Curbside Consult with Dr. Jayne 10/22/12

I mentioned last week that I was hoping to find a way to attend MGMA. In a stroke of good luck for me, one of our revenue cycle staff had a situation crop up that prevented her attendance, so I promptly agreed to fill in for her.

I actually enjoy dealing with practice management and revenue cycle issues and knowing more about those topics has been helpful in my work as a CMIO. Not to mention, I like San Antonio and needed a warm getaway after several weeks of chilly rainy weather in my hometown.

Today’s attendance wasn’t as high as I anticipated. That might be due to pre-conference socializing, however. I was surprised that in the years since I last visited, San Antonio’s Riverwalk has become somewhat of a Tex-Mex version of the French Quarter. The revelry going on below my hotel went well into the wee hours of the morning, and I couldn’t believe the amount of bottles and trash I saw on the Riverwalk during my morning jog. (Seriously people, there are recycling containers all over the place here – use them.)

Today featured a variety of specialty-specific preconference activities as well as the exhibit hall, which held a “tailgate party” event with food and drink served in the aisles which made it fun and casual (although I’m sure the booth staffers wish they could have shared in the drinks part). My favorite booth of the day was VaxServe, which was giving out free flu shots to willing takers.

As the industry consolidates, there are so many people moving around. I saw several vendor reps who are now with different companies than they were with just a few months ago at HIMSS. There’s quite a focus on ICD-10 and lots of people in the booths asking pointed questions about when vendors will be ready.

There are some good panels and education sessions scheduled and I hope to attend as many as possible. Hopefully I will run into Inga and catch some sponsor get-togethers as well. Be sure to follow us on Twitter @IngaHIStalk and @JayneHIStalkMD for the play by play.

What do you think about MGMA this year? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 10/15/12

It’s been a rough couple of weeks around the hospital with several ambulatory practice go-lives. It’s also the last time this year that Eligible Providers can start their Meaningful Use attestation periods.

We had a couple of affiliated physicians decide at the last minute that they wanted to give it a try. Since my hospital never says no, the team had to scramble to get everything in place for them to be ready to report. Everyone is so afraid of the audits that the level of documentation being produced to support attestations is simply staggering.

Whenever there’s an increased work load in my day job, I find myself spending more and more time on Twitter and other social media sites just surfing around and trying to get my brain to shut off for the night. I also end up sifting through little notes I make throughout the week reminding myself of potential content for HIStalk. Many of us should be glad that we work in IT because it somewhat insulates us from being on the front lines. Here’s tonight’s highlight reel:

• Healthcare “feel bad” story of the week: A Detroit paramedic lands in hot water after giving a blanket to an elderly fire survivor who escaped his home wearing only his underwear. This is a great parable for preventive medicine. It sounds like the powers that be would have preferred to have to treat the man for hypothermia and transport him to the hospital instead of keeping him warm in the first place.
• The supersonic skydive: I’m eager to see the data they gathered regarding human physiology in extreme conditions. I have a soft spot for space exploration and am also excited about potential new technologies to help astronauts in the event of a catastrophe.
• Healthcare “gross out” story of the week: The New England Compounding Center fiasco, which has led to hundreds of sick patients and at least 15 deaths. While I’m being audited to make sure my recommendations meet strict guidelines and that I check meaningless boxes to meet federal requirements, these guys are completely unregulated at the federal level.
• Black market silicone injections: I spend a good part of my day telling patients that their backsides are too big and they need to lose weight. Another chunk of time is spent with patients who are trying to fight me about the costs of preventive care and screening tests. And yet, there’s a subset of the population out there who is willing to give thousands of dollars in cash to charlatans selling illegal cosmetic treatments to plump up their posteriors. Some of the substances injected by perpetrators: hardware-grade silicone, mineral oil, Fix-A-Flat tire sealant, and furniture polish additives.
• Proofreading is dead: The editor of CMIO Magazine (now Clinical Innovation + Technology) pens an article about their recent CMIO Leadership Forum. Unfortunately, her headline copywriter doesn’t know the difference between a marquee and a marquis. Farzad is definitely a headliner, but now I’m excited to learn he’s also a nobleman.
• Too much standardization is just too much: I received my flu shot recently at an occupational health clinic where I received it last year. I was handed a patient demographic form (clearly printed from their billing system, because they hadn’t replaced the vendor’s logo with their own) and asked to verify the contents. My employer information was completely incorrect, so I made sure to mention it to the receptionist rather than just handing back the clipboard after I marked it up. I work for a large health system with hundreds of locations, but know for sure that we don’t have a building at the address that was listed. The explanation: they wanted to standardize their master files, so they only allow one location for any given employer name. I can buy that, but if you’re going to do so why not choose the address of the corporate headquarters at least? I hope they never have to call me at work, because I didn’t recognize the phone number either. I’m also not sure why they wanted me to waste my time updating it if they have no ability to correct it.
• D’oh, I can’t believe I missed this: I ignore a lot of e-mails I get from certain organizations, simply because my mailbox is so full it’s barely functional. As the days get shorter I can’t believe I missed that the AMA 2012 Interim Meeting is in Hawaii in a few weeks. It would have been a great opportunity for some sunshine and a tax-deductible trip to stock up on material.

Let’s hope this week is better than the last few. Thank goodness I have a vacation coming soon!

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 10/9/12

Despite recent calls by some members of Congress to halt Meaningful Use incentive payments, providers are still gearing up to attest. The last 90-day reporting period for 2012 just began and it’s interesting to see people who haven’t yet been able to meet the requirements try to gear up and get it done.

I ran across an article that’s really timely. Basically it poses the question: Who gets the money? Whether providers are employed by large integrated delivery systems or whether they are partners in small practices, it’s often not clear how incentive payments should (let alone will) be allocated.

This doesn’t apply to just MU payments, but nearly any kind of pay for performance bonus, quality bonus, or capitation payment. Often physicians seem to be too busy actually caring for patients to spend the kind of up-front thought needed to solve these questions before they become practice-shattering issues.

The article presents a cautionary tale about a solo physician who employed a nurse practitioner in her office. After spending more than $50,000 to implement an EHR, the employee received the MU check and walked away with the cash, leaving the practice holding the bag. There’s probably more to the story, but it raises important questions about the intent of MU incentives and how they are paid.

The employed physicians working for our large health system have language in their contracts that basically state any incentives received for work done as an employee belong to the health system. In the event that they are paid to the physician personally, they are to be signed over to the health system who also has the right to pursue legal remedies to obtain the funds. The language is clear that it only applies to work done within the course of employment. It also requires providers to complete any assignment paperwork within 30 days of receipt or penalties apply (the same language applies to credentialing paperwork, conflict of interest documentation, employee code of conduct updates, etc.) It’s very “take it or leave it” and that’s part of what being in an employed situation is about.

The key here is that these stipulations are made clear during the hiring process – no surprises. Should the health system decide to be benevolent and actually share quality bonuses with physicians, it’s completely up to the leadership. Although it’s maddening as a provider because we’re doing the work, it’s understandable because none of us personally put up the $45,000 it cost to deploy our EHR system. The one time they did pass funding through to the physicians, I ended up with a whopping $40 bonus. I think at the time it covered about a week’s worth of interest on my student loan payment.

Even in small practices with physician partners, I’ve seen resentment between those who embrace EHR and enter the majority of the data and those who coast on the coat tails of their colleagues. There need to be minimum standards for data entry if payments are to be divided equally. This is not a lot different than the decisions that need to be made when partners who have capitation agreements cross-cover patients or when one partner takes more call or works less than another.

Bottom line: regardless of which side of the table you may be on, this needs to be addressed contractually before it becomes an issue. If you’re an employer and your providers haven’t brought it up yet, don’t assume they won’t be bitter when they figure out in the future that they should have. Be the bigger person and start the dialogue now. And if you’re an employee, be ready to discuss what kind of a split you think is fair and why you feel that way. Interesting discussions will certainly ensue and it may not be easy to avoid hurt feelings or bitterness on either side. Personally, after living through my last contract negotiation, I might just be inclined to arm wrestle for it.

How does your organization allocate incentive payments?

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 10/1/12

It’s the first Monday in October, which means the United States Supreme Court is back in session. No, those aren’t our justices dressed up as Santa Claus. That’s actually a photo of the Justices of the Supreme Court of Canada. I found it much more eye-catching than the photo of our Court, where poor Ruth Bader Ginsburg looks like she’s off in the time-out chair.

Just when the Court thought it was done dealing with healthcare and the right to refuse government intervention, it agreed to hear three cases this session that deal with those issues at least on some level:

• Delia v. E.M.A. handles the concept of whether states can recover money spent to deliver care for poor or disabled Medicaid beneficiaries when it is found that they have received funds from another source.
• Levin v. United States addresses whether military medical personnel can be immune from alleged “battery” while providing medical care to a civilian.
• Missouri v. McNeely will look at whether law enforcement officers have the right to obtain blood samples from allegedly drunk drivers regardless of consent.

Except for the Medicaid issue, these cases don’t seem terribly earthshaking for the masses. There’s an underlying concern in some camps, however, that the Court is somewhat fractured after the Affordable Care Act drama of the last term. The Atlantic reports that Chief Justice John Roberts alienated his conservative colleagues when he saved the Act.

I trust that the Justices are adults and would be above any middle school-style backstabbing to make up for perceived (or real) slights in the previous term. They’re human, however, so there’s still the potential for some drama. I’m personally looking forward to some entertaining transcripts. Last year provided some rare treats, and I don’t think broccoli has received that much national press since George H.W. Bush refused to eat it.

Although the court has only accepted a few cases so far, more will be reviewed for inclusion this term. We could potentially be looking at decisions on same-sex marriage, the Voting Rights act, or election law. With a Presidential election looming, let’s hope we don’t have to hear any cases about hanging chads or other election day fallout.

Another major case on the docket, Fisher v. University of Texas at Austin, looks at affirmative action in university admissions. Depending on which way that one goes, it could lead to shakeups in medical school admissions that could have a profound impact on the diversity of the future health care delivery workforce.

Regardless of your political orientation, the Court always seems to bring something to the table for everyone to be happy about. We don’t get that very much from our other branches of government, so here’s to another term.

Have a favorite Justice? Want to suggest some kickier shoes for those that sit in the front row for the official portrait? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/24/12

As a primary care physician, I think the concept of health information exchange is exciting. I’m tired of seeing patients who forget to bring their medication lists. Don’t get me started on those who really have no idea about their health history. I’d love to be able to exchange with other practices in my community, but for now I have to settle with downloading their medication list from Surescripts and digging through hospital charts and scanned records.

Several groups are trying to get private exchanges going in my area. Our state is woefully behind in the exchange game, so it’s not surprising that people are stepping up to fill the gap. The technology is there, the desire is there, but unfortunately the governance is not there. Small, medium, and large-ish independent groups are in active discussion about sharing information, but are woefully undereducated about data ownership, participation agreements, and patient consent.

A colleague of mine was involved in one of these exchanges several years ago. It ultimately folded due to lack of agreement among the four participating practices. There were no arrangements for determining “source of truth” for patient information and the database quickly became corrupt and ultimately unusable. It was a shame, because initial participation yielded outcomes that were published in peer-reviewed journals and looked truly promising.

I was excited earlier this summer when ONC issued a Request for Information on Governance of the Nationwide Health Information Network. The RFI asked for input on how to make patients and providers confident about information exchange. As someone who has had to counsel patients on why they should share their data, the idea of a national standard was enticing. I’ve also had to hold the hands of providers as well – making them understand that having “somebody else’s stuff” in their charts is not necessarily a bad thing.

The other shoe dropped earlier this month when ONC announced that it will not “continue with the formal rulemaking process at this time, and instead implement an approach that provides a means for defining and implementing nationwide trusted exchange with higher agility, and lower likelihood of regret.”

I sympathize with all the statements that Farzad Mostashari made on his blog – that there are voluntary governance bodies, that regulation may slow trusted exchange, etc. ONC hopes to “identify and shine the light on good practices” and “provide a framework of enduring principles to guide emerging governance models.” I’m afraid, though, that for some nascent exchanges, it will be too little, too late.

Who is going to shine the light on the private exchange that is sharing patient data without their consent? The providers think it’s just fine because “the patients signed the HIPAA form,” not understanding that HIPAA consents typically cover treatment, payment, and operations. A standard form may not cover the fact that all the patient’s data just got populated into a private HIE which has no provisions for filtering sensitive information or tracking patient authorization. It may not have restrictions on who can access the data or who monitors data consumption. The providers can’t even articulate whether they’re practicing in an opt-in or an opt-out state.

Some of you may think this is a fable, but it’s the reality of a practice where I was a patient last week. After figuring out what was going on, I should have billed the practice for the free consulting I gave them explaining that in their state they simply can’t just choose to populate patient data to a health information exchange without consent.

I hate over-regulation as much as anyone, but the private HIEs that are popping up are starting to feel a little too “wild, wild west.” Voluntary bodies aren’t going to help them if they’re not even aware the voluntary bodies exist.

What do you think about private health information exchanges? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/17/12

There’s been a lot of talk lately about the perils of cloned documentation. I had several readers forward me the recent notification from Medicare administrative contractor National Government Services that states that it will deny payments for encounters whose documentation appears cloned.

Let’s face it. Many of us have been creating what could be construed as cloned documentation since our residency days. Back when the average length of stay was a little longer (especially on a teaching service), we were encouraged to completely recap the contents of the previous day’s note, which often led to copying.

With 15 or 20 patients on our rosters, it was often impossible to remember subtleties about each patient, so you just copied what you had from the previous day, updated the lab values, any new complaints, etc. It was a lot like using copy forward / update technology in EHRs today, except a pen with a drug company logo and some truly horrific penmanship was involved.

When dictating discharge summaries, the vast majority of patients had strikingly similar exams since patients had to have largely normalized to go home: Heart regular rate and rhythm; no murmurs, rubs or gallops; lungs clear to auscultation bilaterally; and so on. When confronted with a stack of discharge summaries to dictate (which lazy attending physicians had kindly “flipped” our way) on patients we had maybe seen once, they all started to sound remarkably alike in other ways as well.

I remember being on service at a pediatric hospital, where in a single call night I personally admitted 17 patients for asthma exacerbation. The other interns on the team had at least five or 10 asthma patients each as well. Since there were three interns on a team, the senior resident was covering nearly 50 patients – and more than 30 of them had similar chief complaints and presentations. We had strict criteria for who was admitted (thanks to evidence-based medicine), so their presentations were actually very similar, and all had failed identical interventions in the emergency department before admission. You can bet those senior resident notes didn’t have any new or different information than what was presented in ours.

Ditto on Labor and Delivery during residency, where I trained at one of the highest volume birthing hospitals in the region. Since a normal uncomplicated childbirth really isn’t an illness, the documentation was routine and nearly identical. It would have been difficult to find truly unique information to write about some of the patients. I supposed we could have put in frivolous information like, “This blonde Caucasian mother of the adorable blue-eyed infant has no complaints,” but we were tasked with rounding, not writing beautiful, flowing prose.

My problem with the entire issue of cloned notes is that no one really has defined what they consider cloned, making this just another arbitrary way for payers to deny reimbursement. One contractor defines it as, “Documentation that repeats language from previous entries on that patient or from other patients with similar conditions.” I dare anyone to find a note written in the last two decades that doesn’t repeat language in some way, shape, or form.

Prior to EHR, I used a homegrown paper template documentation system that created remarkably uniform notes. On the positive side, it also created remarkably high-quality visits. Clinical decision support was baked into the documentation forms for various chief complaints. We often took materials provided by various professional organizations (AAFP, AAP, ACOG, CDC, etc.) and customized it to meet local and payer guidelines. For uncomplicated illness (strep throat, sinusitis, urinary tract infection, etc.) the notes would be strikingly similar from patient to patient.

Why is it bad thing for the physician to document exactly the appropriate information to substantiate level of care and quality? Should extraneous information be required for payment so that the note appears individualized just for the sake of being individualized?

I can easily avoid the appearance of cloned documentation across patients by including nuance information in the history of present illness. I have no problems doing so if it is relevant to the patient’s story and his or her care.

Another issue entirely is that of cloned documentation within a single patient chart. Regulators and anti-EHR voices are after those of us who like to “drag and drop” previous visits into today’s note, then update it. Note that I said “update.” I didn’t say drag, drop, and depart. Who among us who actually cares for patients does not have at least a few dozen “Groundhog Day” patients, those where every single visit is the same? I’m talking about patients like the noncompliant hypertensive diabetic who refuses to follow the instructions from the previous visit. Every single assessment and plan looks something like this:

1) Diabetes: Reviewed blood sugar log. Counseled patient to take medications as directed and continue 1,800-calorie ADA diet. Patient to exercise 30 minutes daily and check blood sugars daily, bringing meter to next visit for download.

2) Hypertension: Counseled again regarding sodium intake and packaged foods. Exercise as above, continue medications.

3) Obesity: Discussed diet and exercise as above. Refer to nutritionist. Discussed consequences of continued noncompliance including worsening of chronic health conditions, heart disease, and potentially premature death.

Really, what else do I need to say here? Maybe I should start adding incremental data like, “Counseled patient for the 15th time” to make it more individualized. Or I could document specific details of the data in the blood sugar log, but that would be redundant and also introduce a potential source of error as I manually key numbers into my note.

The bottom line is this. Why should I not be able to pull this data forward, then update or add to it? It’s clear, it’s complete, and it accurately documents what I stated in the visit. I shouldn’t have to add extraneous information just to satisfy an auditor.

A friend of mine has a collection of hilarious patient visit notes (of course, with any patient identifiers carefully redacted with a broad-tip Sharpie) from both the paper and EHR realms. One of my favorite pages in his scrapbook is the ultimate healthcare haiku, written before the days of E&M Coding:

Boil-Lanced.

And that, dear readers, is a thing of beauty.

Have a great example of patient documentation to share? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/10/12

Today is the start of National Health IT Week, which was created to “raise awareness about the power of health IT to improve the quality, safety, and cost effectiveness of health care.”

One of the events being held in conjunction with the festivities is a Blog Carnival. HIMSS invited bloggers to submit posts answering the question, “How will health IT make a difference a year from now at the next National Health IT Week?” Posts had to be submitted during the last month, and selected contributors will have their pieces appearing this week. I wasn’t confident that HIMSS would select anonymous bloggers for their showcase, so I didn’t bother to try. Plus I’m not much for deadlines these days since I’m getting pounded with work at my day job.

Another event will take place on the 13t, the Capitol Hill Health Information Technology Showcase. It is sponsored by the Congressional Steering Committee on Telehealth and Healthcare Informatics and will offer Members of Congress and staff “first-hand demonstrations of health IT and interoperable communications capabilities.” I was surprised to learn that this Steering Committee was founded in 1993. You would think if you had a bunch of lawmakers advocating for telehealth for nearly two decades, they would have figured out a way for providers to be reimbursed for providing it. If they haven’t been doing that, what have they been up to?

I surfed the Internet a bit and couldn’t find that they do much beyond organizing “widely attended educational sessions and healthcare information technology demonstrations” for Congress, legislative staffers, agency officials, industry, and the public. A different search revealed that the Committee is part of the Institute for e-Health Policy, which is part of the HIMSS Foundation. The Institute also sponsors a Congressional Luncheon Seminar Series funded by a vast array of IT vendors, insurers, hospitals, and government contractors. There was a smattering of quasi-nonprofit organizations on the list, but they may be there just for show.

In that frame of mind, I’d like to try to answer the question originally posed. Putting on my academic hat, it’s really a terribly worded question. It may have been more interesting if they added some qualifiers – such as how will health IT make a difference in a specific area? Or to patients? I’m admittedly in a cynical mood, but I’m going to have to say that I don’t think health IT is going to make any more of a difference next September than it does today.

Flash forward to September 2013. Vendors will be shipping out their “MU Stage 2 Compliant” releases to get customers ready to start attesting come January 2014. That means they will have spent the better part of the preceding year “teaching to the test,” or rather focusing their efforts on coding to the specs and achieving certification. Any innovation they had planned will likely be sidelined as they are forced to shift pre-defined blocks of resources to coding for MU goals rather than being revolutionary.

Customers will be readying last-minute upgrade plans and running full tilt towards the dual threats of Meaningful Use and ICD-10 mandates. Rather than focusing on clinical transformation and physician adoption, they will also be “teaching to the test” and training clinicians to make sure every nonsensical “i” is dotted and “t” is crossed. Providers will receive monthly (or worse, weekly) reports from practice and health system administrators that do nothing more than measure their performance on checking boxes.

Patient care will be largely unchanged. Rather than focusing on specific diseases or quality improvement projects, they will be scrambling to make sure they don’t lose revenue or get dinged in audits. Hundreds of millions of dollars will be spent, but clinical metrics will not be appreciably better.

Maybe it’s better that I didn’t submit for the blog carnival. I bet the chosen bloggers will paint a dramatically different picture. I can’t wait to see what they come up with.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/3/12

This weekend on HIStalk Practice, Dr. Gregg wrote about the possibility that the “infamous tricorder from Star Trek” is about to become reality. A company called Scanadu has a prototype handheld diagnostic device that (at least according to their website) will debut in a little over a week. Although I agree with Dr. Gregg that it has huge potential to empower consumers with auto-diagnosis tools, I really have to wonder about the entire premise.

Their trailer video is quite engaging. They walk through a parent diagnosing their child’s rash, a mom receiving a warning about a whooping cough outbreak and the fact that her daughter needs an additional immunization, and parents diagnosing their sick child with a potential urinary tract infection and being sent to an urgent care facility. The voiceover states, “We’re building a way for people to check their bodies as often as they check their e-mail.”

Like so much today, some technology is surrounded by a lot of hype. While I don’t doubt that this is going to be a very cool and potentially powerful technology, I have some concerns with it. It feeds into the idea that we just have to embrace technology and we will live happier, more fulfilled lives.

I’m betting most Americans will hope that at the end of the diagnostic algorithm, it suggests a single pill that can fix everything. Just a few seconds of scanning a day will convince us that everything is OK.

Guess what? It’s not OK. Americans are fatter and more unhealthy than ever. We don’t need any miracle technology to tell us this. There are simple things we can do every day for our health that we are simply unwilling to do because they’re not sexy or high tech. They’re hard work and involve difficult choices and possibly sweat.

Physicians and other health providers have been preaching these things for years, yet people do not follow these recommendations. Will it make a difference if the recommendation comes from an impersonal device? I doubt it. I’m willing to keep an open mind, though, if there is even a small chance it will make a difference.

I’d like to live in an age where people are as obsessed about their body mass index as they are about finding out what Snooki named her baby. An age where people sit around the pub comparing their best fitness data instead of the statistics of their fantasy football teams. An age where I never have to diagnose another child with diabetes.

The folks at Scanadu have a great tagline: We are the last generation to know so little about our health. I really don’t think that’s true. I think we know a lot about our health. We’re just unwilling to do anything about it.

I look at my thousands of co-workers at Big Hospital. We all have to check our biometrics every year in order to get the best discount on our health insurance premiums. But looking at our population as a whole, having this information hasn’t led to a tremendous cost savings or healthier employees. People know their numbers, but they simply don’t care. They don’t want to give up habits or behaviors they find pleasurable. They haven’t come to grips with the fact that in the end, it’s a zero-sum game. Unless you’ve won the genetic lottery, each of us has to pay for our dietary and exercise indiscretions.

Being a physician doesn’t make me any better than the next guy. I have weak spots for chocolate and martinis. Those who know me really well know that I also have a thing for Buffalo chicken wings and all things fried. I love to watch bad TV and once became nearly vegetative watching a marathon of Deadliest Catch.

At the opposite end of the spectrum, I work with residency faculty members whose most indulgent meal is a baked potato with some olive oil and spices. They may get by on that, but I know that ultimately I am going to make less than perfect food choices and I’m going to have to balance it out with healthier meals at other times and also with daily exercise. I don’t take my health for granted – none of us should.

Technology can be a great motivator to help people track their health. I love reading HIStalk Mobile and seeing all the cool trackers and apps that Dr. Travis finds. I’ve even tried some of them. Recently a community group I’m part of decided to take part in the Presidential Active Lifestyle Award challenge. We created a group where we could log our activity and track some group goals as a motivator. As a community group that mentors youth, the adults have a vested interest in making healthier lifestyle choices so we can serve as role models.

After two months on the challenge, we have exactly four people who are willing to go online and log their activity, and only two of them are actually active. It’s a sad commentary. (I have to think we’d have better participation if The President’s Challenge had a mobile app, but alas, they do not.) Today I can’t even log in. We can put a man on the moon, but we can’t handle our exceptions, apparently.

I’m looking forward to seeing what Scanadu has in store for us. Having served on the sidelines for youth sports teams, I’d love a hand-held scanner that can help me determine the prognosis for a concussion or whether that student with mononucleosis really has an enlarged speen and needs to sit on the bench. As someone who cares for children, I’d love something that can reassure a parent when their toddlers slip in the tub and hit their heads. I’d be thrilled with any handheld device that can actually get people excited about their health and convince them of the need to eat less junk and move their bodies regularly. Unfortunately, I’m just a little bit skeptical at the moment.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 8/27/12

One of my personal heroes passed away on August 25. Neil Armstrong’s death was marked in a way that matched the way he lived – quietly and with little fanfare. By commanding the Apollo 11 mission and being the first person to walk on the moon, he had earned the right to be celebrated.

The amazing part of his story, however, is what happened after July 20, 1969. He didn’t dance in the end zone or become tabloid fodder. He went back to work and back to his roots. I’m touched by a quote from an article marking his passing. In an interview in February 2000, he said:

I am, and ever will be, a white socks, pocket protector, nerdy engineer. And I take a substantial amount of pride in the accomplishments of my profession.

We should all take a substantial amount of pride in the accomplishments of his profession. Not to take anything away from the astronauts, but I’m talking about the engineers. NASA’s steely eyed missile men sent people to the moon using chalk boards and slide rules. They didn’t have anywhere near the technology that most of us carry in our pockets today, but they changed the world.

Those of us working in healthcare IT today are up to our eyeballs in technology. It feels like things are moving so fast we will never catch up. As hospital leaders, we are challenged to deploy the latest “thing” regardless of quality or outcomes.

I have many friends in the medical software industry, ranging from developers to CEOs. The aggregate of their skills and creativity could propel us into a new era of patient care. Instead we seem mired between the twin terrors of governmental compliance and simply improving yesterday’s products. I want to see the software equivalent of the space race, where vendors are competing for the best designers and engineers and working to deliver a superior product.

Rather than the challenge of getting a man to the moon and returning him safely, the goal should be to deliver patients safely through the health care experience while we collect all the telemetry data needed to make the next trip with even better safety and quality. Another challenge – it’s easy to forget that as broken as our health care delivery system is, it is still better than what is available in some parts of the world. Let’s figure out how to make those leaps for all mankind.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 8/20/12

Mr. HIStalk, Inga, and I don’t get to see each other in person very often – usually just at HIMSS or in the odd instance our paths cross while traveling. It’s always a nice surprise though when one of them publishes on a topic that parallels something I’m doing at my day job. It happened this week when Mr. H ran one of his Time Capsule pieces on hospitals aligning with private practice physicians.

Not unlike other hospitals and health systems across the US, my employer is no stranger to the relaxed Stark anti-kickback rule. They’re using the EHR exception to offer a variety of subsidized EHR products to community physicians. One tenet of the exception is that the software being provided must be interoperable.

It would have been nice if the hospital simply offered the same EHR that the employed physician group uses so that we could all begin exchanging data immediately. This would potentially have had an immediate impact on reducing duplicative testing, ensuring referrals arrived with appropriate clinical data attached, and strengthening referral patterns. Throw in a couple of laboratory interfaces and it would have been a winner.

Instead, the hospital chose to do what Mr. H suggested and let the recipient practices choose their own EHRs. Trying to connect different platforms via point to point interfaces can be tricky, so the hospital decided to throw a health information exchange into the mix as well, promising quick connectivity. Community physicians chose four different EHR systems which vary dramatically in quality, comprehensiveness, and production of discrete data.

A wise CIO would have allowed third parties to implement these physicians on their systems of choice. Ever eager to curry favor with the various regional administrators and informal power-brokers, our CIO chose to form a “tiger team” to implement and support all four products as well as the yet-to-be-deployed HIE.

Several years have passed, and as you can imagine, the project has been somewhat of a mess. I’m glad I haven’t been involved and can’t believe they’ve staffed it with only three people. Frankly, I don’t know how those poor souls cope. I only have to deal with two EHRs (one ambulatory, one inpatient) and that can be a challenge in keeping up with different releases and features.

Even in ideal circumstances, I can’t imagine trying to learn, implement, and support multiple ambulatory EHRs. This team is not working under anything remotely close to ideal circumstances. They’ve had to cut corners just to stay afloat and haven’t fully implemented the features of even one of the systems.

Like those mentioned by Mr. H, the physicians taking part in this subsidy program are largely unreasonable and haven’t been terribly cooperative with practice reengineering or making sure office staff members are held accountable for learning the systems and using them correctly. They complain bitterly about how much money they’re spending (even though they’re footing between 15% and 30% of the total EHR bill) and how little they’re getting for it. Enter Dr. Jayne, who has been placed on temporary duty assignment to “find out why those doctors are so unhappy and fix it.”

I’m pretty sure the CIO thinks I have some kind of magic wand that I can just wave and make this whole thing go away. After visiting with a handful of providers, however, it’s going to be a lot more complicated. I’m pretty sure it’s going to involve the practice management and healthcare IT equivalents of a backhoe, a steam roller, and seven sticks of dynamite.

I’m not confident we’re going to improve things unless the providers learn to check their egos at the door and the practice managers start running the practices like businesses. The hospital administrators leading this project need to learn to hold the practices accountable. Even if all of these pieces fall into place, I still give it no more than a 50% chance of success.

Without a change to the regulations, the Stark exception is set to expire at the end of December 2013. The hospital administrators and the CIO are confident that the provisions will be extended. HIMSS has lobbied that the EHR exception be made permanent. Although I don’t see the government announcing any extension until at least 2013, I know of three people eagerly waiting for this project to die a timely (if not early) death. Depending on how long this “temporary” assignment lasts, I’m going to be counting down the days alongside them.

Have an EHR exception horror story? Have a fantastic tale of success? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 8/13/12

When I originally applied to be a HIStalk sidekick, Mr. H and I discussed what I could potentially bring to the table. One of his ideas was for me to review and comment on articles from the physician point of view. I’ve done that from time to time, but this is the first time I’ve decided to completely dissect an article with the intent of defending physicians from bad information.

There is so much going on in healthcare today that it’s nearly impossible to keep up. According to the conversations in the physician’s lounge, many physicians (especially those in primary care) rely on a variety of blogs, newsletters, and trade journals to try to keep up. Who wants to read 800+ pages of Meaningful Use legislation and thousands of pages of commentary? Who wants to read the Supreme Court transcripts related to the Affordable Care Act? (OK, y’all know I did read it all, and I know some of you did too, but that’s beside the point.)

One of my favorite quickie journals for trying to keep up is Medical Economics. The July 25 edition had a couple of articles which I found mildly aggravating, as they grossly oversimplified the analysis needed to determine if a physician should enter into the business of running a moderate complexity laboratory as a means of increasing revenue. However, the article on the potential influx of millions of patients to our already dysfunctional health care system left me grinding my teeth. Physicians who aren’t well versed in the gory details of the legislation, the regulatory environment, and how health systems run are likely to take this kind of writing as fact rather than as the quasi-opinion piece it is.

You’re welcome to read for yourself, but I’m putting on my “Mythbusters” hard hat and safety goggles to start debunking.

Myth #1: Having health insurance is going to make people run to the doctor and undergo lots of tests and procedures. I don’t disagree that there are quite a lot of people who would certainly take advantage of new coverage, many of them with existing health needs. However, I know a great number of people who have really good health insurance (many are my co-workers, neighbors, and friends) who simply don’t go to the doctor. Even with fully-covered preventive visits (no co-pay) they don’t see a need to go. Some patients are afraid of physicians and others are instead afraid of the federal government tapping their personal and health information. Others prefer to spend their time and resources on unproven alternative treatments and distrust the medical establishment. I imagine the percentage of people falling into these categories may be quite similar among currently insured and yet-to-be-insured individuals.

Myth #2: We can’t grow the physician workforce. The article states: “The AAMC notes US medical schools have complied with requests to boost class sizes by 30% time [sic] over the past 6 years, but the overall supply of US physicians cannot expand unless Congress increases the number of federally funded residency training positions, a number that has been frozen since 1997. The AAMC is working hard to revisit this freeze… staying where we are will leave US medical school graduates without a training position.” Not exactly true (and questionable editing, but I digress). According to 2012 National Resident Matching Program data, nearly 5% of family medicine positions were unfilled. A large number of federally-funded residency positions were filled by foreign medical graduates – in family medicine, only 48% of the positions were filled with graduating seniors from US medical schools.

Saying there are no positions for US grads simply isn’t accurate. The problem is that the positions are in specialties where US grads don’t want to work, such as family medicine. Low pay, grueling hours, and constant insurance and regulatory hassles do nothing to draw prospective physicians. Imagine the marketing campaign: Do you want to drive a ten-year-old Honda Accord? Love those Dockers you wore during your medicine sub-internship? Want to be 50 years old and take extra shifts in the ER to send the kids you never see to college? Primary care is for you!

There are a number of other ways to increase the number of physicians in the work force. I’d like to know how many of those new medical school slots are being used by MD/JD, MD/PhD, MD/MBA, and other combined program students with no intention of ever practicing. My medical school alone has historically graduated up to 10% of students who never intend to pursue clinical care. Additionally, why in the world do we require qualified physicians who have been educated in other countries to pursue a residency in the US? I’ve worked with a number of highly competent physicians who were practicing physicians in other countries who have been forced to either repeat training or change specialties to practice in the US. Years ago, my family knew a highly skilled physician who had defected from the Soviet Navy and was working as a home health aide because he couldn’t obtain a training slot. If we really have a shortage, this doesn’t make sense.

Myth #3: It’s easy to add capacity to the system. I was truly angry after reading the article’s “8 ways to see more patients” sidebar. The author interviewed Michael D. Brown of Health Care Economics in Fishers, Indiana. “Brown believes that physicians can easily move from seeing six patients per hour to 10 by socializing less. Many physicians spend the first 80% of a visit chatting.” First of all, having spent more than a decade in the primary care trenches, even seeing six patients an hour and trying to deliver comprehensive, compassionate, quality care is a challenge. Add to that the need to deal with complex regulations, insurance snafus, and time-sucking EHRs and it’s enough to overwhelm even the hardiest of souls. Ten patients an hour in primary care? Patients have revolted at the notion of the six-minute HMO visit and unless they’re bionic or extraterrestrial, I really do not see the majority of the PCP workforce being able to achieve this.

I haven’t spent 80% of a visit chatting since I was in medical school. I frequently have to redirect patients to stay on topic to just get through the updates on their diabetes, heart disease, and obesity. They want to tell me about their children and grandchildren and their vacations, but that’s just not a reality any more. The old-time family doctor I hoped to be is an extinct species. I have to ask patients to pick their top three issues to talk about just to stay on time. Patients always come in with more concerns than they told the scheduler, and that’s my only way to survive. It’s certainly not what I signed up for, but it’s the nature of the beast, and I run a reasonably high patient volume with a highly interoperable EHR and a strong staff. However, if I run late, my patient satisfaction scores drop. Since that’s what partially drives my compensation (and keeps the parade of regional practice administrators off my back), it’s what I do to stay afloat.

Brown goes on to say, “You can’t spend 8 of the 10 minutes you have allotted for a patient on unrelated matters and stay on schedule.” That’s funny, because in the previous paragraph he only allowed us six minutes per patient. Brown also goes on to say physicians who can’t handle 10 patients per hour should add two more appointment slots to each day. “At $75 each, times 10 per week, doing so can increase earnings an additional $37,500 per year with no added overhead.” I’m not sure what kind of practice management consultant forgets that seeing patients involves staff (especially if you’re going to leverage medical assistants and mid-level providers as he also recommends) which certainly involves overhead. If you’re already optimized, you can’t just cram more slots on the schedule without adding staff capacity or more time to the day unless you cut corners.

I’d keep going with the Mythbusting, but it’s late and I’m on teaching rounds this month. I have to be at the hospital at the crack of dawn, and due to work hour restrictions, most of my residents and students will have had more sleep than I will. It’s always challenging to be on service, but there’s no better way to shape the future physician workforce.

Have a medical or health care IT myth you’d like busted? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 8/6/12

One of the things my organization has always struggled with is the concept of professional development. Of course we require the physicians, nurses, and other licensed professionals to attain the required hours of continuing education in their respective fields. For all the other disciplines where it is not mandatory, we tend to do a relatively poor job.

Case in point: physicians and nurses who transition from clinical practice to administrative positions are no longer granted continuing education time or funding. Although we’re required to keep licensure, it’s up to us to do it on our own.

Those of us in the IT realm have come up with creative ways to earn our hours, such as attending sessions at our vendors’ user group meetings that have been granted continuing medical or nursing accreditation. Others teach medical students and residents or simply complete online continuing ed classes. While that meets the letter of the law, I’m not sure it does much for us as far as professional development.

Being a CMIO, CMO, or medical informaticist requires skills we weren’t born with. It is important to keep up with the constantly changing environment in which we work. It’s critical that people operating in those roles be allowed time and funding to attend formal programs to enhance their knowledge of healthcare IT, software, change management, conflict resolution, process improvement, and the many other disciplines that make the difference between successful projects and failures.

Considering this, it was a rare treat when I had the opportunity recently to attend formal training with our vendor. My last “official” training on our primary system was at least five years ago, and I must say that at that time I had no idea what I was getting myself into. It isn’t as if I’ve had no training since then, but the training that I’ve been able to attend has been very focused – around specialties that are being deployed, planned upgrades, and of course Meaningful Use. There hasn’t been much of an opportunity to really look at the EHR product as a whole and how it’s implemented in our hospital.

As I sat in the training center surrounded by soon-to-be new users, I enjoyed seeing their eager faces and lack of cynicism. It was fun to be the grizzled veteran in the bunch. We went through the applications from the ground up and what I learned was surprising.

Although we are among some of the most robust users on the company’s client list, there is still so much that we’re not using. I quickly learned of a handful of features that could make our providers’ lives easier and also some that would ease the burdens of configuration maintenance. It was also good to network with medical leaders of organizations who are late adopters. They have a very different view of things than those of us who are used to being on the cutting edge, and our after-class conversations were full of great ideas.

It really caused me to think about how we missed finding these items over the past several years. I’ve decided it was because the team was thinking like the IT equivalent of physician subspecialists rather than as primary care specialists. To put it in clinical terms: while we were focused on the musculoskeletal function of the wrist, we missed hearing about the latest and greatest strategies for health promotion and disease prevention. When faced with new features, we may not have understood how we could benefit from them, so we passed them by and never came back to them (usually because our team is running 90 miles an hour with dozens of competing priorities, so I completely understand how it happens.)

I’m encouraging our leadership to plan to fund opportunities for various team members to attend formal training sessions at least every few years so that we don’t find ourselves missing out on features or workflows that could have been beneficial. At the same time, I’m hoping that the experience will give concrete proof to the hospital’s administrators as to why it is important to facilitate learning opportunities for its medical leaders.

Have a great idea about professional development? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 7/30/12

This is the final piece in my series about vendors using physicians and other clinical experts in design, implementation, and support. I heard back from a few individual physicians working for vendors who asked not to be named. I’ve paraphrased their responses as well to give them a little more anonymity.

Miriam works for a top-tier ambulatory vendor. Although she does primarily go-live support and physician-to-physician training, she also works with content designers on specific specialty-related projects. Although there are a large number of physicians in her company, she thinks that the physicians are underutilized in the development process.

I would like to be involved more upstream in the development cycle. Since we’re in the field so much, we know better than the development teams as far as how the users work.

She notes a high degree of physician turnover due to the 75% travel schedule her company requires.

Jae is an internal medicine physician working as a consulting firm subcontractor. Although he would like to work for the vendor directly, he previously worked for a client and an anti-poaching agreement prevents him from being hired. He was involved in what sounds like a fairly messy practice breakup and the remaining partners would not give him a release, so he’s spending a year in what he calls “independent contractor limbo.” Although he does the same type of work as other physicians employed by the EHR vendor, his services are passed through the consulting firm to avoid actual employment.

I do a lot of liaison work with sales prospects, especially sales demos since I still do some locum work and can say I am a practicing physician. I can also technically say I’m not on the company payroll, although I’m not crazy about how the sales team sometimes plays that. The contractor thing isn’t all bad, though. I probably make about the same salary as the employed physicians once you figure the difference in hourly wage vs. paying for my own benefits, but I probably have a lot more control over my schedule this way. I don’t think I have as much influence in development, though.

There’s more to his very interesting story, and I must say I admire the vendor’s way of intentionally working around their no-hire agreement. Given the recent reader comments about a certain vendor’s no-hire agreements, it’s interesting to see it work the other way.

I’ve been saving this early submission for a strong finish. Dr. Ryan Secan of HIStalk sponsor MedAptus sent information about his work as chief medical officer, including an action photo.

I share many of your concerns about medical software, as I’ve often noted that the applications I’ve needed to use don’t seem to have had any input at all from a practicing clinician and are not designed with my workflow in mind. This is why I joined up with MedAptus last year. It was chance to help create software for physicians from the point of view of a practicing clinician. While my role at MedAptus includes participation in the sales process and acting as a liaison with client physicians, I also have an integral role in the design process. I understand physician needs for clean, simple, and intuitive interfaces that facilitate their work rather than hamper it. At MedAptus, we believe that our software should fit itself into physician workflow rather than forcing physicians to change their workflow to match the software. This has been particularly important as we prepare for ICD-10 implementation and the sheer volume of codes threatens to overwhelm the provider. Leveraging my clinical experience has allowed us to continue to put out a product that remains easy for clinicians to use despite the increasing complexities of medical billing and coding.

The above photo is me with James Scott, who is the vice president of engineering at MedAptus. James and I meet regularly to discuss feature enhancements, usability design, and navigation. This was taken during a meeting in which we were reviewing changes to the physician interface of our professional charge capture application to support end-user ICD-10 code searching and selection.

There were a few respondents who said they were going to obtain permission to send something but then never got back with me, so I assume the marketing and communications gatekeepers were not big fans of the idea. Or maybe, like my experience last week, they were pulled to work a double shift at the hospital. If they ever make it through the PR gauntlet, I’ll be happy to run their pieces.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 7/23/12

Last week was the first in a series of pieces about vendors using physicians and other clinical experts in design, implementation, and support. I mentioned that some vendors were awfully quiet, which seemed to shake loose some additional responses. As one of the first folks to reply to the original challenge, HIStalk reader Dr. Lyle sent a few thoughts:

I’ve actually spent a long time balancing clinical care and product development (and have been at various levels, from actual programmer to high-level vision guy), but a few key things always come to mind:  Don’t just ask what docs want – observe them and their workflows to see what they really need. No matter where you start, you will need to evolve, so keep a system in place for quick iterations to get to a better product. And as you implied, even if you have a doctor who can bridge that gap between clinical and IT, the vendors rarely use them that way. I have been medical director and consultant to a number of EMR and IT companies over the years and I finally grew tired of trying to explain things and then watch a product get twisted by IT and marketing to a point where it was no longer usable. I started a new company last year where the core team is me, a human factors engineering expert, and an IT guy. We think that threesome is what it takes to make great healthcare software. We are focusing on building physician efficiency software tools which integrate with EMRs to help automate and task-shift work. We had a nice writeup and I blogged a bit more about it. It’s been fun and quite an experience to move from the idea to building to launching to actually seeing a vision in place. Our first client found that our software cuts their doctor’s refill workload by over 50%, saving them 15-30 minutes a day. Finally, HIT which makes life easier for docs!

What Lyle says about observing physicians to see what they need is so true. I’ve found that clinicians can rarely articulate their workflows in a way that matches exactly what they actually do (except for surgeons, who are usually spot-on) so asking them often misses larger pieces of the puzzle.

I received a nice response from HIStalk sponsor Iatric Systems with a thorough write-up of its Physician Design Team, which was created to develop its IatriCare and OrderEase solutions. They win the prize for accompanying their submission with professional head shots, which I know always makes Inga and Mr. H happy. They also get points for showing that they actually read Curbside Consult:

Iatric Systems’ Physician Design Team is made up of physicians, nurses, and programmers. The providers on our team have years of clinical experience. For example, Suresh Nekuri MD is the medical director and a practicing hospitalist at Roane Medical Center (part of Covenant Health) in Knoxville, TN. He participated in the implementation of CPOE and the development of order sets for all eight Covenant hospitals. Michelle Schneider, a registered nurse on the team, has clinical experience in cardiac and intensive care. She worked for 14 years in a healthcare system that uses Meditech before joining Iatric Systems. The team’s focus was to design a CPOE solution that streamlines physician workflow so doctors can provide quality care to patients in less time.

Dr. Jayne, you indicated priority placement of postings would be given to companies with witty submissions, but it turns out there’s nothing fun or witty about our team’s development process; it was all business! Since members of the team had worked with deficient CPOE systems before, there was a mutual intensity, a real motivation to create an exemplary solution. Michelle Schneider confessed to being a taskmaster in design team meetings. She said, “We had new software developments to show in every meeting, and we needed to get the team’s feedback. So for example, if a meeting lasted 60 minutes, 56 of those were intense.”

Members of the team brought a diverse wealth of knowledge to the table, ranging from emergency department and inpatient experience, to skills that provided outpatient and private practice perspectives. So the team was able to focus on development of a solution that accommodates best practices while keeping in mind personal user preferences, too. Nurses and programmers on our team are full-time Iatric Systems employees, and they remain intimately involved in implementation and support. Because we choose physicians who are practicing providers, we employ them in consultative arrangements.

Since the initial development phase is over, the vast majority of enhancement feedback we receive now comes to us directly from physicians and clinical IT staff at hospitals that use IatriCare and OrderEase. But we retain the physicians on our Physician Design Team as needed. In fact, Dr. Nekuri joined Iatric Systems this month at the 2012 International Medical User Software Exchange (MUSE) Conference in Orlando, speaking with customers and participating in MUSE’s Physician Summit, where he and four other physicians discussed a variety of CPOE topics including standardization, physician engagement, training, support, order sets, policies and more. We are committed to quality patient care and user satisfaction, and we believe our Physician Design Team configuration has served us well in reaching those goals. One might sum it up by reiterating your father’s mantra, “If a job is worth doing, it’s worth doing well.”

I did receive a couple of e-mails from people who seemed to not read the request I originally posed. Just citing the number of full-time physicians on your staff wasn’t what I was after. There was also one addressed to “Diane” that sort of grazed the issue. If I haven’t yet replied to you, you might want to check your Sent Items folder then edit and resend.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 7/16/12

Last month, I threw out a challenge for vendors to brag about their use of physicians and other clinical experts in design, implementation, and support. I’m a bit surprised that certain vendors were so quiet. I know of at least a handful that have large physician teams in addition to significant numbers of other clinical professionals, but I didn’t hear a peep out of them.

I offered priority placement to companies with witty submissions and was not disappointed. The grand prize goes to this one. While I must keep them anonymous, their piece left me grinning like a Cheshire cat. I’ll let them speak up and claim it if they decide to get approval from The Powers to make a public statement:

As the IS department of a multi-specialty group practice, we are bucking the trend of buying vendor software and living with the consequences. Instead, we develop the majority of our clinical software in-house, which provides tremendous advantage and incentive. We eat our breakfast 300 yards from 4,000 medical staff who are trained to kill us, so don’t think for one second we can code with apathy, charge for upgrades, and not be nervous.

When you develop software for an aggregate group of faceless customers, you come to work with a different perspective than when you develop software for the physicians that will sign off on IS raises. The age-old question posed by efficiency expert Bob Slydell, “What would you say you do around here?” to engage physicians in software design is tackled next.

Last year, IS made the organizational transformation from Waterfall to Agile development. To better facilitate and support active provider involvement, we implemented new technologies and architectural platforms, remodeled our workspace, and completely changed the way we work with operations (including providers and support staff.) We created transparency in everything we do and greatly enhanced our channels of communication, transforming from a culture of “Us vs. Them” (operations vs. IS) to a culture of “We” collaboration and teamwork. (we habitually hold hands and break into stirring renditions of Kumbaya!)

Our providers now work closely with us throughout all stages of development, often meeting one or more times per week and are also readily available via e-mail – both our product owners (the providers ultimately responsible for driving the solution) as well as other members of the workgroups created to support the product owners. These cross-functional workgroups are composed of other providers along with members of various operational departments, including care coordinators, administrators, patient financial services, HIM, support staff, ancillary departments, and more. (we even include fictional characters to keep the meetings lively.)

As we develop working prototypes, we regularly engage willing providers, residents, and support staff in focus groups and usability testing in our state of the art usability lab (the unwilling are goaded by inviting them to the same lab under false pretense of providing pizza and light snacks.) In addition, our user experience design research team comes in to give a green light to the product or send it back for more iterations. (reminds me a lot of French class, Fait Encore!)

Requirements workshops, interviews, surveys, and design workshops are yet other methods we utilize to give our providers a voice in our projects. They, in turn, provide a plethora of much appreciated input.

Happily serving our providers so we can still afford to eat,

The IS Department

It’s hard to top that, so I’m going to leave this team standing on the first-place podium. More to come in next week’s Curbside Consult.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 7/9/12

I wasn’t surprised at all when I read this article about a San Diego Padres fan being struck in the chest by a foul ball. Although neighboring fans moved out of the way, the injured spectator was trying to update Facebook and didn’t notice the ball speeding to his section. Studies have demonstrated increases in injuries to pedestrians who text and we all know the hazards of texting while driving. This is another example that smart phones may really be making us dumb.

For many of us, technology has been integrated into various facets of our lives longer than it has been playing a role in healthcare. Because of it, some of us are losing essential skills. Now that GPS navigation is widely available in vehicles and on phones, people seem less likely to know how to read a map or use a road atlas. On family vacations when I was a kid, I looked forward to driving across the state line so we could stop at the visitor’s center and pick up a map. We always had a stack of maps from various states in the glove compartment which were great to look at while on long trips.

Vacations were about getting away from day-to-day activities rather than letting work stress follow us everywhere we went. We didn’t feel obligated to tell the world every little thing we did or broadcast pictures of our food using the internet. If we needed to contact someone, we had to find a pay phone. (Remember pay phones? My buddy Skeptical Scalpel does in this funny blog posting.)

Technology can be great – it’s definitely safer to have a cell phone in case of emergency than to have to walk down the road to find a pay phone which may or may not be in working condition. It’s reassuring to have allergy and interaction alerts in my electronic medical record rather than relying on memory (as if one could actually know every interaction out there – cytochrome P450 haunts my dreams.) But does relying on the system hamper our desire to actually learn and retain the information?

I thought I’d be immune to it by now, but as a primary care doc, I’m still amazed at people’s dependence on technology. The other day, I walked into an exam room where a patient was scheduled for a gynecological exam. I generally run on time and actually had to wait a minute after I knocked because the patient was still changing out of her clothes. I could barely make it into the room because the patient had rearranged the chairs to allow her phone charger to reach the outlet. She also unplugged the exam table, making it impossible for me to perform her exam without plugging it (and the lamp) back in. She was already texting by the time I entered the room and I had to ask her to put the phone down so we could conduct the visit.

I see countless parents who can’t put their phones down long enough to talk to me about their children. What message do they think they’re sending? Unfortunately, the kids develop the idea that what’s on the screen in the virtual world must certainly be more interesting than the real world. They think it’s normal to be connected to the office 24×7. When we’re rounding in the hospital and we’re focused on our phones rather than interacting with nursing staff and the care team, it’s no different. Conversely, trying to interact with members of the team while they’re texting or taking personal calls isn’t a good thing, either.

At a local youth camp where I volunteer, we have detailed emergency preparedness plans and the staff monitors conditions so that we’re ready for severe weather. Nevertheless, parents are still glued to their phones watching weather radar in case it might rain rather than seeing their kids do fun things like archery and horseback riding. I watched one mom tell her son that he needed to get back in line to do archery again so she could take a picture because she missed him doing it the first time. Why did she miss it? She was on Facebook posting pictures from the morning’s activities.

With obesity and lifestyle-related diseases on the rise, it’s even more important for each of us to put down the technology for some part of the day. Try driving without the GPS and actually take in your surroundings. Or, get outdoors and let your brain recharge or give your body some needed activity. Reclaim your critical thinking skills and your sense of wonder rather than letting technology define your world.

Can you name the location pictured above (courtesy of Jake DeGroot) or do you know its purpose? Email me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 7/2/12

It’s been four days since the Supreme Court issued its decision on the Affordable Care Act. I did get to have a little fun with it on Friday. One of the guys I work with fancies himself a Supreme Court aficionado, so I left a beribboned bunch of broccoli in a decorative vase on his desk. He totally didn’t get it, which made the day of several people.

Watching my physician colleagues react to the decision has been interesting, particularly because some are so detached from really understanding its impact. They’re well-versed, however, in knowing what the various talking heads are saying about it on TV and in other media.

In talking through it with one of my CMIO colleagues, we came up with a theory. Since we spend so much time in hospitals, most of the physicians we’re exposed to on a daily basis are hospital based. These are typically procedural specialists in higher income brackets and they tend to be more self protective and income oriented. Not surprisingly, most of them cited the upholding of the Act as the end of truth, justice, and the American way.

Reaching out to some primary care colleagues, there was a greater proportion of physicians who support the act, but I was surprised by the number of front-line family physicians who reacted with extreme negativity. Several expressed the opinion that this decision is just the beginning of ongoing legal wrangling which will distract from the real work that needs to be done in reworking the American health care system. Although the Act will allow more patients to be covered by private insurance or Medicaid, it doesn’t materially change the availability of care in the short term.

Professional organizations are predicting an increase in patients seeking care in the emergency department rather than in the ambulatory primary care setting. The forecast shortage of physicians needed to care for the influx of patients into the health care system still hovers at 60,000. Interventions such as telemedicine that could allow physicians to better care for patients in continuity (and keep them off of overcrowded office schedules) still aren’t reimbursed by major insurance payers. Subspecialty providers are rewarded for performing procedures and high-tech interventions, while primary care practices are forced to subsidize care management initiatives with the promise of potential future income that may never be realized.

The American Academy of Family Physicians praised (their word, not mine) the decision in an online posting and received numerous negative comments. These reflect the ongoing divisions in the medical community that won’t be resolved until real care transformation takes place.

I’m sure additional legal challenges will follow and states will maneuver as much as they can. Physicians will continue to be in limbo. I don’t foresee a jump in the ranks choosing primary care, nor do I see care actually becoming more affordable.

Are you a front-line physician with an opinion on the decision? E-mail me.

E-mail Dr. Jayne.