. I asked about the family charting – which is very different from individual charting – and she had no idea how they plan to resolve that, either.

I’m sure I was giving her some funny looks during this discussion because my brain was positively spinning. They’ve traded one system (where at least they could have turned off those required fields) for another with no long-term plan for whether they’re simply converting to paperless charts or whether they plan to use an electronic health record to transform care.

I suspect that as time passes they’ll find themselves in substantially the same position they were in six months or a year ago, except they’ll be paying down another initial investment. I didn’t ask about the cost of the new system, but I hope that at least their monthly software maintenance payments are a little less. Until they start having some serious conversations with all the physicians though about what having an EHR means to them, what they want to get out of it, and how they plan to go about it, there is the potential for some serious unhappiness down the road. They’ll be doing the same dance but with another vendor.

Although they were never stressing about Meaningful Use, they were having mild heart failure over ICD-10 and were very grateful for the recent reprieve. As a relatively small single-specialty group, their transition will be less complicated (and hopefully less arduous) than some of ours and I wish them well. Given their payer mix and patient population, some of their challenges are different from those faced by my practices on a day-to-day basis, but many are the same. I left her with some good discussion points for her next practice management meeting and a promise to check in more frequently to see how they’re doing.

There are a fair number of physicians and practices in the market for replacement systems. I wonder what percentage of those purchases are truly from system deficiencies (including lack of certification)? I’d like to compare that to what fraction of them are due to a lack of understanding around how to successfully transition to electronic health records coupled with a vendor who is unable/unwilling to take a hard stance with its customers to force them to do things in a manner that will make them successful.

Are you in the market for a replacement system? What makes you think it will be different the second time around? How are you planning to do things differently? Email me.

Email Dr. Jayne.

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.