Curbside Consult with Dr. Jayne 12/9/13

CMS tried to bury it with a late press release on a Friday afternoon, but their proposed extension of Meaningful Use Stage 2 is already making waves. Initially it seems there was quite a bit of confusion about “delaying Stage 2” when the start date doesn’t change. For those of you who haven’t read the actual CMS release (the site was unresponsive most of the times I tried today), the key point is that Stage 2 will be extended through 2016 and Stage 3 will begin in 2017 for those providers that have completed at least two years in Stage 2.

Clear as mud? I thought so. CMS claims the change will allow it to focus on successful implementation of the Stage 2 requirements and also to allow it to use Stage 2 data to “inform policy decisions for Stage 3.” What does this mean for those of us in the trenches, particularly small practices? Is Stage 2 going to be a “best two out of three” where if you miss in one of the years, you can use a mulligan? Are they going to use the data to see that people are failing and make Stage 3 more realistic? Will they see that people are opting out by abandoning Medicare and make some changes? I doubt it.

If CMS really wanted to make a difference for rank and file providers (keeping in mind that not everyone is employed by a hospital, health system, or large medical group) it would remove the need for Eligible Providers to meet every requirement in an all-or-nothing fashion. Our hospital has an entire team of people devoted to keeping up with CMS and reading all the FAQs. The team subsequently educates the employed physicians. I can’t even fathom what it would be like to be in a solo practice or a small group and to try to keep up with it all.

The release summarized the goals of Meaningful Use. It’s been a long time since I read the initial announcements and documentation from CMS and maybe in trying to keep up with all the details I had forgotten what they were. Seeing them again struck me a little funny: “The phased approach to program participation helps providers move from creating information in Stage 1, to exchanging health information in Stage 2, to focusing on improved outcomes in Stage 3. This approach has allowed us to support an aggressive yet smart transition for providers.”

Really? Aggressive yet smart? In my experience as a CMIO having to coach my peers through this, it hasn’t seemed very smart. Although we’re certainly creating a lot of information, it doesn’t feel like most physicians are using it to do anything other than check the boxes for the Meaningful Use requirements. Why couldn’t we have followed Stage 1 with an outcomes stage directly related to the data collected initially? Exchanging information is important, especially for patients who see multiple physicians and receive care in multiple environments, but putting too much focus on it seems a bit like putting the cart before the horse.

In Stage 1, providers are busy clicking boxes about tobacco use, gathering structured ethnicity and race data, and essentially doing nothing with it. I’m not seeing many of my peers using that information to better their attempts to help their patients stop smoking let alone to create or improve population-based interventions based on the makeup of their patient panels even though they now have that data. Physicians feel like they’re on a hamster wheel with no way off and are not making the connection with how the data will be helpful in the future.

In putting outcomes last, CMS shows they’re focused on large-scale outcomes rather than the micro-type outcomes that lead to better health for individuals. In looking at how public health has tackled population-based problems in the past, we’ve seen that it can take decades to move the needle where national health issues are concerned and sometimes we aren’t moving it anywhere near enough, such as with obesity.. Most of my physician colleagues are focused more on individual outcomes and work to do their best for every patient each time he or she is seen rather than worrying about everyone out there.

It’s challenging to get them to think about populations when they’re trying to figure out how to get the patient in front of them enrolled in multiple pharmaceutical company patient assistance programs, how to arrange transportation to other appointments, how to order tests and referrals, and how to address multiple mental health issues all in a 10- to 15-minute appointment. Additionally, let’s not forget trying to get all these services pre-authorized and pre-approved because insurance companies try to block them even though they’re medically necessary. And they’re also doing it while trying to see enough patient volume to pay for employees to handle all of the above so they can actually care for patients.

Hindsight is 20/20, but it seems like it would have made more sense to put in place strategies for physicians to see how gathering discrete data can be of benefit and use those experiences to encourage people to continue through the Meaningful Use program. For those of us in groups that were ahead of the game and have been gathering that data and using it for years, how about bonuses for moving more quickly through the program?

In the announcement CMS also notes that this timeline shift will allow “more consideration of potential Stage 3 requirements [and] additional time for preparation for enhanced Stage 3 requirements.” Any Eligible Providers who don’t think this is an opportunity to make Meaningful Use even more arduous and complicated than it already is should rethink their impressions of the program. There are some providers out there who actually think this is just a three-act play. I would be shocked if Stage 3 is the end.

CMS plans to release a Notice of Proposed Rulemaking for Stage 3 in the fall of 2014 along with the 2017 Edition of the ONC Standards and Certification Criteria. The final rule is to be released in the first half of 2015 which still only gives providers and hospitals (not to mention vendors) about a year and a half to be fully compliant. That certainly doesn’t feel like we’re coming off the treadmill as much as most of us would like.

Organizations such as CHIME have already come out stating that the timeline shift doesn’t change the fact that Stage 2 and ICD-10 are going to hit at the same time in a “perfect storm.” CHIME is pushing for flexibility in the start date of Stage 2. HIMSS is supportive of the extension but continues to ask that the first year of Stage 2 allow at least 18 months for attestation.

I did find one bit of silver lining in the announcement, and that is the voluntary nature of the 2015 Edition of certification criteria. The release specifically states that providers will not be required to upgrade to a 2015 Edition EHR and vendors who have certified to the 2014 Edition would not need to recertify. Since I’m already on a certified version that’s ready for Stage 2, it is a relief to not have to take another major regulatory upgrade for a while. Instead we can focus on updates that bring actual clinical functionality to help our patients which unfortunately feels like a novel concept, assuming our vendor is able to get back to the development plans they had before Meaningful Use reared its sometimes-ugly head.

The devil will be in the details, but I’m not going to lose sleep waiting to find out what they are. I strongly suspect our hospital will elect to continue on our current trajectory (minus the anticipated Stage 3 payments for 2016.) Unless CMS pulls a rabbit out of its hat, we’ll be OK. What do you think about the proposed changes to the MU timeline? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/2/13

Back in the day, I was a Girl Scout. Yes, I sold cookies, which probably prepared me for the sales hustle I’d have to do as a physician, trying to convince patients to do things that were good for their health but that they didn’t always want to do. That sales hustle has also been useful in working with reluctant physicians to convince them the EHR isn’t out to get them. My favorite cookies are the Samoas and Thin Mints, in case you’re wondering. Besides the camping and badges one thing I remember is how we used to close our meetings. We crossed arms and sang a song: “Make new friends, but keep the old; one is silver and the other gold.”

That small song was on my mind this week for a variety of reasons. For many people, the holidays are a time of stress, and Thanksgiving kicks it off. I got to spend the holiday cooking with my grandmother and my mom, who finally let me make the gravy, so I guess I have arrived as an adult. She also shared her secret recipe for stuffing. In yet another stroke of good luck, this year’s Thanksgiving conversations were light on the Obamacare and more focused on whether Thanksgiving shopping is good or bad. Social Security and Medicare weren’t topics either. which made the holiday table even more enjoyable.

This was my holiday to be the on-call executive in the event of an unexpected downtime or problem with a critical system. I was keeping my phone close.  Halfway through the dishes, I heard a text message come in. I’m still a little adrenaline-tuned with message indicators on my phone, so I only use them when I have to – probably Pavlovian conditioning from all the years carrying the code pager in medical school and residency – so when it dinged I picked it up with more than a little trepidation.

The message that came in, however, was just what I needed. A colleague halfway across the country making an ongoing joke that started more than three years ago and wishing me a Happy Thanksgiving.

It was a small thing, yet it got me to thinking about the friendships I’ve made and the relationships I’ve built since I’ve been in the CMIO trenches. Before I went into informatics, my circle of colleagues was pretty small – a handful of friends from medical school and residency, my referral base, and other physicians on staff at my hospital. Now I am grateful to have colleagues across the country and around the globe. I’ve had the privilege of bouncing ideas off of people from rural Iowa to the Arabian Peninsula. It’s heartening to know that no matter where we work we’re all dealing with similar challenges.

It’s not just the other CMIOs, though, for whom I am grateful. I appreciate the relationships I’ve built with our vendors. They haven’t always been easy, but the bonds that are forged in adversity are pretty tough to break. I’ve enjoyed getting to know all the analysts in our department and watching some of them grow from interns to respected leaders on the team. We’ve had weddings, babies, and funerals, and even in the sad times, it’s heartening to watch people genuinely care for each other. Sometimes the day-to-day knowledge makes things fun: knowing who in the office wants the leftover deli pickles nobody else wants; knowing who can be bribed with chocolate cake; and knowing that surprising someone with a cold Diet Coke at the right time can make all the difference.

Having friends in all parts of the EHR universe has been a great experience, though sometimes a challenge. Whether it’s schmoozing developers in the hopes of speeding enhancement requests into code or playing incredibly bad golf in front of the entire IT department, being in this position has taken me places I never thought I’d go, both figuratively and literally. (There are still a few places I’d like to go, but I guess I’ll have to keep holding out for that CMIO gig in Italy.)

Even with the busy holiday week, I had a chance to meet up with a health IT friend I usually see only at HIMSS. The conversation was so easy it was as if we see each other all the time. It was great to share war stories, catch up on family news, and gaze at the crystal ball to see what HIT will bring us in the coming year. This fall has been very good to me. I’ve had the pleasure of meeting great people at a recent national meeting I attended and the comfort of being able to lean on friends both old and new when trouble crossed my path.

As I head towards my fourth HIMSS as a member of the HIStalk crew, I realize what a privilege it is to be part of this team and what an adventure it has been. I never dreamed I would have fans who send me pictures of their favorite shoe finds or even an actual chocolate shoe, but they’re out there and I appreciate each and every one of you and hope to see you at HIStalkapalooza (anonymously, of course). We never know who is going to cross our paths or where things will head, but that is part of the thrill.

While I was looking for a graphic to go with today’s piece, I learned that the song actually has several other verses. One is about a circle being round and having no end, which is touching, but I found another verse that I like even better: “New made friends, like new made wine; Age will mellow and refine.” So I will raise my virtual glass to all our HIStalk readers and to my friends and colleagues old and new. Here’s to the next adventure.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/25/13

I’ve seen a lot of articles lately about physicians who are unhappy with their EHRs because they feel they’re being forced to collect too much meaningless data and to do “too many clicks.” I read most of them to see if I can pick up any pearls that will help my physicians and also to prepare counter-arguments for when my colleagues email me links to those articles.

I’ve used quite a few different systems and each has its own little annoyances. Physicians always seem to think the grass is going to be greener on the other side of the fence. If I had a dollar for every time I’ve heard someone say, “It would be so much better if we just had System X,” I could retire much sooner than currently planned.

I know I have a fair number readers who are CMIOs, medical directors, CMOs, or EHR champions. There are quite a few physician leaders I know who are new to the EHR game and haven’t quite figured out all their responses yet, so I wanted to share some of mine. These should also be helpful to anyone who has to work with physicians, train them, or manage physician practices. Vendors might want to take note as well and incorporate some of these elements into their implementation and optimization strategies.

When physicians complain about entry of discrete data, I like to ask them specifically what data fields they are referencing. Our organization has a pretty liberal policy about using free text or voice recognition to enter data in certain parts of the chart. For example, users can enter the patient’s History of Present Illness (why they are seeking care and how their condition has progressed) in a non-discrete way. No drop downs, no picklists, no checkboxes, if that’s how they want it. When you dig deeper, many of the fields they are complaining about are those that are required for Meaningful Use, quality initiatives, or important things like drug-allergy checking. They are often fields that do not specifically require physician entry.

We created a matrix of required data and documented which staff members could be authorized to enter the data after appropriate training. It also includes directions on where and when it should be done in the flow of the patient visit. For example, the patient’s pharmacy and HIPAA contact preferences can be entered by the front desk check-in staff. Neither data element requires clinical training or expertise, just access to the right screens. If a physician has to enter the pharmacy name (and it’s not because the patient changed his or her mind at the last minute regarding where the prescription should be sent) this is a systems and workflow failure, not a “terrible EHR.”

The matrix also explains specifically why each data element must be collected, what our organization plans to do with it, and how it benefits patient care. This has been a helpful reminder for many of our physicians as well as new information for those who tried to skip out on training. It doesn’t make the data gathering less from a volume standpoint, but often understanding why these might be “good clicks” can make them feel less burdensome.

For those physicians who do choose to enter non-required data discretely, the most common mistake I see is feeling the need to ask about something just because there is a field for it. For example, in the social history section under pets, our EHR has a specific checkbox for “reptiles in the home.” This makes sense if you’re a gastroenterologist or infectious disease specialist treating certain symptoms, or if you’re a pediatrician who needs to counsel against risks, but if it’s not pertinent to the user’s specialty it doesn’t need to be asked.

It’s OK to ignore fields. That’s a hard thing to teach people – if you don’t like it or don’t need it, don’t use it. And if you didn’t ask it before EHR ,don’t feel obligated to ask it now just because there’s a box (unless it’s flagged as required).

One of the other things I hear a lot of complaints about is refill management, especially in the primary care setting. Some EHRs are better than others at being able to streamline refills, but the key is to eliminate the existence of the refill request in the first place. This is not really an EHR strategy. Primary care literature has been talking about this for years, but it’s been slow to catch on. The concept of writing for enough medication to see the patient through the next scheduled appointment (or for up to a year for stable patients with controlled conditions) seems hard for some physicians to accept. Of course there are some controlled substances that aren’t inherently refillable and may require paper prescriptions between visits, so practices need systems and rules to handle these so they don’t cause chaos.

In my practice, I took a lot of time to educate our patients that we don’t do refills. If they are out of medication, they need to be seen. Everyone in the office was schooled on the same message so that it could be delivered consistently. Patients were encouraged to schedule their next appointment before they left. We had same-day and next-day appointments available for people who missed the point and ran low on their medications. Worst case scenario, we could get patients in to be seen within a week and at that time they got new refills for a maximum time period based on their status (as well as re-education.)

Another huge time suck is allowing the patients to call a refill phone line at the office and leave messages for the staff requesting refills, or even worse, to speak directly to a staff member. Those conversations were never brief. Patients often brought up other medical issues or wanted to chit-chat. Given the status of electronic refill requests in most systems, it’s much more efficient for patients to request their refills through the pharmacy and let the staff process them electronically in the EHR. The worst case of this I’ve seen is staff who were transcribing the voice mail messages onto little pink phone message slips, then later transcribing them into the EHR. Not only was it double work, but it delayed the refill process for the patient. Again, there are exceptions (controlled substances being one of them) that may merit a call to the office, but these should not be the rule.

Physicians usually push back here and tell me they don’t want to receive requests from the pharmacy because X pharmacy always sends erroneous requests or something similar. I’ve seen this in practice and have found that a quick phone call to the pharmacy supervisor recommending that they get their staff in gear or you might start recommending all your patients have their scripts filled at Competitor Pharmacy Y is very helpful in producing high-quality refill requests with few errors. It may take 10 minutes to make the call, but it will save countless minutes in the future.

For practices that refuse to write medications through the next scheduled appointment, I often recommend a protocol-driven refill policy that allows nurses to refill based on a signed standing order and written algorithm. The key words here are signed standing order and written algorithm. You can’t just let your staff issue refills “because they know what you would want” because in most states that’s considered practicing without a license. On the flip side, you can’t have standing orders in every state and may only be able to do them with a certain level of staff (RN), but it’s worth considering. If a patient who has controlled high blood pressure and high cholesterol is current on labs and has an appointment scheduled, I as a physician don’t need to see that request because my protocol allows the staff to issue scripts through the scheduled appointment.

These concepts stray a little from our healthcare IT focus, but I’m tired of the EHR taking the blame for clunky and duplicative office processes. In what situations do you find physicians and staff using the EHR as a scapegoat? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/18/13

Lots of buzz this week around San Francisco’s “Batkid” fighting crime with the help of the Make-A-Wish Foundation. The real heroes there were the people behind the scenes, coordinating to make this leukemia patient’s wish happen as he celebrated completion of three years of treatment. I’m fortunate to work with superheroes every day, although most of them are the unsung variety. I’d like to introduce you to a few of them.

The Desktop Support Agent. One of my favorite people in our health system’s IT universe, he lives in another time zone, but you’d never know it. It’s almost like he never sleeps. No matter what time of day I open my ticket, he always responds with a virtual smile. He relocated away from our city to be closer to family and is a great example of how remote employees can be an asset to the organization. I’ve had to call with some pretty ridiculous questions, including problems with my calendar appointments spontaneously mutating (a.k.a. user error) and my entire inbox vanishing. He’s very nonjudgmental when you call for newbie-type problems (or maybe he’s just good at hiding it). Without him our jobs would be a lot harder and I know many users take him for granted, so I always make sure he knows how much I appreciate him.

The Documentation Supervisor. This unsung hero works for our vendor and was instrumental in helping a small, rabid group of clients convince the legal team that it would be OK to give clients copies of the training manuals in editable format. For many years, they were afraid of this and would only provide PDF copies, which was silly since we ended up reproducing all their content anyway so that we could create end user training manuals. She manages an extremely diverse team and ensures that what the technical writers produce is in a truly human readable format. She encourages clients to provide feedback on the materials and actually incorporates the changes. I have to laugh because every once in a while she will slip in something that is a reference to one of the rabid clients – it might be a patient name on a screenshot or a practice address, but it’s always funny.

The Account Executive. Our hospital uses CCOW technology, which was originally provided by Sentillion, which was gobbled up by Microsoft. Although we had multiple systems live and sharing context, we ran into some roadblocks bringing up a new application. Microsoft played the “we don’t support that Software Development Kit anymore” card and our vendor was at the end of its rope as far as what it could do to try to bridge the gap. The Account Exec worked tirelessly on our behalf, calling in multiple favors and arranging calls with the actual developers who helped us code around the problem. It would certainly have been easier to just say no and go along with the party line, but I will be forever in his debt for helping us out.

The Hospital Volunteers. Ours used to be called “Pink Ladies,” but now they’re co-ed. Some of the veterans still wear pink smocks and that definitely puts a smile on my face since it reminds me of my days as a candy striper. They always greet you with a smile and even if you’re having a terrible, horrible, no good, very bad day you can’t help but be engaged by them. They will go out of their way to find things to make our oncology patients have a more comfortable stay, even tracking down unusual reading material. I could say I once saw one bring in a bottle of Scotch for a patient, but that would probably violate their circle of trust, so I wouldn’t dare.

The Citrix Guy. This is my absolute favorite superhero. When our IT department was a little less mature and a little less competent (did I just say that out loud?) he saved us. We had just deployed dozens of offices not only over Citrix, but using wireless at a time when it was a relatively new technology. Our team just wasn’t very good at it and we had all kinds of issues with dropped sessions, random application hangs, and misbehaving CCOW. He swooped in (I swear it was like he had a cape) and helped us fix our own dysfunction, yet never made our team feel less than capable even though they were. He travels 48 weeks out of the year and is in a different city nearly every week yet never seems tired or worn out. I don’t know how he does it.

There are many other unsung heroes we encounter every day. Who are yours? Email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/11/13

Jayne Goes to the Doctor

Like many Americans, I’m going through my employer’s open enrollment period for health insurance and other benefits. Additionally, my health insurance is changing at the beginning of the year, so there’s a bit of a double whammy trying to pick a new plan that has the physicians I see as well as coverage that works for me. Trying to read through the various summary plan descriptions is a bit like reading a foreign language. If it’s that difficult for someone who is a healthcare professional, I can’t imagine how difficult it is for the average patient.

My hospital requires that I complete a health risk assessment (online, of course) and have biometric testing done in order to receive a discount on the employee portion of the premium. I got the results today after receiving an email to access the lab vendor’s secure portal. There I experienced what I’m sure many patients also experience – confusion and misleading information.

First, there were graphics with screaming red exclamation points indicating problems in the “heart” and “other” categories. Navigating through the results showed that anything outside the reference range flags an alert. Looking more closely, it flags the same alert whether a value is high or low, which I think is confusing for patients. My cholesterol was a few points below the reference range. Having been through several epidemiology and biostatistics classes, I know how reference ranges are derived, but the average person doesn’t understand this.

According to the accompanying text, low cholesterol “can indicate malnutrition, intestinal malabsorption, hyperthyroidism, chronic anemia, liver disease, or other medical conditions.” I happen to know I don’t have any of those conditions since I just had other (more extensive) lab work done a few weeks ago with my new primary physician. Unfortunately, my employer’s third-party health contractor wouldn’t accept that lab report and made me go again to have blood drawn. Why is this kind of waste in healthcare OK? Could they not trust labs I had done at the same national reference lab? Did I really need to fast again and have another needle stick?

Conversely, had I not been to my primary physician recently, wouldn’t it have been nice if there was a way to securely send the results to my physician? No such luck unless I wanted to print it. I’m baffled that physicians and hospitals are being required to view / download / transmit patient data but the rest of the health vendors such as pharmacies, labs, etc. are not held to the same standard.

Going forward through the website’s report for me, it displayed the US Preventive Services Task Force recommendations for a person my age. It wasn’t surprising that USPSTF recommends screening less frequently than my employer requires. Based on my age and values, I don’t need another blood pressure screen for two years. I don’t actually need a cholesterol screen at all – I have no risk factors and am below the screening age. I don’t need a diabetes screen either, yet I was required to have both of these two tests done in order to receive a discount on my insurance premium. I’ll also have to do them again next year despite the fact that I still won’t need them.

There were some things about the visit to the biometric screening lab that were less than optimal – they relied on my reported height rather than measuring me and didn’t bother to ask if I had fasted or not. I don’t advocate cheating on health-related tests, but I wonder how many people do? Another inch of height always makes a girl’s BMI look a little better.

At the draw station, tubes from multiple patients who had gone before me were sitting in a rack with names visible. I was required to sign a form that said the blood tubes had been labeled in my presence and were accurate, but I didn’t actually see the tubes and the phlebotomist didn’t actually ask me to sign the form but instead pointed and shoved a pen at me.

Bottom line, though: I did my health assessment and got my discount. Now I get to spend the next couple of weeks trying to fit in various health appointments before my insurance changes. I’m sure it will be fine, but it’s always a pain to figure out new coverage and I’d rather just get things done on the plan I’m familiar with (and with my deductible already satisfied for the year).

My previous physician’s practice had issues with its patient portal, including erroneous demographics that they never could correct and a kludgy user interface. My new physician has a slick portal and actually sent timely and relevant information to me after my visit, so I’m glad I get to keep her.

Have a good health IT story from the patient side? Email me.

Email Dr. Jayne

Curbside Consult with Dr. Jayne 11/4/13

For the last few weeks, my email box bas been filling up with lots of comments and feedback. I particularly like hearing from other CMIOs in the trenches who are sharing the same experiences. Let’s dip into the reader mailbag and see what’s buzzing with our readers.

Dear Dr. Jayne,

What do you think is going to happen when folks have those big deductibles because their Bronze or Silver insurance operates that way? Won’t the docs delay billing by months so they don’t have to chase the deductible, especially if it’s the professional fee associated with inpatient or ambulatory surgical care? It used to happen only in January, but could it become a year ‘round phenomenon? Or do you have other thoughts?

No Sleep Till Brooklyn

Dear Brooklyn,

I hope this doesn’t happen. To me, waiting to bill until you think a patient has met his or her deductible is kind of like playing Russian Roulette. If you wait too long you could run up against timely filing deadlines and miss out altogether. Plus there is no guarantee of when the patient will be meeting his or her deductible.

I’m hoping that this pressure will improve the quality of services offered by eligibility vendors and encourage more adjudication and subsequent collection at the point of care. For elective or semi-elective services, this should be fairly straightforward as long as providers know their contracts and are willing to ask for payment. At a minimum, they can collect the patient portion of the post-deductible allowance. Providers could also elect to go for a higher amount and refund it later, or go ahead and set up payment plans for high-dollar services.

It’s a little trickier with inpatient since it’s not always planned and emergency services will be even tougher. I think the best strategy is to go ahead and bill as you have been doing (preferably as soon as possible) and get the charges in the system. We bill daily in our organization although statements only go out monthly. For patients who see multiple providers, this will help those deductibles be met faster. It’s not going to change how fast patients pay their bills, however, so there will still be the need to collect up front as well as to chase the rest of the payment.

I think there is also the possibility of more medical credit cards and debt programs like those we used to see only in the cosmetic and dental realms. Some can be a good deal, especially those that are low interest, but there have been some abuses recently and patients will have to protect themselves from predatory lending.

Jayne

Dear Jayne,

I’m outraged at a recent blog post from Evan Grossman at Athena. He talks about retail clinics “following guidelines” more often than the actual doctors’ offices. I always wondered what it would look like when we have all this “data” to look at. I am convinced that what we are measuring now is actually what is easy to measure – the low-hanging fruit. What we do with that data is going to be important, but all this data interpreted in silos is going to cause more harm than good. Like Einstein said, “Not everything that counts can be counted and not everything that can be counted counts.”

In reality, many of my patients may only get to see me when they come in with a “cold” and get to talk about their prevention, cholesterol, and BP or weight and now even that is not happening as we have an even more fragmented system for the sake of convenience. I cannot give the flu shots to my patients, but I am supposed to report on it? I am merely reduced to treating train wrecks who could have had a chance at a conversation for prevention but they dismissed it because the Walgreens was closer and cheaper. Penny wise and pound-foolish.

The Thrill is Gone

Dear Thrill-less,

I share your disappointment with this simplified analysis and agree that right now we’re looking at the low-hanging fruit. We’re also looking at many factors that I’m not sure make a bit of difference in the long-term outcomes for patients – factors like wait time and patient satisfaction scores. We also can’t just look at retail clinics as low-cost providers – we have to look at total cost of care. We know that comprehensive care by a single primary care physician can be very cost effective. That’s one of the reasons behind the patient-centered medical home pushes we’re seeing and is also important for the accountable care movement.

We’ve figured out though that we can’t get enough primary care physicians to operate in the way they need them to for the reimbursements they receive, so we end up with multiple care providers and locations and hope interoperability can patch it all together. I understand that the PCP can’t do everything and we need interoperability to put together the hospitalizations, post-acute stays, home health, and other data, but adding the equivalent of multiple PCPs to the mix is not the answer. I’m not opposed to retail clinics. As a solo PCP for a number of years, it was impossible for me to be open 24×7 and I’d much rather see patients have a low-cost alternative to the ER.

In my state, nurse practitioners can only practice independently for certain types of conditions unless the patient sees the collaborating physician first, so it’s important to understand that retail clinics cannot take over everything a primary care physician provides. Incidentally, I ran my office in an open access paradigm where same day appointments were the norm, so during business hours, there was no need to go elsewhere. Patients appreciated that and it made my practice grow quickly.

If I could have staffed my office the way retail clinics staff — with a rotating cast of part-time nurse practitioners (which is largely what I see in my area) — I could have had a lot more access, but it wasn’t what the patients wanted. They wanted a single person to get to know them and take care of them. That doesn’t come cheap, though. It requires smaller patient panels, high-quality staff, and efficient systems (both technical and operational) to ensure quality care.

Check out this story about Illinois physician Russell Dohner, who has been seeing patients for $5 per visit for decades. He had the luxury of doing that because of a family farming business that helped pay the bills. He also sounds like he oozes altruism from every pore and pretty much sacrificed most of his personal life to caring for his patients. Residents of his town “would line up in his office and wait as long as they needed to see him” but he would often be working until 9 p.m. (as would the local pharmacy who always waited for him to let them know he was done seeing patients). That’s just not a reality with many people today who seem to be taking “me-me-me” to the extreme. Now that you can track facility wait times on Twitter and go wherever is quickest (or to whichever retail pharmacy offers you a 20 percent off coupon for non-drug items after your visit) why bother waiting for someone who wants to care for you until you die?

I’ve had patients complain when I ran late after sending a patient out of my office via ambulance. Really? I guess they figured that patient who just rolled past them on a gurney to the big yellow vehicle with the flashing lights triple parked outside the waiting room didn’t need extra time, or maybe the complainers are just narcissists. Medical care should be first and foremost about quality and caring, not cost and convenience. Being a member of the human race should also be about getting over one’s self and putting yourself in the other guy’s shoes from time to time.

I’m not saying physicians should habitually run late because that is disrespectful to patients, but people need to understand that if you don’t want cookie-cutter medicine, you might have to wait now and then. I’m not giving physicians a blank check for outrageous charges, either – but being able to collect enough payments on a visit to actually pay a health coach, a social worker, and a diabetic educator to work with me would be nice since I’m now expected to provide those services on top of normal patient care. It’s rare to get the same kind of long-haul care in a walk-in clinic with a rotating staff as you would in a true medical home. If nothing else, I would almost bet the midlevel providers at a retail clinic aren’t having sleepless nights about their patients nearly as often as the average family physician, internist, or pediatrician.

Jayne

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Curbside Consult with Dr. Jayne 10/29/13

Last week ONC released another game-based security training module. “CyberSecure: Your Medical Practice” is aimed at providers and staff and focuses on disaster planning including data backup and recovery. I didn’t realize that October was National Cyber Security Awareness Month; most of my focus the last few weeks has been on educational pushes around breast cancer awareness and watching the budget fight unfold.

I played it through and as a CMIO it was pretty easy. In each round there are a number of actual questions and also several pop-ups that represent questions or comments made by patients. Several of them made me laugh:

· Wait! I know I had a coupon in here somewhere…

· Honey, don’t forget to tell the doctor about how your you-know-what went you-know where.

· These shoes are pretty heavy. Mind if I take them off and get weighed one more time?

· A virus? Are you sure you can’t give me some antibiotics?

· One second… I’m almost finished with the hardest level of this new racing game.

I’m not sure some of our office staff would receive as high a score as I would hope and it would provide some good review for front-line office staff as well as a humorous break from normal office activities. I didn’t remember playing the other game so I gave it a go as well. It’s focused on Contingency Planning and the questions were pretty entertaining. When you provide a wrong answer, you lose a key office resource such as an exam room. When you have multiple right answers you are rewarded – at the end of Round 1 I received a new vending machine for my break room.

Although there were too many questions where “all of the above” was the right answer, there were some funny possible answers on what to do in the event of a disaster:

· Send all the patients home, there is nothing you can do.

· Smile and hope that no one notices.

· Yell at the doctors for not agreeing to get a back up generator when you suggested it.

My favorite question though was the last one. “We never tested our EHR data backups. Now I can’t retrieve patient information that appears to be lost after an application upgrade. What do I do now?”

· Find out if anyone has backed-up the EHR on tapes or disc drives.

· Contact your EHR vendor to request assistance in rolling back the upgrade or recovering as much of the database as possible from backup media starting with the most recent media.

· Re-boot your server; this typically will resolve the problem and your EHR data will be recovered.

· Try to recover from a previous backup; the data should not have changed very much.

I intentionally answered wrong and was penalized by having a roof leak at my clinic. I guess as they say: when it rains it pours. The detailed answers and feedback that can be viewed at the end of each section has detailed citations from the HIPAA Security Rule including the pertinent Code of Federal Regulations documentation. I’d recommend the contingency planning module for office managers and other business leaders but I don’t think it would be that helpful for end users or front-line office staff.

Gamification can be an entertaining method of communicating information for mandatory review but I’m not sure the modules are interesting enough that I’d do them if it wasn’t required. I enjoy the humor that ONC interjected though and the appreciation of some of the things we encounter in daily practice. I’d like to see our in-house training teams adopt more of this approach. Unfortunately they’re too partial to non-interactive modalities. I was actually glad of the changes to HIPAA because it forced them to update the tired “gangster theme” video they had been showing for years. What do you think of game-based learning? Email me.

Email Dr. Jayne

Curbside Consult with Dr. Jayne 10/21/13

I mentioned a few weeks ago that I had been preparing to sit for the new Clinical Informatics subspecialty board certification exam. Now that the testing period is over, I can talk about my experience. The American Board of Preventive Medicine expressly forbids candidates from discussing the exam content or questions so I’m not going to get myself into trouble, although there have certainly been some pretty significant discussions about it via the virtual water cooler.

The core content outline for the clinical informatics exam includes fundamentals, clinical decision making, health information systems, and leadership/change management. I don’t think there’s anything in the outline that is unreasonable. A major problem in trying to test that fund of knowledge, however, is that clinical informatics is an evolving specialty. Very few of us who have been in the field for any length of time intentionally set out to become informaticists. Of course there are some younger colleagues who decided to pursue it during medical school and attended a masters programs or fellowship, but I don’t believe they make up the majority of the seasoned workforce. The fact of how our discipline has developed (and subsequently exploded during the era of Meaningful Use) means that our field is extremely heterogeneous. That makes any kind of standardized evaluation a daunting experience.

Just look at physician titles as an example: CMIO, medical informatics director, clinical informaticist, medical director of informatics, medical informatics specialist, medical director of EHR, and my favorite: process improvement consultant. All of those titles are held by close friends of mine who are essentially doing the same job. Others have the CMIO title, but do vastly different jobs. Some are almost exclusively administrative, where others are heads-down writing their own code. Most of us are somewhere in the middle. We may practice medicine or not (although to sit for the new exam you do have to be currently certified in another clinical specialty.)

Preparing for the test was a good exercise. learned some things I didn’t know and encountered a lot of minutiae that, although “fundamental,” has very little bearing on my daily work. The thing that struck me most about the actual exam was that depending on your work experience, the difficulty of the questions varied. Like most exams, there were many “which is the best” and “which is the most appropriate” type questions with multiple correct-appearing answers. If you were straight out of a fellowship with little real-world experience, these might be easier. For those of us who have encountered hundreds of different variations on the questions (depending on whether the setting is inpatient vs. outpatient, whether the physicians in question are independent or employed, whether we’re wearing our physician hat or CMIO hat, what kind of system we’re talking about, etc.) the subjective nature of the questions made them difficult. Some of the questions I’ve actually encountered in real life and the answers to them may have been different at different times in the same project lifecycle.

Whether or not I passed (and truly I have no idea because it’s a new test and hasn’t been normed yet) isn’t going to impact my skill as a CMIO or make me less knowledgeable about handling tough decisions in the real world. Preparing for the exam though was stressful and actually taking it was an exercise in lack of user friendliness when you consider the whole electronic test-taking process used a third-party vendor. I was herded into the exam room along with firefighters, real estate agents, aspiring graduate students, and a couple of people who almost got ejected because they wouldn’t cooperate. We had to turn our pockets inside out, lift our shirts to expose our waistlines, raise our sleeves above the elbow, take a palm scan, and pay hundreds of dollars for the privilege. It certainly wasn’t that bad at another facility where I took my primary board exam a few years ago, but I guess things change. They didn’t make me take my glasses off to ensure I wasn’t hiding a chip or camera in them though, but I bet they do next time given the emergence of Google Glass.

Once most people finish taking this kind of test (after several months of preparation and at least some measure of worry) there’s this letdown period where you don’t know what to do with yourself. I did my best to keep busy and not second guess myself, but there comes a point where you just start thinking about the questions and how if you were in charge of the test, you’d do it differently. I couldn’t help but think of all the questions that weren’t on the test. Let’s pose some sample test scenarios and see what HIStalk readers think. It may not be evidence-based, but it is certainly ripped from the pages of real-world experience.

Item 1: As a clinical informaticist, you must often put yourself in the place of your stakeholders and end users as you make complex decisions. Read the following scenario, then select the best response to the associated questions. You are the finance director of a large employed medical group. The IT Director has decided to go to Las Vegas for the bachelor party of one of the IT analysts. He “signs out” authority over the ambulatory EHR project to you while he is gone, because after all, you’re both directors. He does this via email after 5 p.m. on Friday night then turns his phone off.

What is the most appropriate step for your first course of action?

a) Call Human Resources because it’s completely inappropriate for a supervisor to go to a Las Vegas bachelor party with his subordinates.

b) Call the IT director’s supervising VP because you’re not even in the same vertical and it’s not appropriate for you to take responsibility for his IT portfolio.

c) Call the CMIO and the EHR application manager and make sure they have your back.

d) Proceed to the local supermarket, purchasing more vodka than cranberry juice.

The weekend passes smoothly and without incident. However at 4 a.m. Sunday, your cell phone rings. The CMIO’s name is on Caller ID. Which of the following best describes the scenario?

a) This is a bad thing.

b) The clammy sweat you just broke tells you this is a very, very bad thing.

c) Anytime the CMIO calls you in the middle of the night it is extremely ominous.

d) You are glad you went to bed early Saturday night, because you have the feeling it might be days before you sleep again.

The CMIO explains that some cowboy analysts decided to perform an unauthorized “data migration” on your ambulatory database last night. No one was aware of the proposed maneuver as it was absent from the weekly change control discussion. Additionally, contractors were involved and it may not have been tested fully before deployment. It appears there may be some patient charts which have been corrupted, so they called the CMIO for advice. What is the most appropriate next step?

a) Curse the IT director’s name then try to track him down in Las Vegas.

b) Try to stop shaking, and then eat an entire box of chalk to address the heartburn you know is coming.

c) Be glad the CMIO has extensive experience resuscitating patients and staying calm because her demeanor makes you feel like it’s going to be OK.

d) Start making coffee; you’re going to need it.

Item 2: Review the above scenario. You are now in the role of the CMIO. It is 4 a.m. and you have just called your colleague. You calm her down and explain that you’re not that worried about the corrupt data because the organization has a well-vetted backup strategy and the team should be able to restore the database from the nightly backup, then apply the transaction logs up until the point they forced users off the system and started the migration. The finance director approves your plan and you phone the DBA on call. What is the most appropriate information to provide first?

a) Loudly ask, “What were you thinking?” and why he allowed unauthorized access to the production system.

b) Tell him to wake up his boss “because there’s gonna be hell to pay.”

c) Remind the DBA of your no-fault policy for reporting errors. A root cause analysis will be performed later and systems will be evaluated to prevent this from happening in the future.

d) Recommend a good travel agent for a one way trip somewhere far, far away.

The DBA makes some vaguely disturbing comments, so you get all involved parties on a conference line. Using your best patient interview skills (gleaned from years of trying to get the truth from drug-seeking patients) you begin to piece together what actually happened before they called you. Of the following system failures that have occurred, which is the most significant?

a) The team started the untested migration during the nightly backup process.

b) Users were on the system documenting clinical encounters during the migration.

c) The DBA already tried to restore from the admittedly non-reliable backup and it’s been running for two hours, but he neglected to mention it or the fact that he’s not sure the transaction log shipping was running properly prior to the incident.

d) A Level I analyst decided to wait four and a half hours before calling the CMIO for help and only called her because he “didn’t know who else to call.”

You ask for a list of users who were on the system when the incident started in an attempt to determine what kind of documentation they might have been doing and how severe a data loss might be. Should there be an unrecoverable data loss, which user will provide the most severe tongue-lashing?

a) Chief medical officer.

b) Chief of surgery.

c) Self-described “EHR Hater” who will use this as an attempt to mothball the ambulatory EHR project.

d) Your partner, who doesn’t want to be named as actually using the system since he brags to everyone in the physician’s lounge how he refuses to use it.

You invoke downtime procedures and notify the lone urgent care site that will be opening in less than three hours that they should document on paper and use the read-only downtime server for critical patient information needs. You notify all users that the system is down and immediately disable remote login capability so that no one can access the system while you figure out the recovery strategy. What portion of your user base will claim they never received notification?

a) None, as your communication plan is thorough and multi-media with multiple layers of backup.

b) Less than 10 percent, because most users are diligent about checking emails.

c) 20 percent, but they will find the email notifications three months from now when they get caught up on email. They will not apologize for yelling at you, however.

d) 90 percent, because they will jump on the bandwagon and complain about anything EHR-related.

Item 3: Given all the facts above, calculate the odds that the system will be back up with full data integrity before patient care starts Monday morning. Show your work. Estimate the total length of downtime. Conclude by estimating the total cost (in resources, recovery, and lost productivity) of this change control misadventure.

Bonus question: Estimate the number of employees who will be reprimanded for the actions leading up and/or during to the incident.

If you answered “C” to the multiple choice questions, then you just might be a CMIO (or someone who does the job without the title). As for Item 3, the system was indeed back up and ready for business by Monday morning. The total cost of the event was TNTC – as they say under the microscope, “Too numerous to count.” Before it was all over, we had to involve multiple representatives from various vendors, including the regional HIE and other downstream entities that received corrupt information and also had to perform various rollback activities.

I’m not going to give the answer to the bonus question just yet. If you want to make a guess, use the comment feature below. I’ll provide the actual answer later this week. For those of you who sat for the exam, I hope this gave you a laugh because we need one while we wait for the results.

What did you think about the exam? Email me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 10/14/13

I was hanging out this week with my nephew, who introduced me to Mega Shark vs. Giant Octopus, which if you haven’t seen it, explains what happened to Lorenzo Lamas and Deborah Gibson after they left the limelight. There are so many “attack of” movies but this one is truly larger than life. If you don’t believe it, you’re welcome to check out the trailer featured at the link above.

Having to confront things enormous and/or ridiculous reminds me of the daily grind of office practice. There are so many things to worry about from regulatory hurdles and payer nitpicking to patient satisfaction, patient engagement, and quality care. Many of them are important but some are just tiresome. It feels like there is always some shark waiting to eat you or an octopus intent on squeezing the joy out of patient care. I shouldn’t have been surprised then when I started reading a journal article and Top 20 Reasearch Studies of 2012 for Primary Care Physicians turned into “Attack of the Killer Guidelines.”

This is the second year that American Family Physician has worked to summarize the top research studies in primary care. Having been a practicing family doc in a small practice, I know how hard it is to keep up with the literature, and articles like this are very helpful. I don’t have time to read through the 100+ clinical research journals that the authors did in order to find the top 20 studies with the potential to change primary care practice. Having them summarized in a way that makes sense to the clinician in the trenches is key. As primary care docs, we don’t have time for esoteric studies or case reports featuring zebras and unicorns. We need help solving the bread and butter problems we see every day in the office, and help solving them in the most effective and efficient way possible.

Some of the points featured this year are serious game-changers when you’re looking at delivering cost-effective care that makes sense. To some degree, though, they go against the conventional wisdom and if physicians start following them, they’re going to get “dinged” on quality reports and payer metrics. Let’s look at a couple of them:

Diabetes. Does home monitoring of blood sugars lead to better management of Type 2 diabetes in patients who are not treated with insulin? The short answer is no. Hemoglobin A1C levels (which are used to monitor average blood glucose) only came down 0.25 percent after six to 12 months of home testing. The reduction was not clinically significant, but the discomfort and cost that patients bear is certainly significant. How many obese patients are going to develop diabetes in the US? Lots of them. How many are checking their blood sugars for years with little change in their overall diabetes control? Plenty. The authors conclude that home monitoring should be reserved for patients on insulin.

What? What about those commercials with Wilford Brimley hawking diabetic testing supplies “at little or no cost to you?” What about the fact that Medicare pays for it? I’ve had patients argue with me about this before, stating that if Medicare pays for it they should be entitled to it simply because they’ve paid into Medicare, clinical appropriateness be damned.

Again with Diabetes. Do older patients who have functional or cognitive impairment and tightly controlled diabetes do better than those with less tightly controlled diabetes? Surprise, those with tighter control actually had a greater risk of functional decline than those with less tight control of their blood sugars.

It sounds like heresy, but maybe we don’t need to be driving all these blood sugars down as low as we thought we should in the past. And we certainly don’t need to be overly lowering the blood sugars of the octogenarian up the street who is starting to show signs of dementia. Relaxing his blood sugar control (and his wife’s also, for that matter) could reduce their medication bill by $150/month and might prevent secondary complications due to low blood sugar. Unfortunately their primary care physician still has them on multiple medications and has them checking their blood sugars several times each day.

Back to the category of things Medicare pays for, so it must be the right thing to do. Bone Density screening. Review of evidence indicates that women with normal or mildly low bone density can wait up to 15 years before a second screening and those with moderate loss of bone density can wait five years. So why does Medicare cover this every 24 months? I’ve been on the other end of this argument, with a patient who accused me of being in favor of “death panels” simply because I told her the test wasn’t indicated after two years because her bone density was normal and she had few risk factors.

I’m tired of CMS pointing the finger at providers accusing us of fraud and abuse all the time. They come after us for upcoding, but have you ever seen a giant refund to a provider due to the vast downcoding that many perform out of fear? They routinely deny payment for services when physicians fail to understand the arcane minutia of local billing rules, yet are perfectly happy to pay for annual mammograms in 90-year-old patients when the government’s own US Preventive Services Task Force recommends screening every two years for patients stopping at age 75 because “among women 75 years or older, evidence of benefits of mammography is lacking.”

I’d love to see CMS stop paying for services that go against the government’s own evidence-based guidelines. Although some may see this as a slap in the face of patient empowerment, it would be a great help to those of us who spend a lot of time trying to convince patients that just because services are covered by their insurance plan doesn’t mean they’re a good idea. Like personalized medicine, if patients want services that aren’t evidence based, they’re welcome to pay out of pocket. In the realm of non-CMS payers, I’m still dealing with insurance companies that refuse to cover all vaccines, so maybe we could shake enough money loose to prevent some cervical cancer with wider use of the HPV vaccine.

I’m tired and cranky after a gruesome shift in the ER and don’t feel like doing the math, but I bet cutting out unnecessary mammograms, premature PSA testing, aggressive diabetes treatment in the elderly, and a handful of other things would help the Medicare trust fund go a little farther. I’d like to see dollars go into research, subsidized continuing education for health care providers, and preventive medicine rather than paying for services that may be popular but don’t lead to better outcomes.

The burning question however is this: how rapidly can guidelines and protocols adjust to these changes? Similarly, how do we convince front-line physicians that they need to behave contrary to how they have been for decades? What do you think about a truly evidence based coverage revolution? Email me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 10/7/13

I attended an outdoor leadership training session this weekend. It was billed as an opportunity to learn different techniques for working with groups as they manage change. I’ve done similar sessions in the past and was looking forward to coming back with some new ideas for team building and creative strategies for making training sessions more exciting.

Even though several people from my organization attended, the organizers intentionally divided us up so that teams were made up of people who didn’t know each other previously. The plan was to spend three days and two nights rotating through different stations where we would learn a mix of outdoor skills and workplace skills. We would have the opportunity to work on various projects that incorporated both sets of skills, such as lashing downed trees together to build various structures.

When we weren’t in class, we would have to work together to complete basic outdoor activities – setting up a camp site, planning menus and preparing food, and figuring out how to divide the work. We would also have to remember our corporate roots and arrive at sessions on time and prepared regardless of weather or competing priorities.

We arrived Friday afternoon to our site, which was located in a valley with surrounding ridges that I thought might keep cell signals at bay. Once we received our team camp sites, it was time to load in our gear and set up our tents and cooking area. Several of my teammates habitually checked their phones (presumably to look at “the weather”) though which quickly became annoying. Call it mean, but I hoped they had recently upgraded to iOS 7 so that their batteries would be gone quickly.

Our team had four men and two women and I was glad to learn my tent-mate had experience camping. When I have attended sessions like this before, the women typically have less outdoor experience than the men and it can create some challenges, so this was a good thing. Three of us were IT professionals and it made me happy that our companies recognized the need to develop our skills in change leadership. One member had lived on a sailboat for several years, which I figured would come in handy for ropes and knots. We also had a young man fresh out of college with the added bonus of being an Eagle Scout. The last member of our team was a man who didn’t say very much, although he seemed enthusiastic about attending the session.

We quickly got our tents pitched, our dining fly set up, our allotment of supplies stowed, and were ready to go. Our first challenge was to come up with a team name and a cheer. We agreed on the name pretty quickly, chose a cheer, selected our representative to introduce us, and headed off to the opening session. With our without iPhones and the Weather Channel app, we had been told to expect bad weather, including rain and the arrival of a major cold front, and to prepare accordingly as we wouldn’t be able to go back to our tents.

After introductions, we started a session on team dynamics. Tuckman’s stages of group development (Forming, Storming, Norming, and Performing) was familiar from a previous class, although quite a few of the 30 attendees didn’t seem to have heard of it before. The instructors led us through the fact that we had just worked through the Forming phase, where the team organizes and works through introductory tasks while avoiding conflict. We had been eager to achieve consensus on our name and cheer, but there wasn’t a lot of leadership or direction.

We were next given a proposed project to plan. As we circled our camp chairs, we found one member of our team was missing. No one had seen him step away and we assumed he’d be back quickly, so we thought we’d try to move ahead. It reminded me a lot of meetings I’ve attended over the last few months where everyone is present and ready to participate but one critical attendee doesn’t show up even though they accepted the appointment. It was as frustrating in the outdoors as it is in the office since the task required everyone to participate and we were stuck in place until he returned.

When he did show up, couple of members immediately confronted him for letting the team down by disappearing without letting anyone know. I figured that was a sign that we had moved to the Storming phase. Our disappearing man didn’t seem to understand that his absence was a problem and had a hard time getting back up to speed. We sat in the circle and brainstormed potential solutions for our assigned problem. Just when we got going, the rain started. Most of us reached into our day packs and pulled out gear, but a handful of people popped up to run to their tents.

Again I was reminded of the office and people who show up to paperless meetings without a laptop or who show up to demonstrate an application which isn’t loaded and ready on their machines. Like the office, the project moved forward whether people were prepared or not, forcing the remaining team members to pick up the slack, which often leads to resentment and distrust that the team will be available in the future. We were only a couple of hours into the weekend and this wasn’t looking good.

We made it through the rest of the evening. The evening meal was provided by the training center, although we had to attend presentations on camp cooking and sanitation as we earned our supper. We knew we’d be cooking our own meals from there on out, so most of us paid close attention. After we headed back to our camp site, we struggled to make up the duty roster for the next day. Since class started at 7:30, it meant a 5:30 wake-up to start fires, prepare food, and clean up. Although people were eager to volunteer, no one seemed to take charge, which was frustrating for those who wanted to get it all decided and head to our tents. Ultimately we finished then secured our food against wildlife intrusion and turned in for the night.

We woke to a humid morning but quickly got started on cooking bacon, eggs, tortillas, and rice. The group pulled together except for our “missing man” who hadn’t yet come out of his tent despite multiple attempts at waking him up. Ultimately he emerged but declined breakfast, saying he already ate. He must have missed the lecture about raccoons and other wildlife since he was keeping his own food in his tent. I tried to give him the benefit out the doubt, but knowing the training center’s attention to providing for different dietary needs (our team was gluten free), it was a hard sell. One of my team mates commented that he felt like he was still at work since he often encounters people who feel the need to do their own thing regardless of team strategy or planning.

For our first session, half the teams headed to plant and animal identification. Although most corporate types don’t have a lot of need for that skill set, the point of the exercise was to learn creative strategies to train material that the learners would assume was pointless or irrelevant. Having attended corporate training on fraud and abuse, passwords and privacy, and various regulatory programs every year regardless of mastery, I knew exactly what they were talking about. The instructors had some great strategies that many of us thought would translate easily to our offices. As we worked through categories covering everything from noxious plants to animal scat, I could see the other half of the teams at their session and I began to worry.

We were scheduled next for knots, ropes, and lashings. Although I know my way around a handful of knots, I can’t tie them off the top of my head without a refresher. I had never done lashings before and certainly hadn’t built any structures that needed to support a person. I was grateful to have the Eagle Scout and the sailboat fan on our team, but my hopes faded when I learned that our finished structure had to have at least one lashing constructed by each person. After a time of instruction, we were allowed to practice or head to be tested. Those students who tested early were supposed to return to their teams to assist with practice. I was surprised when our disappearing colleague headed off to the testing station. I wasn’t surprised though when he didn’t return after passing the testing station.

The two who did return did a great job of helping the rest of us through the basic knots and on to the more complicated lashings. We felt like we had moved to the Norming phase as we completed our structure but were disqualified due to our missing man so went back to Storming. Once again my thoughts turned to the office where time and again I’ve seen teams derailed by one member who ends up sabotaging the team, whether deliberately or subconsciously. Our missing man returned in time for our next rotation and it was there that we figured out at least part of what was going on with him.

We were tasked with preparing a session to train another team in a wilderness first aid topic. Each team was given an instructor to serve as subject matter expert for the content, but we had to construct the lesson plans and deliver the training session. In this more focused discussion environment we realized our missing man had a significant hearing deficit. That might explain his behavior at the ropes session – maybe he didn’t realize he was supposed to come back after testing. Maybe he didn’t hear the warnings about aggressive raccoons and not storing food in the tents. My tent mate said it reminded her of a co-worker who was in treatment for a life-threatening condition but didn’t tell the team, resulting in a lot of speculation about why her performance was declining. Although workplaces must accommodate disabilities, it’s hard to make appropriate modifications when no one is aware.

Saturday night wrapped up with a chili cook-off and a traditional campfire, which helped us relax and refuel after a long taxing day. I fell asleep with the sound of rain on our tent, which was better than any white noise generator I’ve encountered. The cold front arrived overnight and we awoke to a crisp morning. Our missing man again gave us something to talk about while he proceeded to take down his own tent while the rest of us were busy cooking as a team and taking care of group needs. Since he reminded us of the people we’ve worked with who are psychologically checked out, coupling that with all the other episodes made us wonder if he was a plant by the instructors to force us to think through the various teamwork and conflict resolution scenarios.

We had several more stations on Sunday with a little rain interspersed. This time the participants were better prepared. Our missing man was around half the time and contributed maybe a quarter of the time. He disappeared for good right before our debrief session and although that allowed us to talk openly about how his behavior made us feel, we weren’t able to experience the group dynamics needed to confront a dysfunctional team member.

Although sometimes frustrating, the weekend overall was outstanding. I learned a great new chili recipe and that the gluten free cookies that look like Oreos are better than the original. I learned that no matter what environment you’re in there will always be people who aren’t following the playbook and that we have to have strategies ready to deal with them. I learned new techniques to train students on material they find uninteresting.

Last, I learned 10 good knots, three different lashings, and their potential uses. Have you ever attended corporate training in the great outdoors? Need to learn how to secure your food in a bear bag? Email me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/30/13

Being an anonymous blogger can be very isolating, which is why I think I enjoy following other anonymous bloggers. One of my favorite, Skeptical Scalpel, recently penned a satire about a website where clinicians could rate their patients. Most of my colleagues are less than thrilled about websites where patients can rate physicians. Some have faced negative reviews for patient outcomes that were beyond the physician’s control. Others have been criticized for inability to meet unrealistic patient expectations.

Although it will never happen, the idea of being able to rate our patients is an interesting one. I’m not talking about gathering data for cherry-picking the healthiest patients or dropping those that are the sickest. I’m talking about using data based on previous patient-physician experiences that could better inform how we care for patients. As a PCP, I would occasionally have patients come to my practice because they had been fired from a previous physician for missing appointments. I didn’t have enough staffing or funding to do close follow up on all my patients, but I could immediately assign this patient to a variety of reminders and services to make sure he or she makes it to scheduled appointments as soon as he or she joins the practice rather than waiting for enough missed appointments to see a pattern.

The proponents of patient engagement don’t talk a lot about this, but patients are sometimes inaccurate about their histories and behaviors. It’s simple human nature – we all want to be doing a better job with our health than we might actually be doing, which often leads people to under-report their alcohol consumption or over-report their exercise behaviors.

There are a fair number of diligent and dedicated patients that are as honest as they need to be. Their ranks may grow as records become more transparent and more portable. I don’t know any patient though who comes in and says, “I miss one out of every three appointments I schedule.” That kind of data isn’t anything that mainstream practices are currently sharing with HIEs or CCD exchange.

These non-medical health factors are a huge deal when you’re trying to function as a patient-centered medical home or accountable care organization. Often there is not a good way to figure it out unless the previous caregivers documented that level of detail in the chart. Sometimes when records are transferred, those items are specifically left out because they may fall under behavioral health, which in many states requires a special authorization for release. Rarely does the patient volunteer those details during the initial visit.

I’m a big fan of patients bringing in their data, but only if it’s honest and valid. Technology is a great help with this. Having a patient bring in an exercise log from Garmin Connect is pretty solid because unless they’re strapping the GPS unit to their dog and letting it run the neighborhood, it’s not easy to fake. On the other hand, when patients bring in their handwritten log that shows they’ve walked 60 minutes a day every day for the month and have been compliant with their diet yet have gained 10 pounds for no medically explainable reason, it’s likely that the fudge factor was involved in logging the data.

As an added bonus, being able to rate patients would also provide an opportunity for something that is becoming more and more lacking – physician engagement. I am working with an increasing number of physicians who are burned out, apathetic, and considering other careers. Many practices can’t afford to have health coaches and care coordinators. It’s a Catch-22 where you have to provide the care to get the incentives, but you can’t afford to provide the care without having the incentive payments. Because of that, many physicians take on the work themselves.

You can easily run the return on investment numbers and show them that if they could see two more patients a day (which they could easily do if they delegated more work) they could afford another staffer. Most independent physicians aren’t willing to take the interim pay cut while a new staffer gets up to speed and they can get to the point where they can add those two visits a day. Employed physicians are often locked in to arbitrary staffing numbers their health system forces them to meet regardless of case mix or panel size.

For even the most burned out and disgruntled among us though, I bet I could get them to participate in a patient rating site. If not a patient rating site, there could be other ways of actually gathering objective data about real vs. reported patient behaviors. What do you think? Email me.

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Curbside Consult with Dr. Jayne 9/23/13

I spent most of this week conducting a site visit at a primary care practice that subscribed to our affiliated physician EHR offering last year. When they decided to take the bait on my hospital’s hook (as well as the accompanying subsidy) they were on an ambulatory system from another vendor. They had a contractor perform a partial conversion of their clinical data (“partial” due to cost) but my team was told to officially stay out of the conversion due to concerns with the subsidy agreement, data ownership, liability, and other contract-related issues. It was instead approved by the practice’s clinical champion. Since they are on their own instance of the application and their data doesn’t commingle with mine, I had no reason to push back or demand involvement.

When they migrated to our platform, our team conducted their training in the same manner with which we have trained hundreds of other physicians. Since they are affiliated and not employed (and also because they are located several hundred miles from our corporate mother ship) I hadn’t been out to visit them. Their leadership complained to our CIO that they were struggling with the system and requested that we send someone out to “fix it.” The practice is in a prime location for some fun outdoor activities, so I decided to conduct the site visit myself. After some preliminary discussion with practice leadership to obtain some background information and specifics on their concerns, I was on my way.

Performing a site visit like this is not for the faint of heart. As part of an employed medical group, we have people who are constantly after us to make sure we are compliant with OSHA, CLIA, HIPAA, and a host of other acronyms. Many small practices struggle in keeping up with these basics, not to mention with the multiple regulatory requirements that keep popping up like dandelions in spring. I always remind our process improvement team that it is important to clearly define the areas of observation and the questions to be answered before you start the site visit. Otherwise, it is possible to be overwhelmed with findings that may be outside the project parameters. Many of us have been confronted with findings that although out of scope, are so critical that they must be immediately addressed and sometimes the site visit comes to a screeching halt because of it.

I’ve had providers scream at me about unrelated issues, have had providers cry while I try to interview them, and have had them complain about their spouses making them late to the office which interferes with the schedule. There have been those that argued, others that pleaded, and some that stood up and walked away when we presented our findings. We try to stay objective and professional even when we see things that make our skin crawl.

With those experiences under our belt, sometimes we numb ourselves to the things we see because we’re there to assess people, process, and technology, not how providers are practicing or how diligent the housekeeping staff might be. In my role, I’m not there to address the fact that you just performed what you thought was a diabetic foot exam but what I thought would have earned one of my interns a trip to physical diagnosis remediation class. However, if I see you wearing a dirty lab coat with a Santa Claus pin on it in August, I’m probably going to say something whether it’s in scope or not. Luckily I didn’t run across anything like that on this visit, but what I did find was a group that is trying to perform the practice equivalent of running a marathon in high heels.

The practice has a great layout and plenty of space – it was built for six physicians but currently holds only four and all of them feel that they are equally busy. Their levels of productivity are similar except for a senior physician who no longer takes call but makes up for it with lower compensation. It’s nice to have that kind of a level playing field when you’re observing practice dynamics because when some partners are busier (or feel they are doing more of their share of the work) it’s usually a marker for dysfunctional team dynamics. They’ve had some staff turnover but not an unusual amount, and currently have two clinical support staff for each physician. Another good sign.

As part of our Meaningful Use preparation, we recently upgraded their EHR to the most current version available from our vendor and they received the same training our own physicians received. Unfortunately, the positive signs stopped there. Some of the first questions I ask when shadowing physicians involve how they feel the use of the EHR is going for them, and what their personal priorities are for use of the system. I also ask what they feel are the practice or health system’s priorities. Not only did all five of them have very different personal priorities, none of them could accurately identify the practice’s priorities. They could not identify a mission statement or a vision for how care is to be conducted in the office.

I wanted to assess how the recent upgrade impacted them and they admitted that they were not using many of the new features including some that streamlined workflow, reduced manual data entry, and others that provided clinical decision support. I felt bad that despite our educational efforts, they either failed to understand the clinical utility of the content or didn’t know how to incorporate the features into their existing work flow. In digging deeper though I found the root cause. The providers had made a deliberate choice not to use the new features. Instead, they decided that they needed to focus all their efforts on the many incentive programs available to them.

In addition to Meaningful Use, they are trying to obtain recognition as a Patient Centered Medical Home and are participating in a diabetes care collaborative. They are also participating in four different pay for performance plans that each have different metrics. Due to the disparity, they’re trying to focus on the key elements for each patient based on insurance rather than taking a population-based approach. In regards to Meaningful Use, they were not able to articulate which clinical quality measures they would be reporting or how they were performing on the MU measures overall. They haven’t run any preliminary Meaningful Use reports despite planning to attest soon. They have no idea where they stand.

Over the lunch hour, I decided to queue up some of their reports and I had some not so pleasant surprises. The first things I found were some pretty serious artifacts from their conversion. There were diagnoses such as “Verify: Gout” and “Verify: Diabetes” and “CONVERSION: DO NOT USE.” All of them had ICD-9 codes of 000.00 associated with them. I drilled down to a handful of patient charts and found that they also had multiple versions of similar diagnoses (250.00, 250.02 for example) that had not been reconciled. In addition to causing havoc with the reports, the patient diagnosis lists were messy and difficult to read with the conflicting codes present. It seems that they were supposed to clean up the diagnosis lists the first time the patient had a visit on the new EHR, but it didn’t get done. Unfortunately the providers have continued to select diagnoses of 000.00 from the patient diagnosis list which carries it forward and the coders have been fixing them on the practice management side, but no one closed the loop in the EHR.

Additionally, after a couple of months on the HER, they had stopped reconciling altogether. I had been thinking about how to create some payer-specific alerts for them for their pay for performance programs (assuming I couldn’t convince them to either care for all patients with the same standards regardless of payer or drop the incentive programs that created conflict) but without accurate codes to identify the disease states, it was going to be extremely difficult.

As much as they decided to mix it up with the pay for performance indicators, they took the opposite tack with Meaningful Use. Uncertain of the actual thresholds for some of the measures, they decided to go whole hog. Instead of reconciling medications at transitions of care, they were performing full reconciliation at each visit. Instead of summarizing tobacco use and updating any changes since the last visit, they were eliciting a complete tobacco use history even if it had already been documented. One patient actually complained about being asked the questions at every visit even though he had stopped smoking years ago. They are performing full vital signs on all patients (including infants) at every visit, regardless of the reason for visit or the time since they last presented to the office. They are trying to provide patient education for every visit, even when education may not be relevant. By the end of the first day, I was tired just watching them.

I observed each physician’s care team for several hours over a couple of days and also shadowed in the lab. Working with the billing and coding staff and the office manager, we identified additional areas for improvement. Typically at the end of a site visit I do a report-out with the providers and leadership. Most of the time I am recommending that they get moving and add MU activities to their processes. This time, though, I had to make recommendations for them to do less in some regards, which felt very strange as a recommendation. We had some good discussion and they really struggled with how to determine which things they should do for every patient and which they should do only when required.

I left them with a simple litmus test: actions should be performed at every visit only when they are clinically significant or are required by a regulatory body. We looked at the tobacco use item as an example. If the patient is not currently smoking, does it make sense to ask about their past use at every encounter? Probably not, as long as they are flagged as a never smoker or a former smoker. If the patient is currently smoking, does it make sense to ask about cessation at every visit? Yes, because all four P4P programs are looking for that element. I’ve asked them to go through their work processes and ask those kinds of questions for the various documentation elements. I’ve also asked them to start reconciling diagnoses on each visit to get those lists cleaned up before we head for ICD-10.

We’re going to set up monthly calls to check on their progress. I’ve given them some homework that is due before the first one. I’m hopeful that we can make their workflow more streamlined and less stressful while delivering quality care. They’re going to be working hard to get ready for their attestation period, but I’m cautiously optimistic. Hopefully I’ll be able to keep you posted on their progress.

For those of you who are curious about the picture, it’s Julia Plecher of Germany. She holds the Guinness World Record for the fastest 100 meters in high heels. Her time: 14.531 seconds. I wonder if Inga will be able to top that in her party hopping at MGMA? I can’t wait to find out.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/16/13

I mentioned in last week’s EP Talk that I’m preparing to sit for the Clinical Informatics board exam next month. At the board review course I attended recently, there were several comments about the recommended reading list published by the American Board of Preventive Medicine. At some point during the last few months it grew from something like six books to a dozen, plus relevant journal articles. Luckily I came into the process a little on the later side, so the list has already been its current length. Being the compulsive over-preparer that I am, I had decided a couple of months ago to at least make the attempt to read all of them.

The first challenge was cost. Many of the books on the list are textbooks. Renting them, buying them used, or getting the Kindle editions would have been over $1,000. I hit my local library website and found that only one was available – John Kotter’s Leading Change. If you deal with IT implementations, project management, or anything related to healthcare or healthcare IT and haven’t read this book, you should add it to your list. It’s quick – only 200 pages – and explains some key elements of projects that involve change. His eight reasons that change efforts fail are often visible in projects I encounter, which continues to surprise me when no one seems to have made attempts to remediate them.

Although the overall cost was a concern, so was the cost of some of the individual texts. I didn’t want to get stuck with a bunch of expensive books that I’m not sure I would use again (even if they were electronic and wouldn’t be hanging out on my bookcase) so I decided to go old school with my studying. I’m a good 25 miles from my nearest academic medical library, so I decided to request them through my local public library. Allow me to just say that Inter-Library Loan is a thing of beauty. Before long, I had many happy emails telling me that books were ready. The first one came in from the University of Nebraska at Omaha and it soon became a little game to see where they would be coming from. Unfortunately their arrival was a little unpredictable, and receiving three thick texts at the same time was giving me unpleasant flashbacks of my first year of medical school.

The second challenge in reading some of the materials was their age. Some of the books on the list were written more than 15 years ago. I enjoyed taking a ride in the Wayback Machine while skimming through the chapters on how computers became part of the healthcare landscape and learning more about some of the foundational systems for clinical care. Except for when I was a Candy Striper, computers have always played a role in patient care during my career even if it was just a lab information system. It was fun to see the pictures of some of the early information systems as well as the sideburns that went with them.

Nearly all of them were written in a world before Meaningful Use. In some ways, that was a less complicated age, even if the tools were less sophisticated. Some of the texts are more targeted towards administrators or non-clinicians and it was interesting to see what people on the other side of the street think or know about what we do.

The third challenge was dealing with the fact that I had the readings in textbook format. It’s been a long time since I turned the pages of anything thicker than a good mystery novel. After a week or so of reading, I had a muscle spasm in my neck that didn’t do much for my concentration. One of my Australian colleagues had given me The Book Seat as a gift and I have to say it was a lifesaver for propping those 800-page books at an angle that made them easy to read. I also ran across one book about informatics in public health that was printed in a typeface that was blurry and distracting. I’m not sure if it was just the copy I had and since it was from the University of Ontario it wasn’t like I could just run out and get another copy, so I had to power through it.

Forcing myself to try to read all the books was an experience in discipline. It reminded me how often all of us have to multitask and how little time most workplaces allow for intellectual pursuits. I thought about a couple of presentations that I had given over the last year or so that could have been more powerful had I included some of the concepts from the readings. Although some of the books were more general than I expected, it’s nice to know about them and to be able to recommend them when people ask about “getting into informatics” or how computers impact healthcare. I’d recommend Thomas Payne’s Practical Guide to Clinical Computing Systems: Design, Operations, and Infrastructure for physicians and other clinicians who have been volunteered as the clinical champion on a project or who don’t have a lot of experience with computers.

One of the books I most enjoyed reading was one of the ones that came last – Health Care Information Systems: A Practical Approach for Health Care Management. In addition to some IT fundamentals, authors Wager, Lee, and Glaser include a lot of information about structure and management of IT organizations. That topic won’t necessarily be on the test, but it should be required reading for groups who have trouble delivering solutions on time and on budget. There are some solid discussions of project management, goal setting, and accountability in there that are worth the time to read and share.

Several of the books I ended up skimming through because I felt comfortable with the material – I should do well on the architecture and infrastructure parts of the exam. Others I read a little slower because I needed to do some brushing up or because they had chapters by people I know in the real world. It’s always more interesting to read something a friend has written, especially when you find quirky phrases or descriptions that remind you of how they speak in person.

The major benefit of doing the formal board review course and reading the texts was being able to link the knowledge I’ve built from experience back to the scholarly material describing it. I can rattle off a lot of real-world information about change management, but I’m sure being able to link various techniques back to their formal names and methodologies will be helpful for answering boards-type questions. A couple of us joked about whether they should have offered an oral board exam. That would really help an examining body determine whether we’re qualified to handle the trickier situations we encounter on a daily basis.

I promised some informatics humor, so I’ll leave you with this quote from Thomas Payne at the University of Washington. It’s such a simple assessment, but given the things I’ve seen in the last week, it makes me laugh: “It’s great to have an EMR. It’s even better if you use it.” Here’s to all the great users out there and a special thanks to the library staff across the country that helped the books find their way to Casa Jayne.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/9/13

Before landing my current job, I had a brief sojourn in the consulting world. At my first placement, the director who hired me said this: “A consultant is someone who knows the same things you do but comes from more than 50 miles away and has a nicer briefcase, so people will listen and follow directions even though you’ve told them the exact same thing.” I giggled a little at the time because she had a Chanel tote and I had a Samsonite on wheels, but we had a successful engagement nevertheless.

In looking for other definitions of the consultant role, Urban Dictionary describes it as:

A self-proclaimed expert that extorts inflated fees from a host company in return for vague and predominantly incorrect business advice. The successful consultant detaches from its host at the exact moment its parasitic qualities are discovered by upper management …

I’ve certainly come across that type before. One of the first consultants I ever encountered could have been the reason that the “buzzword bingo” game was created. I remember sitting across the conference table thinking, “Who is this woman and who does she think she’s kidding?” as I tried to weed through the barrage of words that had very little meaning. Luckily our leadership quickly determined she was all fluff and no stuff and showed her the door. Unfortunately there are some people who are so dazzled they don’t see through the hype until long after the consultant has flown the coop.

There are many reasons why organizations hire consultants and there are many different types of consulting offerings in the healthcare IT world. Even with the best consultants, though, it’s important to manage them and understand exactly what they are supposed to be doing and the role they should play in the organization. How consultants are managed depends on the reason they are hired.

Consultants can be leveraged to backfill skill sets that are lacking in an organization. These are often well-defined, one-time projects such as constructing an interface, mapping a lab crosswalk, or installing hardware. In this situations, it’s fine to have a “once and done” philosophy and let the consultants get in and get out.

For other backfill situations such as training users prior to go-live or supporting them after, it’s important to ensure knowledge transfer. A forward-thinking organization will include time in the proposal to allow the consultant to train existing team members in the target skill set and proctor the team until it is able to function independently.

In the first situation (once and done), organizations can get away with minimal management – ensuring timelines are met and deliverables are high quality with sufficient documentation. The second situation requires more active management to ensure that training is occurring and that the team is absorbing in a manner that they can later assume the role played by the consultant. It also requires appropriate instruction to the team so that they can understand what is expected of them and that they are to adopt the methodology agreed on by the leadership and the consultant.

Another reason to use consultants is workforce augmentation – when an organization has a skill set but is involved in a project that requires more resources than they can allocate. Consultants in this role may work better remotely. I’ve seen consultants quickly lose productivity when brought on site because of constant distractions. It’s tempting to try to pull an expert resource into other initiatives and difficult for the consultant to combat scope creep. When staff augmentation occurs on site, expectations regarding time and attendance should be made clear at the beginning of the engagement. Some attention should be paid to the team dynamic so that existing staff doesn’t feel intimidated.

On the other hand, I’ve used consultants in the past simply because I needed someone to BE intimidating. I’ve leveraged our vendor to play “bad cop” to our internal “good cop.” In other situations, I’ve been asked to be the bad cop myself. The key to this strategy is making sure the consultant understands the end game. It’s never polite to knowingly make someone a punching bag, especially when you may have to work with them again down the road.

Consultants are also used for strategic planning efforts. This is where some bad consultants take advantage. The Urban Dictionary definition continues that, “the consultant preys upon upper management’s lack of job expertise and unrealistic dreams of grandeur.” This is more likely to occur when there is a lack of leadership or vision, making it easier for flimflam artists to thrive.

I’ve been in situations where management really has no idea what is going on. They don’t know exactly what they want a consultant to do or what they hope to accomplish, other than wanting someone to “just fix this.” A skilled consultant will sit down with the client and explain that there is no magic wand to be waved. He or she will then work with the client to develop realistic and actionable goals for the organization.

Too many managers assume that because a consultant is on the scene, they can be on autopilot. It’s important to understand that the consultant isn’t always part of the management structure. Unless the engagement is set up in a certain way, consultants can’t force employees to do their jobs or take action when sloppy work is done. They must work with the existing reporting structure to deal with problem people, processes, and policies.

We’ve all had our experiences with consultants run amok as well as with those that pushed us to excel. Send yours my way and I’ll share the best of the best (and the worst of the worst) with HIStalk readers.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/2/13

At one point or another in our careers, most of us have seen excerpts from All I Really Need to Know I Learned in Kindergarten by Robert Fulghum. For those of you who haven’t, it’s got some great tips:

• Play fair
• Don’t hit people
• Clean up your own mess
• Don’t take things that aren’t yours
• Warm cookies and cold milk are good for you

He also advises that “wisdom was not at the top of the graduate school mountain, but there in the sand pile at school.” Many of the projects I’ve worked on over the years would have gone much better had people followed his advice. General rules of niceness never go out of style.

In thinking about ways we work together, I’ve realized that specifically regarding teamwork, Everything I Need to Know I Learned on the Back of a Tandem Bicycle. A mountain bike, in particular. Those of you in the cycling community will appreciate what that means. If you’re not a cyclist, just know that you have to be a little crazy to take a bicycle built for two off-road. Here are the things I’ve learned:

The team needs to know their roles and what they have to work with. On a tandem, we call the front rider the captain. That’s who controls the steering, shifting, and braking. He or she has to know the limits of the team and equipment and how far they can be pushed. The rear rider is called the stoker. It’s difficult for people who are used to being in the lead to have to assume that role. One thing I learned along the way is that the captain can tell pretty easily when the stoker is trying to be a back seat driver because the rear handlebars are attached to the captain’s seat and having your saddle torque around is usually not appreciated. The stoker has to learn to give up some control and trust the captain.

Every team needs a captain. I think that often when teams are formed, people are under the impression that everyone is equal. Although I do subscribe to the philosophy of “leave your titles at the door” to level the playing field, someone must generally be in charge for a team to be successful. Being the captain can mean different things depending on the team. For teams that are forming or storming, it can mean helping people to align goals or figure out how to work together without fighting. For teams that are truly performing, it might be just facilitating meetings and ensuring things stay on time and that minutes are created and distributed.

Each of us needs to pull our weight. Unless you have a DaVinci tandem, both riders have to pedal at exactly the same speed. If one decides to slack off or push too hard, the other rider can feel it right away. It can result in a jerky and uncomfortable ride and can wear out the stronger rider.

Communication is essential. Especially if you’re clipped in your pedals, you have to talk to each other. Even little things such as what foot you like to use for the initial pedal stroke have to be decided and agreed upon. The captain has to communicate when more or less speed is needed and whether there are any hazards ahead such as branches, rocks, roots, holes, or railroad tracks. Coasting must be a coordinated effort. If you’re going to get into advanced skills such as trying to jump the tandem over obstacles, you better have it together.

Teams can provide efficiency, but they have to stay in control. The last time I was out on a tandem, one of the single riders was curious about what riding a tandem was like. Looking at the physics, tandems are heavier, which can make climbing tricky (especially if your frame is under-engineered and prone to flexing). The forward-moving wind resistance and amount of road friction are both similar to a single bicycle. The real difference is that tandems have twice the available power. When both riders are strong, it’s easy to get up to speeds that are nauseating. If you don’t watch the road or control your speed, the results can be disastrous. Prolonged braking from a high speed or on a steep descent can cause the rim to overheat and blow the tire off (unless you have wicked-cool disc brakes like the bike I rode today.)

Fear is not an option. I usually wind up being the stoker, and if you don’t trust your captain completely, you don’t have any business riding. It starts when you get on the bike. The captain holds it steady while the stoker mounts and clips into the pedals. Once the stoker is set, you have to make sure your pedals are in the right position. Nothing makes the captain madder than when the stoker spins the cranks without warning and slaps the captain in the shin with a pedal while he’s standing over the bike. When you’re ready to move forward there’s an uncomfortable moment when you start pedaling while the captain is getting onto the seat and you begin moving. You never quite get used to it, but you have to trust that you’re not going to fall over. (Side note – the two times I’ve actually fallen over on a mountain bike have NOT been on a tandem. Totally my own fault.) One thing that helps me with the fear factor is that most captains I’ve ridden with are bigger than me, so I can’t see what’s in front of us and I just have to go with the flow.

Working together we can perform feats that are impossible alone. The Paralympic games feature tandem pairs that often include blind or visually impaired stokers. In my situation, I don’t ride enough to have the skills to tackle some of the more challenging trails. I definitely wouldn’t venture out alone in some of the more remote areas. But clip me in behind someone who knows what he’s doing and I’m happy to help push both of us forward. Besides, I get to enjoy the view when I’m not worried about steering.

If you ever have the opportunity to ride a tandem, it’s definitely a different experience than going it alone, but it’s one I’d highly recommend. Maybe a reader or two might even spend part of Labor Day weekend on a tandem. If not, I hope you were able to enjoy the weekend with friends and family and pay homage to the achievements of the American workforce.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 8/26/13

Mr. HIStalk ran a Time Capsule piece about electronic timekeeping systems earlier this week. Due to being on staff at several hospitals as well as working as a consultant and as a CMIO, I’ve been through more time and attendance projects than I can count. And definitely more than I’d like to remember.

Most hospitals I’ve worked at embrace two different flavors of timekeeping systems. The first type is the time, attendance and payroll system, used to track time worked for hourly employees as well as vacation, sick, and other time off for both hourly and salaried employees. The second type is the project-based time system, which allows for tracking time spent on various initiatives. Some IT organizations use this type of system for charge-backs to the departments utilizing IT services as well.

Our nurses complain bitterly about the rules that have been implemented around time and attendance tracking. They’re expected to clock in early enough to make it to their work area on time, but not too early or they will be penalized. When the emergency department nurses have to work through their designated lunch break (which happens more often than anyone would like) the procedures they have to go through to clock a “no lunch” and avoid having a break automatically deducted are akin to hopping on one foot while turning in circles and whistling the score from “Les Miserables.”

It’s so complicated that even though the system allows for nurses to bid on days off based on a request queue that looks at their seniority, work status, and previous holiday and weekend work schedules, many of the charge nurses schedule on paper because they have difficulty “seeing” the schedule and how it’s going to work out. Maybe it’s the user interface, maybe it was the training, or maybe it’s just the product in general, but either way people dislike and distrust the system.

Our department has a mix of salaried and hourly employees. We all use the same system, although our department isn’t configured with the capability to request days off. We still have to fill out a paper form and obtain a wet signature from our supervisor. Our shared administrative assistant keys in our time off once it’s approved. Even though I’m a salaried employee, I have to electronically approve my 40 hours each week and submit it to the administrative assistant to approve. I’d love to be able to go in and modify it to reflect the hours I actually work, but unfortunately that functionality would be an enhancement.

As if dealing with the time and attendance system isn’t bad enough, many of us have to work in project tracking systems as well. One hospital for which I did some consulting work tried to interface the project system to the payroll and attendance system. I’m glad I was not an employee (and also that I was not on that project) because it was a disaster. It was pretty easy to tell that whatever user validation testing was done was inadequate or nonexistent. The project system was only configured to track billable time and when employees didn’t have 40 hours on their project card, it automatically deducted the difference as vacation.

Apparently no one noticed that the project system didn’t have categories for the rest of the things that happen in a hospital IT department – drafting proposals, responding to customer inquiries, reading general emails, team meetings, collaboration at the water cooler, etc. Although it was easily fixed by adding all those tracking categories, the rollout left the teams with a bad taste that took more than a year to erase.

Whether time is billable or not, there is a great deal of data in project accounting systems. Many managers don’t know how to leverage it to determine if their teams are productive or not. It’s rare that I see managers compare hours among team members working the same projects or even spend time thinking about whether the time clocked is reasonable based on the nature of the project. It seems like people don’t realize their teams aren’t working as efficiently as needed until the overall project metrics show that staffing is over budget.

I’ve worked with a couple of managers who are really good at this, though. The best was an inpatient pharmacy project manager dealing with a large and complex build. She looked not only at how much time people were spending on comparable tasks, but was able to reference it to their weekly status reports and determine that some team members had as much as 50 percent more throughput than others. After doing some one-on-one assessments to make sure everyone was adequately trained and had the same level of competency (as manifested by error rates) she called the team together.

I was able to watch as the meeting unfolded because she asked me to be the neutral facilitator. Knowing what she had planned, I think it was also so she could have a witness in case the team tried to go over the table at her. She started innocently enough asking them to come up with a consensus response for a variety of questions about how long it takes to do various build tasks. Everyone was very open in the discussion. She took her time waiting for them to all agree on what was reasonable.

What they didn’t realize that she had all the project time and productivity numbers pre-built on a spreadsheet which she modified as she started asking the questions. By the end of the meeting, she had some interesting data that painted a pretty damning picture of how some team members were performing compared to what they all had just agreed was reasonable. At the same time, she had also created a road map for the rest of the project and let the team know she’d be holding them to the productivity parameters they had just defined themselves. Needless to say, they were speechless. They never saw it coming.

I kept a close eye on her team the rest of the build. Fortunately they handled themselves as professionals and I didn’t hear a lot of complaining or see a change in error rates. Maybe they were either embarrassed that they had just been caught sandbagging or were motivated to meet the goals set by the team – we’ll never know. They’ve been live for quite some time and they still use those same time estimates when scoping upgrades and revisions to the pharmacy database.

I have to admit I pirated her approach. I’ve used it to help novice physician leaders who have been told by their tech teams that it will take too long to build customizations that would make the physicians’ lives easier. The physicians can work through the average time needed to do x, y, and z tasks and compare it to the time that would be saved for end users or the quantifiable improvement in patient safety. I’ve used it with tech managers who are being held hostage by programmers who don’t want to exert themselves. I’ve also used it in the clinical office prior to doing time and motion studies.

I’m always interested in ways to better use the data at hand rather than having to implement new systems or use manual processes. Do you have creative uses for data from your time tracking systems? Email me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 8/19/13

During the last month or so, I took a little vacation from Twitter. I found it was taking up too much of my day and I never had enough time to follow up on things I wanted to read, which was annoying.

I’ve been easing back into it this week – culling the list of people I follow, making sure that I’m not just seeing a bunch of noise, etc. I had to unfollow some people I really liked because of the sheer volume of things they retweet from others that really weren’t things I wanted to read.

It’s hard to find the right mix of news and entertainment without being overloaded. This tweet from Jonathan Bush’s account caught my eye, as did the associated article. 

The first thing that struck me is it didn’t sound like the Jonathan we’re used to hearing. It was calm, low-key, and didn’t have his usual push of speech. Whether it’s actually from his keyboard though doesn’t matter as much as the content.

The title of the piece is “Stepping Away, So Others Can Step Up.” I agree with his premise. It’s important for leaders to be able to trust their teams enough to step away. A strong team will run well with the leader absent because its members understand what needs to be done and have the skills to accomplish those tasks. They will have been given clear direction from above and will be ready to execute it.

Each time I see the “when the cat’s away the mice will play” phenomenon, I know there are likely to be problems with the team dynamic. Members may resent the leadership or not understand the roles they’re supposed to be playing. They may have been running on empty and stressed out by their leader and use the opportunity of his or her absence to decompress. Alternatively, there may be issues with succession planning and lack of clarity of who is supposed to lead in the leader’s absence. Managers may have been given pieces of a larger task but are unsure how they fit together or who is actually in charge.

The best leaders I’ve ever worked with made sure they had multiple trusted team members who could mind the store when they were gone. With this strategy, each of us knew that if we were the one temporarily in charge, we had others to rely on who would support our efforts.

The worst leaders I’ve worked with had a tendency to either alienate their direct reports or to ignore infighting among them. This creates an unstable and often unproductive atmosphere when the leader is away.

Another phenomenon I see too much of lately is people who have a trustworthy team but are afraid to step away. Some corporate cultures don’t place appropriate value on allowing employees to rest and recharge. I worked with one service line director who now works at a health system where he is afraid to take all of his vacation time each year because he feels leadership will view him as weak. The hospital has been through several restructuring efforts and most of the upper level management is afraid to be away lest they miss the beginnings of another round of house cleaning.

This is the same facility where staffers are welded to email day and night. If they don’t keep up with the daily spin cycle of news, they are considered “behind” when they walk in the office door in the morning. When the leaders don’t know how to stop working in the evenings, it makes it hard for the staff to draw boundaries.

In the most recent round of layoffs at this hospital, managers were not permitted to choose who on their teams to keep and who might be “made available to the workforce.” Those decisions were handled by consultants. The resulting culture of fear will likely destabilize the facility for many months to come and may also result in the departures of smart people who don’t want to be around when it happens again.

I hope each of you has the opportunity to work for a hospital, company, or leader who values time away. If you have that privilege, take advantage of it and enjoy every minute away. If you don’t work in that kind of environment, consider being a positive agent for change. There are likely others who believe in the value of stepping away and there might be an opportunity to make a difference.

As for Jonathan, if he ever needs a volunteer physician to help look after that “large family of kids and cousins,” he knows where to find me. I’m handy at putting elbows back in place after games of sibling tug-of-war and can remove an errant fish hook in nothing flat. I’ve never attended a clambake, but there’s always time to learn.

What do you think about taking time away? Email me.

E-mail Dr. Jayne.