Curbside Consult with Dr. Jayne 4/15/13

The American College of Physicians and the Federation of State Medical Boards recently released a policy statement regarding online medical professionalism. It discusses a variety of online activities with pros and cons. It also recommends safeguards for each type of activity.

Until I read this position paper, I hadn’t really thought about looking up patients on Google. To be honest, when I’m seeing patients I’m too busy trying to actually perform patient care tasks, document until my fingers are numb, and fill out mindless paperwork. I don’t have time to see if there are pictures of them smoking when they say they don’t. On the flip side, I know patients Google us. I’ve had patients in the ER who stalk me online before I walk in the room, and that’s kind of creepy.

I also didn’t know before reading this that the Federation of State Medical Boards has specifically discouraged physicians from “interacting with current or past patients on personal social networking sites such as Facebook.” Thinking about it, the only patients I am connected with on Facebook are nurses that I counted as friends before they were my patients.

The statement includes a section on “airing of frustrations and venting” as having the potential to “undermine trust in the profession.” Specifically it cautions against criticizing late-arriving patients or patients who aren’t following their diets or working on weight loss. Based on the comments of anonymous physicians I follow on Twitter, those are the mildest offenses.

In an informal review of three days’ of Twitter feeds, I found most complaints around: drug seekers; patients who lie; patients who present to the emergency department for extremely minor or nonsensical reasons; patients who abuse or threaten violence against clinicians; and physicians not getting to take a meal or bio break during their shifts. That would seem to me that the FSMB might be a little out of touch with the realities of being in the patient care trenches. I agree that posting patient-specific information is not appropriate. Even if you black out the identifying information, I don’t think medical images belong on Twitter, and one of the physicians I follow has started doing that recently.

The position paper gets a little pedantic when it starts talking about the social contract between physicians and society. Whoever wrote that section must be a subspecialist who trained in the Marcus Welby era, because for those of us younger primary care physicians, I’m not sure we’ve really experienced that degree of social contract. It states, “In exchange for the privilege of caring for patients, as well as the status, respect, and financial compensation that accompanies that privilege…” that physicians must meet societal expectations regarding professionalism.

Although I agree that caring for patients is a privilege, I disagree on the rest of the points. Physician social status is on the decline, as is financial compensation. Frankly, most of the IT managers in my department make more than the starting primary care physician. Until recently, my student loan payment was more than my mortgage. (And no, I didn’t buy a big house – I finally paid off the loans.) When patients became “customers” and we became “providers,” the social contract started to unravel. Don’t get me started on the commoditization of health care.

Patients who are used to trusting Dr. Oz and Dr. Google for medical advice argue with us and refuse to be accountable for their own health. Patients threaten to sue before a diagnosis is even given. Patients complain on multiple social media sites and clinicians are powerless to present their sides of the stories. Expectations are at an all time high – after all, IBM’s Watson can replace us – and respect is at an all-time low. The fact that physicians vent online should be no surprise to anyone.

As an anonymous blogger, I’m used to drawing clear lines in my online behavior, so the release of this position paper isn’t going to change how I operate. What do you think? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/8/13

One of last week’s Morning Headlines posts mentioned the appalling situation of backlogged disability claims at the Department of Veterans Affairs. According to PBS, one site was so packed with paper claims information that the structural integrity of the building was compromised. A report from the VA Office of the Inspector General cited 37,000 claims folders stacked on top of file cabinets which “exceeded the load-bearing capacity of the building itself.”

Even more horrifying is what this represents – more than 800,000 veterans who are waiting for their claims to be processed, which can take over a year. The workload for disability reviewers varies from state to state, creating further inequity. Nebraska, South Dakota, and Maine have shrinking backlogs but the nationwide average wait time is 286 days for claim review.

I realize that the VA is not CMS is not Meaningful Use is not the Affordable Care Act. However, they all come from the same place. In the spirit of reform and pay for performance, I’d like to offer a new program for Congress to write into law. Any Meaningful Use, PQRS, or ePrescribing penalties should be placed on hold until the federal government shows it can get its own house in order. Since MU is grading me using a variety of metrics as a proxy for quality care, we can use the VA claims backlog as a proxy for process efficiency.

The VA is the quintessential government-run bureaucracy. It has a lot of advantages over the way that the rest of us practice – single payer, single set of regulations, and a well-defined patient population. By extension, the VA disability claims should be able to benefit from some of that homogeneity and be a pinnacle of efficiency.

Of course this will never happen since the whole bureaucracy is brought to us by the same entity responsible for the sequester debacle. I read with great interested about Vanderbilt University Medical Center and what they’re doing to balance their budget shortfall: halting employee accrual of vacation days, cutting discretionary spending, eliminating bonuses, and freezing salaries. VUMC plans to cut $20 million out of this fiscal year’s budget and $30 million next year.

To show solidarity with its constituents, I’d like to see members of Congress freeze their own salaries and benefits until they deliver a balanced budget and show that they have a plan for the future. While they’re holding off on penalizing us, they can also back off on MU (and other) audits to allow health care providers to actually focus on caring for patients. When their house is in order, then they can consider telling us how to run ours.

Viva Jaynecare!

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/1/13

Every time I am invited to present at the hospital’s quarterly medical staff meeting, I feel like I should wear personal protective equipment. No one is hurling rotten tomatoes when we talk about EHR, but the verbal assault can be equally messy.

I was asked to present at the recent meeting with the goal of discussing our ICD-10 transition plan. Despite previous mistakes by our (now-disbanded) ICD-10 Task Force, our new team is confident that our vendor is ahead of the pack. I thought I would escape without too much drama. Thoughts of melting snow and approaching spring weather must have tricked me into forgetting the tendency of my colleagues to go completely off the agenda.

When we implemented EHR, we carefully audited the coding/billing functionality to make sure that not only did it adhere to CMS guidelines, but to the stringent standards of our auditors. We manually audited behind any computer-assisted coding for a period of time until we were comfortable that the algorithms were appropriate. At that point we discontinued full audits, but continued spot audits on high-dollar or high-risk episodes of care. We also continued our regular audit protocol where each physician had a set of charts audited each quarter with coding feedback delivered from our teams.

When the EHR was initially deployed, we saw a shift in the distribution of ambulatory Evaluation and Management codes, but this was expected. It also matched with published data that showed primary care physicians tend to under-document the care they deliver. We were happier with our increased documentation of the care we were appropriately providing.

Over time our EHR has matured and has had added to it a variety of individualized order sets, care plans, patient instructions, and documentation macros that allow our users to personalize their notes. Our coders have stayed on their toes, making sure visit documentation continues to be individualized despite these labor-saving features. We definitely don’t want to fall victim to the problems that can arise from cloned documentation or any other inappropriate use of the EHR.

Since we’ve been live so long and our medical staff has grown so much, many of our newer colleagues didn’t go through this initial auditing process and don’t understand the ongoing auditing that is in place. Without this comfort level with the EHR, they are extremely nervous about what will happen with ICD-10. Our EHR is moving to a new level of assisted coding to aid with the transition. 

People are, for lack of a better description, freaked out. The question and answer period following my ICD-10 presentation spiraled into paranoia and outright fear.

Providers have long been worried about audits that would demand large repayment sums based on a sampling of charts. Now they are worried about criminal prosecution on top of financial penalties and potential exclusion from federal health care programs. Several more vocal colleagues demanded that we go back to 100 percent chart review by certified coders, which is just not tenable given recent budget cuts. Others asked the medical staff to consider endowing a legal defense fund.

Fear of law suits has led to exorbitant health care costs through the practice of defensive medicine. Fear of audits will lead to more spending on non-patient-facing services such as chart reviews and coding audits. I for one would rather spend my healthcare dollar lowering the patient-to-nurse ratio and decreasing preventable harms. What do you think about the increase in audits related to the increase in EHR documentation? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 3/25/13

I’m lucky to have started my career in health IT on the leading edge of ambulatory EHR adoption. My health system was forward thinking and data driven, so we’ve been in the game a long time.

When we decided to implement a system-wide health record, the group quickly realized they’d need a dedicated clinician to help steer the project. I applied for the job and my career in informatics began.

I quickly realized that although I knew a great deal about implementing EHR in my own practice and using it to drive evidence-based care, there was much I had to learn about doing it on a broad scale. I thought SQL was something that followed a blockbuster in an attempt to squeeze cash out of the movie-going public. I had no idea what lurked in the heart of a legacy app that was trying to be more than its architecture allowed.

The first move I made was to seek out a half dozen smart clinicians who had come before me. It was hard to do – most of us were starting our projects at a similar point in the product’s evolution and frankly my health system was the largest customer our vendor had signed to date. I decided that I was going to learn everything I could, regardless of the size of my the organizations of my peers. If they were successful in what they were doing, I figured I’d work with my team on how to scale it.

I ended up with a core group of five close friends, all of whom knew more than I did regardless of their size as a customer. We had that “we’re all in this together” attitude and quickly bonded through many a late night e-mail blast. We recognized that everyone had something to offer.

Half a decade later, I still count these fellow travelers as some of my closest friends. Some have moved to other vendor platforms, but not a week goes by that I don’t find myself thinking about something I learned from them. New faces have joined the group. There are quite a few weeks I still reach out with those, “When this happened to you, what did you do?” type questions. Sometimes they’re EHR related sometimes not, but I know my circle of “phone a friend” colleagues have my back.

Our primary EHR vendor knows this group of leading CMIOs well. We were recently asked to mentor a new client that was converting to our product after a failed pilot with another vendor. The new customer reminded me a lot of myself – they are a relatively large customer compared to the rest of us and I thought our group would have a lot to offer them.

Introductions were performed and one-on-one sessions were arranged at a regional user group meeting. We were poised to share everything we had with this client – from detailed conversion plans and assessment tools to the sacred “known issue” lists that we had compiled. We looked forward to having a new kid on our block to continue to push our mutual vendor to excellence.

We were not, however, prepared for the new customer’s reaction to our efforts. We were completely shot down. The prevailing attitude of, “You can’t possibly understand because you’re not as large as we are” made it impossible to communicate. The new CMIO was convinced that unless a live client looked exactly like their hospital, we had nothing to teach her. She used every opportunity to belittle our efforts despite our demonstrable outcomes.

Had this been middle school, I’d have dropped this new “friend” like a hot rock. Not only was she failing to take advantage of what we had to offer, but she was acting ungrateful and downright rude.

Several months have passed since the new CMIO blew us off. I spotted her recently at HIMSS. Not surprisingly, she’s been “made available to the workforce.” Her implementation never got off the ground and has been outsourced to a consultant.

I wish her luck and hope she’s learned something. Like Mark Twain said, it’s not the size of the dog in the fight, it’s the size of the fight in the dog. There is always something to learn and we can’t be afraid to open ourselves to the possibility.

I’m fortunate I had some great friends in my corner. I hope one day to pay it forward to someone who will appreciate it.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 3/18/13

I got a laugh yesterday when visiting the Southwest Airlines website. In honor of St. Patrick’s Day, they revamped it with a green color scheme and leprechaun-friendly prose. They’re one of my favorite airlines, not only because they are consistently on time and predictable, but also because of their corporate culture.

Culture has been in the news recently with Yahoo’s recent change in its work-from-home policy and the resulting backlash. In many ways I agree with Yahoo CEO Marissa Mayer that having employees in the office is important. As someone who has worked both in a cube farm and remotely, there are challenges to not being in physical proximity to co-workers. There is a loss of ability to read non-verbal communications and it’s hard to build workplace trust with co-workers you’ve never seen or met. My biggest issue with many people working from home is the risk of multitasking – it’s all too tempting to multitask in ways that you would never do in the office proper. I did really enjoy working remotely, however, and was a lot more productive than I was in the office because I could focus and work on complex problems without interruption. I can see both sides of the argument.

A recent piece on the corporate culture at Google illustrated their efforts to keep employees happy when coming to the office. Themed conference rooms, “design your own desk” offices, and free meals join subsidized massage therapy at the office as perks. (I’m not too sure about the claim of free weekly eyebrow shaping, but to each his or her own.) The idea at Google is to make it a place that people want to come to rather than forcing workers to the office each day. The comments on the Google piece were pretty fun to read as well and several gave me a pretty good chuckle.

Comparing a place like Google to the average healthcare IT workplace is like comparing apples to oranges. Unless you’re at a progressive vendor with a lot of money and a culture of innovation, you’re probably making do with what you have and with few perks. Being in the non-profit hospital space, I can definitely attest to making do with very little. My current office is an abandoned conference room, which was taken out of service because the conference table didn’t really fit and also because the ventilation is sketchy at best. Being in a cube at the time, I snapped it up simply to have a door and a place where I could go to have private conversations about disciplining physicians or to just sit in silence for five minutes to get my head together before a day full of meetings. I had to go to the hospital’s “dead furniture room” to pick out a desk that is decidedly from the Reagan administration.

Our ambulatory division is housed in the former billing office and has very few conference rooms, which makes it difficult to have meetings. Even though we’re sometimes crammed in and bumping elbows, we have a rule that if you’re in the building, you’re expected to attend in person. We have a group of extremely cohesive managers and I can’t help but think that our meeting culture helps keep that team strong.

In contrast, our inpatient division is housed in a brand new building that was designed with functional layout in mind. Although the cubes are short and the floor plan is open, there are scores of meeting rooms (from small two- or three-person huddle spaces to massive training suites) which allow for both privacy and collaboration. Despite this, the office culture still doesn’t encourage workers who are physically in the building to attend meetings in person. Sometimes no rooms are booked for meetings, which leads to annoying conference call behaviors and rampant multitasking, not to mention entirely too many “can you repeat that” type statements. There’s also nothing worse than being on a call with the person in the cube next to you when you hear their voice through the air and then hear it on the phone seconds later due to the conference line delay. People are so busy on instant messenger and doing multiple projects that they can’t focus.

Having worked in a variety of environments, I know that getting people in a room together would be beneficial. Alas, it’s not my division, however, so all I can offer is my suggestions and my support to the leadership should they decide to make people start showing up. If they’re not going to make them come to meetings, they might as well let them work remotely and cut the office overhead.

Regardless of division, our employer no longer provides coffee or any other amenities in the office. We’ve turned into people who hoard spare forks and ketchup packets just in case we forget to bring them from home. There aren’t even cups to offer water to visitors, and don’t get me started on the “Coffee Club” vs. “Keurig On Desk” cliques. We’re not on the hospital campus, so there’s no cafeteria and we’re at least 15 minutes from the nearest restaurant, so brown-bagging is a must. I sent the Google article to a couple of colleagues and the responses were generally of the head-shaking variety.

Whether you’re a vendor or an end-user, how’s your workplace culture? Leave a comment and let us know.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 3/11/13

Lt. Dan’s inclusion of “Cisco Study Reveals 74 Percent of Consumers Open to Virtual Doctor Visit” in this morning’s headlines caught my eye. According to the summary, “given a choice between virtual access to care and human contact, three quarters of consumers find access to care more important than physical human contact with their care provider and are comfortable with the use of technology for the clinician interaction.”

I’m not opposed to virtual visits – in fact I’d love to do them for certain patients or for certain conditions. In my market, however, clinicians contracted with the majority of commercial payers are not able to bill for these visits, and patient willingness to pay out of pocket is extremely low. Several of my colleagues have attempted to bill patients for after-hours telephone visits and the practice has been the subject of scorn, not only in the physicians’ lounge, but also with the local medical society.

A true virtual visit is more than a phone call. It’s a scheduled time to talk about the patient’s issues, review medications, review home vital signs, blood sugar readings, diet logs, and other patient data points. Based on a careful history and these elements, changes to the regimen can be made and behavioral interventions can be supported. The history elements, data, care plan, and goals still need to be documented in the patient chart, however, and that takes time. Unless you’re operating under a capitated model where you’re being compensated for these services through a per-member/per-month payment, you can’t perform these services without some sort of compensation.

Virtual visits also generate real liability. They can allow for physicians to care for greater numbers of patients which can increase risk if there is not close adherence to protocols and guidelines or if patients are not well known to the clinician. This makes the need for appropriate scheduling and documentation even more important. Virtual visits aren’t something physicians should be expected to cram onto their schedules in lieu of overbooks to the office schedule.

I do find Cisco’s findings somewhat contrary to my experience in solo practice. When I employed a nurse practitioner to care for my patients as my informatics duties grew, there was a lot of resistance to the team-based approach by some of my elderly patients, who grew up in an era where seeing the doctor was something special and had a unique value outside of the actual medical care. Some patients chose to wait weeks to see me rather than accept same-day appointments with someone other than “my doctor.”

This attitude is somewhat borne out in a later statement in the piece where it was noted that “consumers will overlook cost, convenience, and travel, to be treated at a perceived leading healthcare provider to gain access to trusted care and expertise.” I’m not saying I was a leading healthcare provider (in fact, when I was first in solo practice, I was a fresh grad with a bit too much idealism) but I was a good listener and genuinely cared for my patients. I’m not sure that level of empathy can be easily translated to the virtual experience. I had the privilege of truly getting to know my patients, who also felt they were able to know me.

We exchanged more than symptoms and diagnoses. We also swapped recipes and baked goods, stories of our small community, handicrafts, and more than our share of heartache. I had the distinct privilege of being able to function as an “old school country doctor” in the middle of the suburbs. This was mainly because the opening of my practice solved an access problem, but also gave patients a place they could think of as their medical home, whether it was a designated Patient Centered Medical Home or Center of Excellence or any other buzzword of the day.

I miss having continuity patients and I think about some of my favorite patients often. Every once in a while I will run into one while working in the emergency department and that is a rare treat. Although virtual visits may be cheaper (if they are ever reimbursed where I live) and more expedient, I don’t think they’re going to be as good for building that level of “trusted care” that patients expect when they’re faced with a life-threatening condition. What do you think about virtual visits? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 2/25/13

I’m fairly addicted to Twitter, mostly because some of the people I follow provide a humorous break from reality. I recently saw a tweet about a hospital bill for childbirth. The year: 1951. Ever since I was an intern, I’ve found the history of maternity care in the US to be fascinating (most likely due to all the long hours spent on the labor and delivery floor). I’ve delivered a couple hundred babies and know what charges look like today, so decided to see what this bill would look like in 2013 dollars.

The good people at Dollar Times offer a nifty inflation calculator that helped me with the “today’s dollars” numbers for this five-day hospital stay:

Delivery Room: $91.84
Anesthesia: $91.84
Laboratory: $18.37
Dressings: $32.14
Medicine: $92.30
Formula: $2.76
Circumcision: $18.37
Room and Board: $482.16
Baby Care: $137.76
Telephone: $22.96

Of course, you can’t truly compare apples to oranges against a modern hospital bill, because there is no way you’d be allowed to stay for five days for a normal, uncomplicated delivery. Most commercial payers in my area require patients be discharged no later than 48 hours after a non-surgical delivery and many encourage only a 24-hour stay.

You also can’t compare apples to oranges because payment was made on the day of discharge. No billing or insurance was involved. Paying this bill at discharge would be equivalent to asking a patient to pay nearly $1,000 today and most patients would balk even at that. We’ve become dissociated from the true cost of medical goods and services to the point where if it costs more than a $20 copay or $500 deductible, we can’t fathom paying it.

What do cash patients pay today? A quick Google reveals a two-day labor and delivery package at Tucson Medical Center for $2,300, but only if paid in advance. My hospital offers a similar package that’s priced about the same. Still, that’s more than double the expected price given inflation alone.

Incidentally, while researching this, I learned that my hospital refuses to accept cash as a form of payment. That’s a sad commentary on modern life. Of course there’s a theoretical risk of counterfeiting and you have to have cash-handling policies, but I’d rather have that than the risk of a bounced check or have to bill patients who don’t have credit cards.

I don’t want to get into a debate about natural childbirth here, so let’s assume you’re a patient who wants a “standard” hospital birth. When you consider the modern technology associated with today’s labor and delivery experience, it doesn’t look like such a price hike. In 1951, the anesthesia used at our hospital was Twilight Sleep and was likely to result in maternal amnesia and infant breathing problems.

Today, patients who want it can have continuous fetal monitoring, epidural anesthesia, and highly skilled nurses who are experienced with challenging deliveries and resuscitating depressed infants if needed. Laboring mothers can move from bed to shower to chair to bathtub to labor ball rather than just lying on a gurney. Whole families can share in the delivery experience and babies are able to instantly bond with their mothers.

How then do we translate this to the exorbitant bills we’re seeing from hospitals today? The key difference (besides patient care technology) is the rise of the insurance company and our resulting detachment from the cost of the care we’re receiving. Hospitals and offices must maintain armies of coders, billers, processors, and all manner of clerks, insurance follow-up representatives, patient accounts representatives, etc. just to stay in business. This in turn drives up costs and perpetuates the hamster wheel on which we run.

I have a few good friends who have gone to cash-only practices. I’m not talking about “concierge” or “retainer” practices where the patient pays an annual fee for access to the physician. I’m talking about physicians that know the true cost of their services and what income they want to achieve and charge accordingly.

It’s surprisingly affordable, with office visits in the $40-$50 range. They’re bringing home good money with a higher quality of life. Payment is required at the time of service and no bills are generated. One of my colleagues does provide a copy of a superbill for the patient to submit to insurance, but the others do not. One has a nurse, one has a medical assistant, and the other has no staff at all.

Interestingly, despite being “off the grid,” all three have electronic health records and demonstrably high quality of care. They use their EHRs to enable their workflow rather than to count bullet points and participate in regulatory nonsense.

I’d love to spend some time looking at the true cost of hospital care and modeling what it would look like if third-party payers (and the resulting bureaucratic bloat) were out of the mix. Patients would be closer to the actual costs of procedures and would be better able to determine if it’s worth it to keep grandma in the ICU for her last weeks or whether it would be better to spend a fraction of the money on a hospice nurse tending her in her own bed.

Of course, there would be those crying out that we’re refusing to care for the poor or elderly if we did that. I would argue that some of our high tech interventions aren’t done so much in the name of “care” as much as “because we can.” I’m not arguing that we should deny care to those who can’t afford it, but merely suggesting that if patients (and facilities) were more in touch with the actual cost of care that we’d be in a very different situation than we are now.

As a family physician is wont to do, I’ve told the patient’s story from cradle to grave. I’m interested to see what the tale looks like for the next generation.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 2/18/13

In the last several months, I’ve been involved in a lot of conversations around the concept of unique patient identifiers. A considerable amount of it has been due to our hospital’s participating in an accountable care organization.

We have a very good master patient index (MPI) in place, as well as other tools that allow most of our applications to use CCOW to share patient context as well as user context. Now the ACO is requiring us to tightly integrate with providers external to our owned facilities and employed medical group. That is giving a lot of people in our organization a fair amount of heartburn.

During nearly a decade of practice acquisitions and mergers, I’ve seen how people in various practices may (or may not) correctly identify patients. I’ve seen people perform patient searches using: the first three characters of both first and last name; first name, last name, and Social Security number; first initial, last name, and phone number; and various combinations of name, address, and date of birth. In consulting work, I’ve seen clients with both pristine MPIs and those clogged with duplicates.

The health of the MPI depends on not only the actual data integrity, but how the information is governed. The logic of the matching algorithm also plays a major role in minimizing erroneous matches or missed matches. If person merges are not performed in a timely manner (or if users don’t know how to request a merge when they find a duplicate patient) patient safety can be in jeopardy. In large health systems that have let their MPIs get out of control, it can take months to years for a cleanup effort to be successful.

Our organization is all too familiar with what happens when data isn’t as tightly governed as it is within our MPI. We’ve dealt with the pharmacy intermediaries that use ZIP codes for matching, which is a challenge for our transient patients. We’ve dealt with Sandy vs. Sandie vs. Sandi when the patient’s legal name is Sandra. We’ve dealt with marriages and divorces and the ensuing claim denials that result when names may not match.

There has been a lot of debate in the past about a national patient identifier. As fiercely independent Americans, we seem to fight it as an intrusion into our privacy. However, we willingly submit to a government identifier in order to pay taxes or receive government benefits (the Social Security number) or when we want to drive a car (the state-issued driver’s license number) or go to the Caribbean for spring break (the passport). Yet for the most personal situations (and possibly life-saving or life-threatening, depending on how you think of it), we resist a unique identifier.

I have to have a National Provider Identifier number if I want to receive anything other than a cash payment for my professional medical services. It took time and effort to update clinical, administrative, and payer systems with fields to track the NPI, but somehow we all survived. The same type of update would be needed to track a patient identifier, but the demands of Meaningful Use have proven that vendors can and will update systems based on government regulations.

There would also need to be a new government infrastructure created to issue identifiers and maintain the information. Meaningful Use has also demonstrated a willingness to accept additional layers of bureaucracy in the name of intended reform, so why not for a patient identifier?

Having a unique patient identifier would certainly make interoperability easier. It would also provide significant benefits to patient safety by reducing the possibility of duplicate or conflicting charts. Knowing exactly who we’re treating can also assist in preventing drug diversion and reducing healthcare and insurance fraud.

The original HIPAA Act of 1996 allowed for the creation of unique patient ID numbers, but Congress quickly blocked funding, citing privacy concerns, existing numbering systems, and concerns about government involvement in health care. A decade and a half later, however, those trains have long left the station. It’s time to reconsider.

There is significant support among the professional community. The American College of Cardiology has a nice position statement. Many other organizations cite the 2008 RAND Corporation study titled “Identity Crisis” in calling for support.  The RAND study also discusses the need to use both statistical matching and a unique identifier during the implementation process or if participation is voluntary.

Correct patient identification is essential for effective health information exchanges. There’s a lot of discussion around the Direct protocols for Meaningful Use Stage 2. Privacy rights advocates are pushing for patient-defined identifiers where patients can choose different identifiers in different situations depending on what data they want shared. Although this may allow some data to remain siloed in an effort to protect privacy, it also prevents creation of a true comprehensive patient record.

I support the ability of patients to receive care anonymously, but when patients do so, they should not be surprised that physicians and caregivers may not have the full picture of the patient’s health. Physicians and hospitals should not be held liable for negative outcomes when information is sequestered by the patient. For the rest of us, however, who want to ensure that our physicians have our entire health history present so we can receive the best care possible, this can’t happen too soon.

What do you think about a national patient identifier? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 2/11/13

Dear Dr. Jayne,

I’ve spent most of my career in EHR development. Although HITECH has been a boon for vendors and system sales, it’s been a major stress on development teams. I’m starting to feel like I should think about doing something else, maybe more outside the box. I’m looking for someone who has vision in the Accountable Care Organization space, or even someone who is thinking beyond that at an even bigger picture. It seems to me that the next big wave of health IT will come from outside the traditional vendor space.

Big Data and analytics seem like overused buzzwords, but there is a tremendous need for true clinical decision support and analysis that goes out across hundreds of sources and maximizes not only care but reimbursement across patient populations including multiple unaffiliated physicians who may not be part of a true ACO infrastructure.

I don’t want to wind up at just another vendor that starts with a vision but ultimately ends up fighting over the scraps left by Epic and Cerner. If you were in my shoes (which I assure you are very fashionable), how would I begin looking at this?

Always your gracious reader and devoted fan,
Herve Villechaize

My Dearest Tattoo,

I think that some of the biggest differences in how companies will be able to approach the challenges of the future (both those that are known and those that have yet to reveal themselves) will be defined by a variety of things.

One factor is whether they are publicly traded or privately held. It’s certainly easier to execute a vision when you have leadership that both runs the show and controls the checkbook. We’ve all seen companies sacrifice themselves on the altar of shareholder profits and those behaviors certainly raise red flags. On the other hand, there is a certain amount of protection in being a publicly traded company as there is a higher requirement for transparency.

I’m always intrigued by the development shops that are part of a hospital or health system. I like the aspect of their having to eat their own dog food. Their close proximity to the end users doesn’t give much room to hide behind sloppy code or badly-executed ideas. I would enjoy seeing the major vendors set up model clinics that truly field test their products rather than relying on their customers to perform the final round of QA and usability testing.

Although it’s not specifically in the areas you mentioned, I think there is tremendous opportunity in the market spaces that Dr. Travis and Lt. Dan cover on HIStalk Connect. Patient outreach and engagement are going to be major parts of any Accountable Care strategy. Companies that address virtual visits or link different types of providers across the care continuum – from prenatal education to ambulatory to acute care to home health to hospice –will be well positioned. We need to start coordinating care from cradle to grave if we’re going to be successful at providing higher quality coordinated care as well as controlling costs.

Sincerely,
Dr. Jayne

As vendors combine and products are sunset, I’m sure these questions are on many people’s minds. I’d like to ask our readers what they think. What do you think is the next “big thing” in healthcare IT? If you could work in any healthcare space, what would it be and why? What companies do you think will be around in ten years and who will be leading the pack? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 2/4/13

I wrote a few weeks ago about the ICD-10 planning debacle at our hospital. Our ICD-10 task force had come to a physician staff meeting to discuss the transition plan, which had been created in a silo. I asked betting folks how long they thought it would take until the application team managers were asked to redo the planning. Any of you who guessed four days wins a prize.

The announcement that the IT teams would now own the initiative occurred just before our annual IT planning conference. During most years, we lock ourselves in a room for several days of bad takeout food, worse coffee, and questionable prioritization exercises.

I usually find myself at the end feeling bewildered at some of the initiatives that are given the green light. For example, last year we approved a hideous EHR conversion project for a single practice, but placed a project for hospital charge capture on the back burner even though the charge capture project was cheaper and easier.

If anyone asks, we use a well-known proprietary decision making process to decide which projects are most valuable to the organization. We all had to go through a multi-day course to use this methodology, although at the time it felt like multiple weeks. For those of you whose organizations are into that sort of thing, I salute you as survivors. (I don’t want to get sued using their name, but if you’ve ever dealt with The Red Sweat, you know what I’m talking about.)

For the physicians on the team who are used to assimilating numerous disparate data points and coming up with a diagnosis rapidly, it was pure torture to sit creating grids, weights, and ranks for various decision points. The hospital spent a huge amount of money licensing the program and training all of us, however, so we’re stuck with it.

For each project proposal, we have to create a matrix where we then rank things to hopefully achieve an objective outcome. It’s a completely biased process, however, because most of us know how to game the different measures to up- or down-rank a project. The outcomes remind me of the worst kind of back-room dealing. At least if we agreed up front that the decisions would all be political, we could save a couple of days and a few thousand calories of bad catering.

This year, we really should have skipped it. The results were so skewed it can hardly be called a prioritization process. Every project proposal seemed to earn the highest marks except for ICD-10 and MU-2, which of course shouldn’t have been part of the process since they’d already been labeled as mandatory.

One team member was hell-bent on twisting each of her pet items to associate to a regulatory requirement. It reminded me of Animal Farm, where all animals are equal, but some are more equal than others. By the end of the planning retreat, my fingers were raw from speed-surfing the Web trying to research and contradict her continued demands that we do every single item “because it’s regulatory.”

My current boss is extremely non-confrontational, so this behavior was allowed to continue. We are now left with a list of things to do that would require a team three times our current size. So much for prioritization.

Now it’s up to the managers to get together and cut deals to see they can help each other out and what projects overlap or can share resources so we actually have a shred of hope that we will get them done. There’s certainly no extra money floating around, so we’re going to have to shuffle the pieces on the board and figure out how to deliver the impossible. It’s lining up to be a very interesting year.

Have a great story about your organizational planning strategy? Do you feel like you spend every day in a war room? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 1/28/13

I spent most of my week trying to help colleagues retool budgets, which is never a pleasant task. Everyone is being asked to do more with less. In healthcare, sometimes that’s extremely tricky.

I’m lucky in that my medical informatics group is a department of one. I don’t have to worry about our current hiring freeze or the potential of laying anyone off unless they decide they don’t need a CMIO any more. With the current climate in MU, that’s unlikely. We already had our travel and conference budgets slashed last year, so there are no surprises there. We’ve already figured out how to receive education and training for free — no surprises there either.

From an IT perspective, we’re cutting budgets for hardware and extending refresh cycles. No one can expect to see new devices on the scene any time soon. I’m glad lots of vendors are designing for the tablets and Apple platforms, but our teams won’t be able to take advantage of any of those new features. As much as feel like I’ll be missing out, I can live with it. We’ve been using the same hardware platforms for years and we’re used to them. I don’t think continuing to use a wheeled cart as my workstation is going to kill me. (on the other, hand it might – keep reading.)

The hospital where I work is fully committed to its brand spanking new Accountable Care Organization. It has announced that it’s putting all hands on deck to make sure we’re investing in care management, patient engagement, and marketing. We’re going to spend tens of thousands of dollars making sure patients don’t want to leave our organization so that we can achieve shared savings. We’re going to make sure that we’re their hospital of choice.

As a part of that effort, I’ve been asked to prepare a handwritten thank you note and deliver it personally to each patient I discharge from the emergency department. I’m also supposed to recite a fairly canned statement about how much I appreciate the patient choosing my hospital and thank them for the opportunity to deliver excellent customer service.

When I saw the memo this week, I was just speechless. As a physician who has to care for patients, I’m horrified by sinking so much effort into marketing and frivolity when we’re making cuts to the bone in frontline clinical service areas. What about delivering excellent care? Where did that go? Here are some chilling examples:

• After 5 p.m., we only have one housekeeper on duty for the entire ED and two floors of the hospital. Nursing staff and patient care techs are expected to clean all the emergency department rooms after patient discharge. Most of the time we don’t have a tech, so an RN (or sometimes the physician) is cleaning rooms. I know this is not a new phenomenon, but it’s still not right. This also means that if we have a situation where we need a “terminal clean” of an exam room (highly contagious disease, etc.) we have to shut down the room, often for hours, while we wait for housekeeping.
• Lack of housekeeping also means trash is overflowing in the exam rooms. But there’s more. To cut down on costs, staff has been asked to conserve on the use of trash can liners. I didn’t believe it until someone showed me the memo. This means that rather than pull up the plastic bag around the trash, seal it, and carry it to a larger waste receptacle, they are expected to wheel a larger receptacle into the exam room, heft the trash can into the air, and dump the trash into the larger can. Inevitably things wind up on the floor, not to mention the potential for infectious material to be flung into the air. This is also done with biohazard cans, although I haven’t seen a specific memo that says that the can liner recommendation applies to “red bags.” Leaving the liner in leaves the bacteria in. Whoever came up with that policy should be gifted with a trash can containing a used diaper.
• We no longer follow isolation protocols in the “low acuity” portion of the ED because our patients are “low risk.” Last time I checked vancomycin-resistant enterococcus didn’t play favorites.
• Exam rooms are often “turned” so quickly that registration brings new patients back before the room has been adequately cleaned.
• Non-clinical areas do not get cleaned at all. The floor of our work area in the ED is so dirty that staff places towels or drapes on the floor before depositing their tote bags (no, we don’t have lockers).
• IT hardware is no longer cleaned. That picture above is the keyboard I was greeted with last week. It is not fit for use by anyone. The worst part is that there was visible food on it, meaning someone touched it while also touching food.

It is in this circumstance that I am expected to write thank you notes. This is in between trying to see patients, providing decent quality care, getting all my documentation competed (including the mandatory sepsis screen we just added for all ED patients regardless of presenting problem), educating patients on not coming to the ED inappropriately, serving as my own social work staff, figuring out how to get patients to afford their $4 generic prescriptions, and convincing patients that plugging their iPhones in to the outlet above the bulging biohazard trash can so that the cord dangles into it is a bad idea.

You’re probably thinking right about now that I work in some third-world hospital. Not so much. We’re urban and safety net, but we’re decidedly first-world with an academic presence. We have the endowment to prove it.

You may also think I’m just complaining, but seriously, I love my job. I love the people I work with. I love my patients, even the ones who are handcuffed to the gurneys for the duration of their stays.

I apologize for the wait. I apologize for delays. I apologize that the police used a Taser on you and I ask you politely to stop spitting at us. I apologize to the other patients for having to witness your behavior. I thank patients for coming and wish them well even when they scream at me or when I have to call armed guards to help discharge them. But if the administrators want thank you notes, they’re going to have to hire Emily Post. Maybe she’ll bring a feather duster (or a blowtorch) to clean the computers.

Good luck with making our facility the destination of choice. Congrats to the marketing team that dreamed up the thank you note scheme. Maybe we should start with basic sanitation if we want patients to come back. It’s hard to understand how we’re going to be meaningful users of EHR technology when we can’t be meaningful users of sponges and mops.

Have a story of administrative ridiculousness? Can your gross pictures top mine? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 1/21/13

I often make fun of the American Medical Association and some of its initiatives. Despite being a life member (with a lovely crystal paperweight to prove it), I find some of their initiatives extremely whiny and self-serving.

Last week Mr. H mentioned their recent letter to ONC urging review of Meaningful Use Stage 1 and Stage 2 prior to committing to Stage 3. Given some of the murmuring about a potential Stage 4, I’m supportive of this request. The AMA shares key concerns and recommendations from physicians.

First, the requirement for achieving 100 percent on all measures is problematic. Failure to meet one measure by one percent invalidates the physician’s entire effort and opens the door to penalties. I agree, and if Eligible Providers are going to be held to this type of standard, I’d like it to also be applied to federal disability processors, Medicare claims reps, and the people at the Department of Motor Vehicles. I’d also like it applied to my personal insurance carrier. For the four medical claims I had last year, three had processing errors leading to demands that I pay amounts I didn’t actually owe.

In addition to trying to achieve MU perfection, providers are trying to gain Patient-Centered Medical Home recognition, become part of Accountable Care Organizations, submit data for PQRS, and maintain board certification. There are also payer-centric and employer-centric quality initiatives. They all have different rules. I can barely keep up with the CMS FAQs let alone all the other information out there and I have a team to assist. I can’t fathom what it’s like to be a solo physician on this hamster wheel.

Second, one size doesn’t fit all. All specialties are required to meet the same core measures with few exceptions. The document goes on to state that the program is too primary-care focused and asks that specialists be allowed to opt out of any measure that has “little relevance to the physician’s routine scope of practice.” Knowing that my group’s orthopedic surgeons tried to opt out of vital signs (stating that blood pressure wasn’t relevant to their scope of practice), I urge caution here. Personally I think anyone who prescribes medications should be concerned about blood pressures, but quite a few of my colleagues disagree.

Third, the program needs independent evaluation to allow improvement. I agree here as well. Often MU seems like one giant experiment without an Institutional Review Board looking out for the safety of the participants. We’re being used as guinea pigs and the potential outcomes could be disastrous. I’m watching colleagues become increasingly burned out and motivated to leave the profession, which is completely counterproductive.

The AMA asks for an evaluation between each stage prior to finalizing the requirements for the next stages. I completely agree here. The timeline is too tight and is forcing vendors to abandon true usability enhancements and code changes that support clinical care. Development time and effort is instead focused on making sure their system meets the certification requirements regardless of whether those requirements improve patient care or the user experience. In many ways, it feels like Meaningful Use is stifling innovation.

Fourth, usability needs to be addressed and made part of the certification process. I hope that important issues such as alert fatigue receive attention to better support patient safety and clinical quality. Further down in the usability section, the AMA buries a request that ONC should consider requiring vendors of certified EHRs to commit to supporting subsequent MU stages. They also request protection from “excessive vendor charges” for physicians who switch systems. I’ve never seen a conversion project that didn’t generate excessive charges, so this is a great discussion point.

Fifth, IT infrastructure barriers should be resolved to allow improved data sharing. Working in a major metropolitan market, I experience this every day. The patient who showed up in my emergency department in labor had records at another health system that doesn’t communicate with ours. The suspected drug-seeker next to her admits to filling prescriptions at seven different pharmacies, which means she probably uses far more than that. There was no way to see what she was actually on to determine whether she’d have a risk of drug interaction with my proposed treatment.

The document is 20 pages long and you’ll have to jump to Page 10 to see the additional recommendations, which include streamlining regulatory requirements, aligning MU with other regulatory programs, and allowing three years between states to allow adequate time for rulemaking, product development, and implementation.

Considering the amount of change management that needs to go into any successful workflow redesign project, this may be one of the most important suggestions. Practices are not just coping with technology change but a complete overhaul of how they care for patients. Providers need to learn how to be more transparent with patients and how to better coach patients into a true partnership with their care teams. They need to train staff to operate in a new paradigm. They need to figure out how to juggle the constant demands that having electronic records place on them. They need to combat the burnout that comes with those demands and learn how to regain some kind of work-life balance. And if they fail at an initial stage, providers need time to figure out what went wrong and put measures in place to be successful at their next attempts.

I sincerely hope that ONC is receptive and that Meaningful Use doesn’t continue like the runaway train it seems to be. Have you read the AMA letter, and if so, what do you think? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 1/14/13

Just when I thought it couldn’t get any scarier, I had the opportunity to attend a recent presentation on the transition plan for ICD-10 for our ambulatory physicians. It’s been interesting to watch this unfold.

In its infinite wisdom, the hospital created an ICD-10 “task force” that sounded like a good idea at the time. A dedicated team working on a single problem will pull in subject matter experts from various business areas and software teams as needed. Unfortunately, it would have been better described as a “super silo.”

Over the last two quarters, I questioned several times the fact that they haven’t been to see me. I’m on the tip of the spear for our ambulatory physicians, so I expected them to knock on my door at least once. I was told to pipe down and stop micromanaging, so I did.

As the weeks have worn on, however, they’ve been spending more time going directly to the vendors and less time with the actual software support teams. Not exactly a winning strategy in my book. The software teams actually support the users and know their business needs. We know the limits of what they will and will not tolerate as far as workplace disruption. We also know how to effectively use Jedi mind tricks on the users, especially when we have to present something unpalatable.

This week the task force presented the final strategy at our monthly physician meeting. As the presentation unfolded, I was transported back to the college literature class where I first experienced Joseph Conrad’s journey down the Congo River in Heart of Darkness. As more and more PowerPoint slides flashed before my eyes, I felt myself going deep into the wilderness. The physicians’ eyes darted around the room trying to identify which of the department chairs would rebel and which would join the savage oppressors. I buried my head in my hands, grateful that my lack of involvement conferred plausible deniability.

The key points of their transition plan were simple, yet terrible:

• Since the ambulatory vendor plans to release its ICD-10 software in May 2013, we’ll just plan to upgrade in June. Had they talked to my team, they’d have known that it takes us a minimum of three months to prepare for an upgrade once a new code package is available. They’d also know we have a dozen go-lives that must be completed before any upgrade. These are contractual obligations and cannot be moved.
• Providers will dual code from the time of the upgrade until the requirement commences in October 2014. Are you serious? Providers aren’t going to do double work under any circumstances (that is, unless they’re paid extra or threatened with termination). The fact that they even suggested this told me that they didn’t talk to the Practice Operations leadership either. A quick look at the ashen-faced VP two rows behind me confirmed my assumption.
• Provider training will require a full day out of the office and all training will occur during a two-week span. Given the size of our group and the need to stagger training to accommodate various work schedules and vacations and to ensure patient access, this suggestion is simply absurd. Doing the math would conclude that it’s impossible to train all the physicians unless our training rooms run 24×7 during these two weeks.

Those in the group who round in the hospital will receive extra training. Approximately 80 percent of our physicians continue to see inpatients, so failing to include those details in the presentation led to more questions and frustration. Needless to say, the physicians were not pleased and basically handed the task force their heads. Several senior physicians walked out and the more vocal junior physicians started commenting loudly. It reminded me of a raucous session of England’s Parliament, but without the wigs.

The only good thing about the presentation was that it occurred at the end of the meeting’s agenda and effectively ended any lingering comment on any of the other agenda items as well. The first thing I’m doing tomorrow morning is organizing a betting pool. How many days until the application team managers are asked to essentially take this over and start from scratch? My money is on three.

How is your organization planning to transition providers to ICD-10? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 1/7/13

I lucked out this year by having the privilege of being on IT backup call for both Christmas Eve and New Year’s Eve. Since health IT is by definition part of the 24 x 7 world of health care, a lot of us were working. Although our clinical departments never take a day off, our administrative organization is trying something new this year and actually allowing a full day off for Christmas Eve and New Year’s Eve rather than the traditional half days. I always thought the half days off were kind of silly, since any work that was actually attempted was half-hearted at best.

With the long weekend over New Year’s and the short work week to follow, I hoped our team would take advantage and spend time with family and friends or otherwise recharge their energy for the coming year. The team knows better than to expect responses from me on e-mail when we’re officially not working. However, I forgot to sign time cards, so I found myself online on New Year’s Eve. I found dozens of e-mails waiting. Several of them wanted answers or decisions.

Apparently in addition to signing time cards, I also forgot that we have a couple of staffers working on our team who are on loan from another part of the organization. From the looks of my inbox, a couple of them decided to spend their long weekend working, and I could tell that at least one of them was still online. I instant messaged him and reminded him it was a holiday and that he really needed to take a break. We went back and forth a bit and he eventually figured out that I wasn’t kidding, that I wanted him offline and doing something other than work.

When we returned to the office on Wednesday, I approached him to talk about the weekend / holiday work situation. He admitted that in his “home” department, they are expected to check e-mail several times a day, even on weekends, “in case someone needs something.” Like a lot of people, he had a hard time just “checking” e-mail and would get sucked in to answering e-mails and working on projects and had difficulty letting things sit. I reminded him that in our department we have on-call coverage for that eventuality – someone is always reachable via the help desk. Should the on-call person not respond, the help desk has permission to contact the managers or directors (or even me) to make sure our clinicians have what they need.

In his department, there seems to be a lack of trust that the help desk group knows how to appropriately escalate issues to the on-call team or that the on-call person will be able to solve the problem. The team doesn’t necessarily trust each other and they don’t feel that there is adequate cross training to allow for rapid problem solving. It leads to a cycle of continuous frustration and feeling like they can’t get anything done and that they always need to be watching over their shoulders.

It was a good conversation and really got me thinking about our team culture of time management and what makes teams effective versus what makes teams struggle. I thought about some of the most productive teams I’ve been a part of and some of the worst team experiences I’ve had. With that bit of reflection, I’d like to share my thoughts on what I think works.

Have an E-mail Policy

I personally like a “three day” policy. This means that people have three business days from the time the e-mail is sent before a response is due. This also means that if you need an answer sooner than three days, you need to either call the person or speak to them personally – no texting. This also applies to meetings, since invitations come via e-mail. If you need to schedule something with less than three days’ notice, you have to reach out to people by phone or in person.

Our policy discourages people from working e-mail at night unless there are unusual circumstances or employees are working flex time. Staff who aren’t routinely at their desks are encouraged to block time on their calendars to handle e-mail. They quickly learn that calendars fill if they’re left open, so it’s to their advantage to set up regular times to focus on e-mail. They’re also encouraged to not check e-mail during meetings, which can be incredibly disruptive. Some individuals even need to avoid trying to check e-mail between meetings if they’re not disciplined at knowing what they can answer quickly and what will be a time suck. In addition, appropriate use of “out of office” replies is required.

Have a Voice Mail Policy

If you’re a field employee, indicate on your outgoing greeting how often you check your voice mail and if you prefer an alternative method of contact. Some of our field employees (such as trainers and desktop support liaisons) don’t even have voice mail, because they’re never at their desks to check it. My voice mail greeting specifically says to not leave a message as it will not be returned. You’d be surprised at how many people leave messages anyway. That gives me a general idea about those folks and their listening skills, especially when they do it more than once.

Have a Text Message / Instant Message Policy

The text message policy is easy at our organization. The hospital doesn’t pay for texting service, so people don’t use it except for personal messages. Although instant messenger is in use (and integrated into our e-mail suite), I don’t encourage my team to use it and actively discourage some staff from using message notifier popups. The constant distractions on the screen are lethal to those who have difficulty paying attention. (This goes for e-mail notifiers also.) Instant message is also challenging because it often doesn’t leave an easily followed trail. Saving chat logs isn’t as efficient as using e-mail reply tracking when you have to prove who you told, what you told them, and when the message was delivered.

Have a Meeting Policy

Meetings should have agendas which should be distributed at least one full business day in advance. I used to have a team member who routinely sent the agenda for an 8 a.m. meeting the night before at 8 p.m. Note the use of the past tense. Sending agendas in a timely manner allows people to actually read them and speak to you if there is a problem with the agenda or if they’re not prepared to discuss an item. Agendas should be adhered to. If the leader isn’t a good time manager, he or she needs to appoint a time keeper to stay on track.

The most successful teams I’ve ever been a part of have meetings that only last 45 minutes. The trick to squeezing an hour meeting into that block is to start on time and end on time. This prevents productivity loss at the beginning due to late arrivals and at the end due to those scooting out to attend the next meeting. This allows 15 minutes between meetings for people to check e-mail, walk to the next meeting, return to their desks to dial into conference calls, or take care of other needs.

Another trick – do not recap for late arrivals. Nothing is worse than being on time for a conference call and having the leader recap the roll call and activities for late arrivals. A word on conference calls – if you have access to web meeting software, require its use and require people to sign in so you can see who is on the call, avoiding the whole roll call issue altogether. Many packages even allow you to sign in from your cell phone, removing that as an excuse for not signing in.

My last meeting pointer is to always end on time. Adherence to the agenda is paramount. If a topic is taking too long, that means it likely needs its own meeting. A key element of my team culture is ending early whenever possible. People who try to cram new agenda items into three free minutes are quickly neutralized by their self-policing teammates.

For many of you, these are common sense items, and hopefully most of you follow similar rules in the office. I know from experience though that there are a large number of workplaces that have no clue about these (or many other) time management and team management dynamics. If you’re on the leadership team and you don’t have these policies in place, consider implementing them as part of your resolutions for the new year. You might find yourself with stronger teams, happier workers, and greater output.

Have a solution for sticky workplace problems? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 12/24/12

‘Twas the night before Christmas, and all through the ward
The patients were resting with some sleeping hard.
The IVs were hung on their pumps with good care|
And staff hoped the next shift change soon would be there.

The Stroke Team was nestled all snug in their beds,
While visions of t-PA danced in their heads.
One nurse wore a kerchief, but none wore a cap
I’m pretty sure my intern just took a nap.

When out on the helipad – whoa what a clatter,
We sprang from the NOC to see what was the matter.
Away to the lift we all flew towards the crash,
The double-doors opened and we saw a flash.

The moon in the sky and the landing lights’ glow
Made quite a nice picture for patients below.
When what to my wondering eyes should appear,
But a shiny red chopper touched down on its gear.

Out jumped the pilot, so lively and quick
We knew from his bow tie he wasn’t St. Nick.
More rapid than audit requests came his voice:
Compliance is simply our goal and your choice.

There’s quality metrics and data galore
Patient empowerment isn’t a chore!
From rural America to NYC
A Meaningful User is the way to be.

As dust clouds before the big chopper blades fly
He took all our worries and bid them goodbye:
You’ve attested Stage 1 and now to Stage 2,
With lots of requirements for all to do.

And then quick and nimble he jumped to the deck
I saw there were Mardi Gras beads ‘round his neck.
I just went to NOLA, he said with a grin
In March we will all get to visit again.

We’ll share lots of stories and maybe a drink,
And Epic’s booth artwork will make us all think.
Will wonder ‘bout Allscripts and where it has gone
And which cool new startups might just get it on.

As he spoke his eyes twinkled! His bowtie looked merry!
He said to have no fear, Stage 3 is not scary!
He gave us a big smile drawn up like a bow,
And told us he’d brought gifts – now didn’t we know.

Shoes! Nothing better for Inga and Jayne
And for Mr. H in a whimsical vein
A shiny new wearable reflector thingy
Matches the new site – a little bit blingy!

This O-N-C elf was so happy and jolly
I laughed when I thought of EPs and our folly
Of thinking the money was easy to claim
And later the prepayment audits we’d blame.

The pilot he winked and went straight to his work
And threw us some guidelines, then turned with a jerk.
And laying his finger aside of his nose,
He climbed in the front seat, and up up he rose.

Away went the chopper and I gave a whistle:
They aren’t only guidelines but almost a missal.
Team HIStalk exclaimed, as he flew out of sight:
Happy Christmas to all, and to all a good night!

(With apologies to Clement Clarke Moore)

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 12/17/12

ONC released the 2014 Edition Test Method for EHR Certification on Friday. In case you didn’t have anything to do over the holidays, now you can curl up in front of the fire with some cute and cuddly Test Procedures.

I have to be honest. I still struggle with Meaningful Use. I completely understand the goal. I also understand that there are a number of baby steps that must be taken in order to make data more transparent and transferrable. It’s extremely frustrating as a clinician, however, to have to codify data in ways that are seemingly meaningless.

Take the certification criteria for smoking status, for example. The Test Procedure document includes the approved SNOMED CT concepts “to assist the developers and implementers of EHR technology in the implementation of this requirement.” The concepts are:

• Current every day smoker
• Current some day smoker
• Former smoker
• Never smoker
• Smoker, current status unknown
• Unknown if ever smoked
• Heavy tobacco smoker
• Light tobacco smoker

For a minute, I’m going to take of my informatics hat and put on my average primary care provider hat. Let’s assume the only thing I know about SNOMED is that it’s some kind of coding system that sits under my EHR (if I even know that much, which I might not). Although the coding allows each of these to be uniquely identifiable, I’m not sure any of these (other than “Never smoker”) have specific levels of meaning to the majority of primary care physicians without detailed explanation.

For example, what is the definition of a heavy vs. light tobacco smoker? There are significantly different clinical risks to the former smoker depending on whether they’re a former heavy smoker vs. a former “only when I drink with friends” type of smoker.

There is a clarification that “smoking status includes any form of tobacco that is smoked, but not all tobacco use.” There are different risks to pipe smokers and cigar smokers than to cigarette smokers, but we’re not required to capture that nuance. In the old world, I could write TOB: 2ppd x 20y and 99 percent of clinicians would translate that to “cigarette smoker, two packs per day for twenty years” and could appropriately assess the patient’s risk. Now, to meet Meaningful Use, I’m going to be steered towards selections that don’t have a lot of clinical meaning.

Some vendors who had detailed and granular ways of documenting this information prior to Meaningful Use have kept their ability to gather that useful data and mapped it to the required codes. I can’t help but think that this will cause the data to lose something in translation.

Other vendors who are focused more on certification have added the new fields alongside their old ones. This forces clinicians to document the data twice – once for clinical significance and once for a federal program. Although it meets the letter of the law, it makes for unhappy users and poor design. I know of at least two products out there, however, which function in this way.

ONC works through the paradox of mapping on page 3 of the smoking status document. It gives the sample of a “pack a day” smoker that the Certified EHR maps to “current heavy smoker.” It notes that when the transition of care document is created, the additional text description and any other metadata could be included along with the SNOMED. It continues”

Note that “heavy smoker” is not the only concept that is appropriate here, and we leave the decision regarding which of the eight codes is the most accurate descriptor of clinical intent to the judgment of those implementing the form, template, or other EHR data capture interface.

I’m not sure that makes me feel much better. Unless they have dedicated clinicians working through these design specifications, it leaves us with software developers deciding how to best document clinical intent.

As the document continues, they include language from the 2011 preamble of the Health Information Technology standards document. It specifies the definitions of the various selections:

… we understand that a “current every day smoker” or “current some day smoker” is an individual who has smoked at least 100 cigarettes during his/her lifetime and still regularly smokes every day or periodically, yet consistently; a “former smoker” would be an individual who has smoked at least 100 cigarettes during his/her lifetime but does not currently smoke; and a “never smoker” would be an individual who has not smoked 100 or more cigarettes during his/her lifetime. The other two statuses (smoker, current status unknown; and unknown if ever smoked) would be available if an individual’s smoking status is ambiguous. The status “smoker, current status unknown” would apply to individuals who were known to have smoked at least 100 cigarettes in the past, but their [sic] whether they currently still smoke is unknown. The last status of “unknown if ever smoked” is self-explanatory.

I wonder how many of my primary care peers have read this language and share this definition? It’s been awhile since I was in medical school and residency, but I’m pretty current on my continuing education classes and haven’t seen this emphasized in recent articles about the risks of smoking. What’s magical about 100 cigarettes? Is there solid data that shows a difference in risk once a smoker hits that number? Maybe I need to go back to school.

Continuing on, the document clarifies the cutoff of “heavy vs. light” smoking as being more than 10 or fewer than 10 cigarettes per day, “or an equivalent (but less concretely defined) quantity of cigar or pipe smoke.” What if they smoke exactly 10 cigarettes per day? They don’t meet either definition.

I realize I’m splitting hairs here and some of you may have tuned out by now, but that’s the point. We’ve taken data that had clinical meaning and was easily understandable and turned it into data that is confusing and potentially meaningless. I’m not sure if that’s really taking us forward. The data is only as good as the staff entering it and the likelihood of physicians understanding the concepts (let alone training their staff to understand the concepts) may be low.

Compared to other parts of MU, the documentation of smoking status seems fairly straightforward. That’s not very reassuring considering a program which will continue to become more complex as we move forward. We’re not even to Stage 2 yet and I need a break. As they used to say, smoke ‘em if you got ‘em.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 12/10/12

It was cold and rainy, so I decided to file my state license renewal this weekend. When I was in a community practice, the office manager used to take care of that (as well as credentialing, liability insurance renewals, and just about everything else). Now that I’m in informatics, I’m on my own. The administrative assistant I share with four other people barely has time to open the mail and manage our calendars, let alone handle something like licensure renewals.

My state requires a certain amount of Continuing Medical Education (CME). Although I meet that requirement without issue each year just through routine activities and journal articles, it’s only half of the amount required by my specialty society. I was grateful for the reminder to catch up on my hours. Coincidentally, CMS continues to send e-mail bulletins about ICD being “closer than it seems” and one sent this week stated they had CME available.

(Apparently they partnered with Medscape Education back in September, but I must have missed the original announcement.)

I decided to check out the ICD-10 CME. There are two modules and an article offered. The modules are targeted towards small to medium practices and large practices, respectively, and are specifically for physicians. The article is more general for all health care providers. Since I work in Big Healthcare, I made a cup of tea (Earl Grey – hot) and settled in for the large practice video.

The video is narrated by Daniel Duvall, MD MBA of the Hospital and Ambulatory Policy Group at CMS. I liked that it didn’t claim that ICD-10 was going to improve care or make our lives easier. It was clear about stating that there would be “much more specificity in information sharing” and that the key point of relevance for physicians was that it is necessary for claims submission and those who delay may not be reimbursed.

I’d have liked the CME better if it had been self-paced. It wouldn’t allow me to fast forward and one couldn’t forward the slides at his or her own pace. I can generally read faster than I can listen to someone read slides to me, and find that I learn more reading things on my own rather than being lectured to. There was some choppy editing that was a little annoying, so by six minutes into it I was pretty much “done” but couldn’t blast through it.

Luckily it did allow me to skip to the test (which I aced – it only had three questions) and the subsequent course evaluation. I was disappointed that the evaluation wasn’t specific to this kind of educational activity. It asked me if I planned to modify treatment plans, change screening or preventive practices, incorporate different diagnostic strategies into patient evaluations, or use alternative communication methodologies with patients and families. It’s always nice to have questions that are actually relevant to the course just taken.

For a physician who doesn’t know much about ICD-10, the course provides a reasonably good base. For anyone who is deep into an ICD-10 playbook, it’s not worth the time unless one is killing time or needs CME hours. I realized when I got to the end of the course that I probably should have verified how I was logged in to Medscape. At least it will make a nice addition to the certificates on the wall of my home office.

E-mail Dr. Jayne.