Curbside Consult with Dr. Jayne 6/24/13

There are some days where I just have to shake my head. Today is one of them. I received some news from one of the hospitals where I moonlight. It was the kind of news that defies all logic, and especially in the era of healthcare cost cutting, makes you wonder what in the world people are thinking. In trying to process through it, I’ve decided that there must be some kind of extraterrestrial accounting system (not to mention logic) that only applies to hospital administration.

It reminded me a little of the starship Bistromath in Life, the Universe, and Everything by Douglas Adams. For those of you who aren’t sci-fi aficionados, the Bistromathic Drive is a propulsion system that “works by exploiting the irrational mathematics that apply to number on a waiter’s bill pad and groups of people in restaurants.” Read the full description — it’s good for a laugh. I always think of it when I’m with a group trying to figure out who owes what part of a check.

I’m not against hospital administrators. This is not an “us vs. them” rant. I understand they have to make the same types of difficult choices that all of us do in trying to deliver high-quality, cost-effective care to the right people at the right time. Some of my best friends are administrators. They seem to be between the proverbial rock and the hard place a good percentage of the time, especially those at non-profit and safety net facilities. How they juggle the competing requests for resources and determine how one priority takes precedence over another is often beyond me.

What did they do this week however that was so logically convoluted I had to take my jaw off the floor? The administration of a semi-urban safety net hospital decided to close the “quick care” part of the emergency department. I’ve written about my work here before, joking that we could provide more cost-effective care by stationing a well-trained Boy Scout with a first aid kit at the front door.

People come to this hospital for everything under the sun. I’ve worked on the express care unit for half a decade because the “real” emergency physicians don’t want to go there. Those of us that are board certified in other specialties enjoy the work because it looks a lot like a primary care practice although without a stable patient population.

Quick care has been doing its part to keep the overall ED wait times low. We handle all patients door-to-door in close to 60 minutes or less, which is amazing when you consider the population, their lack of follow-up, and the volume. The hospital is one of the busiest facilities in the region, which is why I was completely floored when I received notice today that the quick care unit was closing. Since this isn’t my full-time hospital, I had no idea it was coming. Worse yet, neither did the staff with whom I just worked last week.

The hospital has decided to take the unit and roll it into the rest of the ED. As another part of the cost-saving measure, they’ve decided to terminate the services of all the part-time physicians. Quick care patients will be handed by nurse practitioners and physician assistants embedded in the “regular” emergency department.

Why doesn’t this make sense? Several things jump out at me.

The physical quick care unit will be repurposed and the patients will be physically seen in the existing ED. This is a net loss of nine beds. The existing ED physicians will be expected to supervise the midlevel providers in addition to their normal shift duties. Nursing staff ratios will be kept the same and the quick care nurses were laid off as well. I almost cried when I realized that. These men and women are the rock stars of the ED, handling nine patients at a time and keeping the flow moving while doing the same level of documentation as the rest of the ED, often having to clean rooms themselves because of the lack of other support staff and sometimes taking care of really sick overflow patients still at a 9:1 ratio. They are hard workers who know just how to juggle patients to keep the visits under 60 minutes. Most of them have been in quick care for more than a decade.

It was this realization that led me to believe they must be using some kind of Bistromathic accounting. In this healthcare climate, who lays off nurses? Especially nurses who can juggle patients and flip rooms as fast as this crew? Who thinks they can just take an additional 50 to 60 patients per shift and funnel them into the ED workflow without drastically sabotaging the ED wait time statistics? And with nine fewer beds? I also wonder who thought the ED physicians would be game to supervise additional midlevels without compensation, which is part of the package.

I think there may have been a bit of sorcery involved as well because none of the line staff seemed to know this was coming. I’m sure the department chair and the nursing directors were in cahoots with the administrators and accountants, but the rest of the team sure wasn’t. Keeping a secret like that is pretty impressive. They managed to keep it quiet a good long time too, only showing their hand the week before the closing. I guess I won’t be bringing my famous chili dip to the July 4 shift party after all.

For those of us that don’t have regular shifts, it was like a death in the family – realizing that you may never again see people you’ve (literally) shared blood, sweat, and tears with. For the handful of staff that are losing their full-time jobs, it’s stunning. Maybe it will go better than I expect, although I can’t wait to see the next quarter’s numbers for wait time, patient satisfaction, and provider productivity.

I’m mourning for my colleagues and missing them already. I suppose it’s a good thing since I’ll have unexpected free time. But if you happen to need a skilled adrenaline junkie to pick up some shifts, give me a call.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 6/17/13

Over the last month or so, I’ve become a frequent flyer patient at an orthopedic surgery practice. It’s been kind of fun because it’s a practice I rotated at when I was a resident. They’re also part of a local IPA and I’m able to see the workings of our competition.

I have to suspend the process redesign part of my brain when I go there because there are some office processes that drive me crazy. I’m amazed that they’re operating this way in 2013 and am hopeful that Meaningful Use will give them a kick start.

At this week’s visit, a sign appeared announcing they’re preparing to implement EHR, so it was hard not to make observations. One of my running buddies is part of the IPA, so I’ve heard her side of how the system is being rolled out. It doesn’t look like they’re taking lessons learned from one practice and carrying them to the others. I’m pretty familiar with their EHR vendor and I hope they’re not surprised when this practice isn’t successful, because what I saw was not pretty. If you haven’t implemented yet either, you might take some of this as a cautionary tale. Here is the recap.

With the market consolidation going on and the concessions vendors are willing to give to ensure a sale, does it make sense to keep a practice management system from a different vendor than your EHR? What about if the PM vendor is notorious for sunsetting products? The EHR vendor also has a practice management system, and in a lot of ways the PM system is stronger than the EHR. I know from my buddy that the vendor offered to throw in the PM system nearly free, but the IPA was concerned about a conversion. Instead, they thought creating a unidirectional interface from the PM to the EHR was a much better idea. The providers will continue to operate on paper fee tickets even after EHR is live.

It might be a good idea to optimize the practice management workflow and office processes before implementing EHR. Although they are strong at scanning the insurance card at every visit, they are still hand-writing receipts in a duplicate book. I would have thought they were on downtime procedures if I didn’t see it five times in a row. They have a credit card swipe device attached to the monitor at check-in (good) but the printer is 25 feet away on a back desk and they have to get up and walk to get the receipt for signature (bad). They then hand-write the co-pay receipt.

The credit card receipt doesn’t even have the practice name or show that it’s a co-pay. On three of four visits, they forgot to write co-pay on the paper receipt, and because their paper receipts doesn’t have the practice name either, patients can’t submit them for reimbursement from flexible spending accounts.

The staff then has to manually staple the top copy to the patient credit card receipt and the bottom copy to the patient demographic sheet, which they didn’t ask me to verify at any visit. On three of three post-procedure visits, they also collected a co-pay during the global period, which they had better be cheerfully refunding to me once I receive my Explanation of Benefits statements. Based on the chaos at the office, it seemed easier at the time just to pay it than to delay my visit with a discussion since I was juggling my appointments around my work schedule.

There are doors at each end of the large L-shaped waiting room to the patient care areas. They don’t warn patients as to which side their physician is working, and the employees don’t speak loud enough to be heard around the corner of the L (or over the loud televisions) when they call patients. This results in delays because patients can’t hear that they’ve been called and take longer to get to the door on crutches or in a wheelchair because they’re waiting on the wrong side.

Check-out is at the same desk as check-in (although with two separate lines), so there is constant competition between getting patients in and out. Each time I was offered a follow-up that was at least a week later than what the physician recommended, and the front desk staff had to call back to the physician area to have me approved as a work-in. I wonder how many patients insist on the follow-up interval they were told versus how many just take what is offered? Where orthopedics is concerned, that can sometimes make a difference in a patient’s return to function if their cast is left on longer than intended or they don’t get timely follow up. It’s also a waste of time to require the front desk to have work-ins approved when they are approved 100 percent of the time, which I witnessed in my multiple tours through the waiting room.

Workflow in the patient care areas was actually pretty good, with smooth handoffs between the medical assistants, radiology tech, and cast techs. There was a delay with the physician, which gave me time to read the brochure about the practice’s upcoming medical mission trip to the Dominican Republic, scheduled to start three days after my most recent appointment. I’ve actually used the EHR that they’re installing, so I chatted a bit with the cast tech about it and found out they were having training that afternoon.

She mentioned they will be going live while half the office is away and that the physicians won’t attend training. Instead, employees will attend he training and then train the physicians when they returned. I shuddered a little at what a terrible idea this is. Although train-the-trainer programs can work, it does take time to develop solid training competency and enough understanding of the software to be able to train it. Expecting front line staff to be able to train their physicians after a single round of training and only a week of real-world experience is not a good idea.

Scheduling a go-live when half the office is out is not the best idea, as those physicians going live will have to cover emergencies and other office tasks for those away. Expecting the rest of the practice to go live the week they return from being out is a disaster in the making, given the existing backlog and wait for patient appointments and the fact that they’re always double (and triple) booking. It’s not as if they didn’t know this trip was coming since they’ve been fundraising for it for six months based on the date of the brochure.

On the way out, I noticed the staff in a conference room, huddled around tablet PCs and going through training. What a way to spend a Friday afternoon! I’m scheduled for a follow-up the week of the second round of go-live, so it should be interesting. I have an add-on appointment at the end of the day, which guarantees it will be good for at least one story. I can’t wait to see their workflow for EHR or how well their train-the-trainer plan went. Stay tuned!

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 6/10/13

I’m a sucker for 1960s and 1970s pop culture. Whether it’s the vintage lunchboxes at the National Museum of American History or watching “Scooby-Doo, Where are You!” with my nieces, I’m in. You’ve got to appreciate that level of kitsch, the likes of which I’m not sure we’ll ever see again.

I’m glad to work with IT leadership that believes in developing our employees. We tend to hire quite a few relatively young grads who may or may not be “computer people,” but are critical thinkers who want to transform health care. Before I get accused of age bias, we also hire a fair amount of older workers who may be on their second careers and demonstrate the same level of malleability. I enjoy introducing both ends of the spectrum to some of the crazier things I’ve seen on my quest to find the kitschiest thing ever.

One of my favorite TV shows was “The Six Million Dollar Man.” I love the initial voiceover: “Gentlemen, we can rebuild him. We have the technology… Better than he was before. Better…stronger…faster.” That’s the way I like to think about some of the seemingly lose-lose projects our team is assigned. They are things that no one wants to deal with that can make users’ lives more complicated and can be generally annoying. The challenge is to work your way through the muck to find the one piece of the project that can bring positive benefit, and then try to build on it. Sometimes this has positive results and sometimes it just results in silliness, which happened this week.

We’re working on some projects to look at resource planning and employee time allocation. Like most organizations, we have more work to do than can be accomplished by a team that is not bionic. Our goal is to look at productivity patterns and try to figure out how to not only maximize what the team has to offer, but reduce the waste and inefficiency that happens despite our best efforts. The problem is that our enterprise resource management software isn’t that great. We’re not able to do a lot of customization to it and certainly don’t have budget to replace it, so we were brainstorming.

The idea on the table was finding the best way to manage meetings to ensure that required attendees are present, no extraneous people are pulled in, and no more time is spent in a meeting than is needed. Even with all the different productivity tools and add-ons that are plaguing our employees in Outlook, the team came up with one that I’d seriously like to see: the Relative Meeting Cost (RMC) analysis widget.

We would need to add some additional fields (hidden, of course) to the contact data to track an employee’s equivalent hourly wage as well as the billable rate for chargeable employees. It would look at the invitees and meeting length and display the RMC value not only in dollars, but with big tacky graphics to make it clear whether the event was a BEM (Big Expensive Meeting) or a PCM (Pretty Cheap Meeting).

Functionality would be added to create security options that would prevent people below a certain status from scheduling BEMs without review or approval. You could even prevent a BEM from being scheduled if more than a predetermined number of required attendees had conflicts.

Of course this will never happen, but it was a great way to blow off steam. Somehow the thought process circled back to being bionic, which led to a wide open debate on whether Steve Austin or Jaime Sommers was tougher. We’re not going to have a technology solution just yet that will let us avoid booking a Six Million Dollar Meeting, but we did bond as a team, which is no small feat. Maybe next time we’ll try some macramé owls.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 6/3/13

A recently posted Commentary in the Journal of Graduate Medical Education reflects on a study looking at resident physician use of iPads. The study itself only looked at 12 young physicians and their self-reported behavior. The commentary, however, provides food for thought about the risk of “distracted doctoring.”

There have been plenty of stories about badly-behaved physicians: surgeons making personal phone calls via Bluetooth in the operating room, physicians posting patient-specific comments on Facebook, and others ranting on Twitter. More insidious and possibly more dangerous is the negative impact that being constantly connected can have on concentration and attention. The commentary mentions residents responding immediately to requests from remote nursing staff while potentially ignoring the patient physically present.

We’ve all experienced this in customer service situations when we’re standing at a checkout line or customer service counter and are functionally “put on hold” while staff answers the phone rather than attending to the customer in front of him or her. I see this in physician offices all the time, especially as incentives are put in place to reduce hold times or voice mail queues. While increasing satisfaction for remote patients, it does little to contribute to the satisfaction of the patient standing at the desk or sitting in the exam room.

The commentary mentions a medical student using Facebook while rounding on patients, particularly when an attending physician was discussing a cancer diagnosis with a patient. There is no excuse for this kind of behavior, but unfortunately I don’t think everyone agrees with me. Social media can be incredibly enticing and it takes a lot of self-control to be able to put down the phone and be present.

We’ve all seen media articles wondering if smart phones are making all of us dumber. One could argue this is just an extension of the anti-technology rants of the 1960s and 1970s (remember when television was referred to as the “boob tube?”) but I think we could all use a little reflection about the amount of time we spend interacting with technology instead of people, especially when it’s not required.

I can’t count the number of times I’ve watched physicians who complain about having to use computers for patient care sit in the work area surfing the Internet. I once shadowed a physician who said she had to spend hours after work documenting, and during the course of the shift, she bought multiple pairs of shoes from three Internet sites. Although I have to admire her sense of style, it completely undermined any points she was trying to make about the computer slowing her down.

Although it’s frustrating, I guess I should be grateful that there’s virtually no cell signal in my ER. We’re located in the bowels of the hospital between radiology and the morgue. I usually end up turning my phone off to avoid battery drain. I guess I should also be thankful that we don’t have computers in the exam rooms because it really does force you to pay attention to the patient in front of you (although I think there’s a patient safety problem with not having the chart, but my Department Chair doesn’t agree).

I had the privilege of doing a rotation in the UK while I was a resident. I quickly learned that the easy availability of echocardiograms in the US made my ability to diagnose heart murmurs pale in comparison to my British colleagues. I’m sure there are other ways that technology is eroding our skills. What do you think? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/27/13

The Greatest Generation

I enjoy volunteering. One of the most meaningful things I’ve done is placing flags on the graves of veterans. My family has a tradition of military service going back to the Civil War. Although placing flags at the National Cemetery gets a lot of recognition, there are smaller projects that may not hit the national news or even the front page of the local paper. I was invited recently to join one of those projects and I have to say it was a great experience.

What makes this event different is that it is significantly smaller and allows youth to interact with veterans directly. The morning starts with the veterans providing breakfast to nearly 300 youth volunteers who experience first-hand the concept of servant leadership. There’s nothing quite like sharing bagels with a WWII veteran and watching young people realize that war isn’t something from their history books or Wikipedia. After breakfast and a brief religious service, the young people (many who aren’t from the same faith tradition as those they’re serving) fan out across nearly a dozen religious cemeteries.

Over the last several years, volunteers (some as old as 97) have combed through cemetery records and identified veterans’ graves, adding a flag holder with a medallion next to each grave marker. In deference to the sacrifice of the veterans, volunteers approach the graves with some ceremony. The flag is placed and saluted and a brief statement of thanks is recited which includes the name of the veteran being recognized. It’s more than just adding the flags, it’s taking the time to speak directly to the person whose service allowed us the freedom we enjoy.

The majority of the veterans we honored were from WWII – often called The Greatest Generation. As we spoke the names it was hard not to wonder who they really were – whether they had children, what they liked to do in their free time, and how they came to rest in these small suburban cemeteries. This generation served their country not for fame or recognition, but because it was the right thing to do. Those who made it home from the war spent the rest of their lives continuing to do the right thing – raising families, taking care of their elders, and supporting their community.

They didn’t have the Internet, smart phones, or billions of dollars of technology at hand. The biggest technology revolution for many of them was getting telephone service that didn’t involve a party line,  and maybe a black and white television. Their solutions for many problems revolved around hard work, sacrifice, and sheer determination. I was grateful to spend the morning communing with them and watching the spirit of service be passed to the next generation.

The peaceful morning was in sharp contrast to the rest of my day, which was spent in a busy urban emergency department. Except for a handful of octogenarians, most of my patients were under age 50. Many of them presented with problems at least partly related to our dependence on labor-saving devices and the quest for convenience – obesity, computer-induced repetitive motion injury, diabetes, high blood pressure.

More than half presented strictly because they wanted the technology of the hospital to convince them they were OK. These patients ranged from the woman who refused to allow a co-worker to remove a bee stinger “because she didn’t have any medical training” to a teenager who refused to believe her two negative home pregnancy tests, demanding a blood test to convince her boyfriend she was indeed pregnant. Nearly every one of them had an iPhone and several were surfing the Internet during the interview or exam, despite requests to stop. A couple of patients argued with me about their treatment, citing Internet information they found while in the waiting room.

Several demanded CT or MRI scans for simple sports-injuries despite having no ability to pay for such a test even if it was indicated, which it wasn’t. Guess what? If you run down a steep hill wearing flip flops, you will fall and sprain your ankle. The Ottawa Ankle Rules say you don’t even need an x-ray, let alone a scan. You need an Ace wrap, some ice, and a pair of real shoes.

It was one of the rougher shifts I’ve worked. I’m sure the contrast between people who want technology to solve all their problems effortlessly and those who were willing to give their lives simply for the concept of a world free of tyranny had something to do with it. I’ve been in informatics for nearly a decade and have seen the wonders that big data can do. I’m excited by the promise of personalized medicine and genomics, but I understand that it all comes at a price. Looking at global economics, it is likely more than any of us can afford. We’re mortgaging our future while we overlook the basic lessons of the past.

Technology isn’t the solution – it’s merely a tool. We have to learn how to use it wisely and at the same time how to temper our addiction to it. I challenge every reader to consider spending a day off the grid. If you can’t spare a day, consider an hour. Go volunteer. Go do something simply to show caring to someone else. Or just go lay on the grass and see that there is a world beyond the screens and clicks. And while you’re at it, say thank you to those who gave all.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/20/13

Several readers shared this link about a smartphone app that tracks patient activity and reports it to physicians. Called Ginger.io, the app is being studied at several hospitals in the US. The goal is to mine data on phone use and movement to show changes in patterns that could indicate illness or worsening of chronic conditions.

The app has to be activated by a hospital or health care company and obtains a baseline on personal activities once it’s activated. Caregivers are notified when there are changes in patterns of travel, phone calls, texting, etc. According to the Ginger.io website, it uses both passive data collected from the phone and active data reported by patients to create context-sensitive interventions.

The behavioral analytics platform is based on research from the MIT Media Lab. Several interesting papers are referenced on the website. With the level of data that can be gathered, privacy is a concern. The site claims to “only collect data we need to paint a rough texture of your behavior.” Patients are able to control whether data is shared with clinicians and researchers and can opt out at any time.

As a primary care physician I find the idea intriguing. The key is in the predictive ability of the algorithms to identify when a patient would benefit from an intervention. For this to really take off with hospitals and health systems, however, outcomes are not enough. It’s going to have to demonstrate cost savings as well. It will also take some patient education to make some of the “insights” valuable. Just looking at the screenshot, they’re pretty vague. “On Wednesday, you spoke with 2 fewer people than average.” “You interacted with 22% more people than average on Thursday.”

It reminds me of a virtual parent of high school students. You need to get out more. Stop talking on the phone and go to bed. You’re spending longer on your homework than usual. Get some exercise. You’re texting too much. Your music is too loud. There are twice as many miles on the car as there should be for where you said you were going.

Thinking back to what my phone has been up to the last several days, I wonder what the app and related algorithms would think of me. My boss is out of town, so I used Monday and Tuesday as rare opportunities to work remotely. I love working from home – I’m at least 40 percent more productive than in the office and feel a greater sense of accomplishment. I was able to use my land line and wasn’t running around so I made virtually no calls. Would it think I was withdrawn? Or would it interpret the flurry of text messages as I tried to reschedule a girls’ night out as evidence that my behavior was still within the range of normal?

Have you tried Ginger.io or do you know anyone who has? I’d love to hear what they have to say about it. E=mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/13/13

I attended a very traditional medical school. We weren’t allowed to actually think about diseases (let alone actual patients) until the second year. Once we had nearly finished the second year coursework and had learned enough about diseases to merit his appearance, one of the more senior members of the clinical faculty would teach.

Dr. Elliott was an extremely well known internal medicine physician who had published enough papers to scare the willies out of all of us. Since we hadn’t met him before, we didn’t know what to expect from his lecture. We quickly figured out that although he looked a little bit like Santa Claus, he wasn’t bearing gifts unless that gift was a personality that was a cross between Dr. House and an extremely grumpy teddy bear.

All the syllabus said about the lecture was the title: “Sick or Not Sick.” Dr. Elliott went up to the podium and started reading a patient case study. At the end, he’d look out over the class and say, “Sick, or Not Sick?” and call on some poor unsuspecting student.

The student would give his or her answer, which was invariably wrong. We were used to reading about diseases, so we figured if the patient in question had anything that sounded like one, they were “sick.” Only after sitting through about 20 minutes of torture did he begin to tell us what he was looking for.

By definition, “sick” was a patient who needed hospital admission. “Not sick” was someone who could be cared for in the ambulatory setting. To second-year students, all of them sounded pretty sick.

Flash forward to today. Probably none of those patient would be classed as “sick” since we’re now discharging patients that are sicker than those we used to admit. Once the length of stay is reached, it’s a race to get them out of the hospital.

The simple black-and-white nature of “Sick or Not Sick” crossed my mind today as I was reading a depressing string of articles. Topics included the 80 percent C-section rate at private hospitals in Brazil; the rise of patient empowerment; the drastic increase in healthcare costs as a portion of our economy; and the rabid competition of hospitals for market share.

I have to mention that I was reading these articles in the frame of mind of someone who is extremely tired of the consumer culture in which we live and just survived an ER shift where no less than three patients threatened to report me to the state board for “denying care” when I was delivering evidence-based practice for viral illnesses. Overlay a couple of articles about how one of the richest people in the world is trying to end polio and improve sanitation around the world with a flashback of the patient who threw her bedazzled iPhone across the room because I had to unplug it to use the outlet for a medical device, and there you have it.

If we want patients to be rational thinkers about their healthcare, they need to be both intellectually and economically engaged. We need to play a black and white game of, “Do I need it to get better or is it a marketing gimmick that will drive up all of our costs?” as we look at hospital initiatives.

I’ve written before about hospitals that post their ER wait times on the Internet or services that allow pre-scheduling of ER visits. Sure, that can increase patient satisfaction. But is it actually going to make me better? Probably not. Would I pay extra out of pocket for it? Probably not. So why is the hospital spending thousands of dollars on IT systems to support it?

Same thing with “dining on demand,” which has been a nightmare at my hospital. Since I started my medical career as a Candy Striper delivering meal trays on a labor and delivery ward, I’ve seen lots of hospital meal trays over a fairly decent period of time and have even partaken of a few myself. Is allowing a patient to order their meals on a touch-screen at the bedside cool? Sure. Does it allow patients to eat when they want? Definitely. Has it improved the quality of the food in proportion to the amount of money it cost to interface the ordering system with the EHR dietary orders and the additional personnel cost needed to operate like a restaurant and make sure it’s all accurate? That’s debatable. Again, will it actually improve my clinical outcomes or is it something we just think we need? Would I rather have a lower nursing ratio or dining on demand? I know what I would choose.

We need to think carefully about cost vs. convenience and quality vs. gimmicks. More are more people are going without healthcare this year than I’ve ever seen. It’s largely due to cost. This is driving hospital revenues down at the same time that costs to lure patients with the latest robots and gadgets are going up.

It’s time to stop the madness. It’s time for all of us – patients, physicians, and administrators – to stop thinking about “me” and start thinking about “we.” Put down the smart phones and stop being self-absorbed and look at the world around you. There’s a difference between “need” and “want” and “what is good for you.” We all need to embrace that difference as quickly as possible.

Have a gimmicky system at your hospital that cost more than it was worth? Are you tired of the tail wagging the dog? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/6/13

I think many of us in the healthcare IT trenches have simply become beaten down. There are dozens of different initiatives, regulations, and “incentives” causing daily pressure to change how our systems deliver care and how we interact with patients.

Some days I feel like I’m barely able to keep my head above water. There are so many competing priorities you can’t afford to get too worked up over any one issue or you might be sucked under.

In my informatics role, I’m exposed to a lot of different venues for care delivery. This week I served as a locum tenens in a primary care office and again had to confront something that has bothered me for years: pharmacies sending electronic requests for refills on controlled substances when they cannot be refilled electronically. Not only is this bothersome, but it wastes significant time in the practice.

Yes, I’m aware that the DEA issued rules that allow electronic prescribing of controlled substances. However, for this to be legal, the physician has to use certified e-prescribing software and two-factor authentication. Additionally, the pharmacy has to upgrade their systems to receive and process the prescriptions.

My state was one of the last to clarify its requirements for these transmissions, so adoption has lagged. Practices aren’t going to go through the credentialing process if the pharmacies aren’t ready, and our informatics team checks with the pharmacies monthly to see if they’re prepared to accept these scripts.

Our region has several major pharmacy chains that have spent the last decade sending refill requests for drugs that physicians cannot prescribe electronically. The physician (or his/her designee) has to deny the prescription electronically (otherwise be marked as “unresponsive” by the pharmacy intermediary system) then either call the script in if that’s permissible, or print and sign a prescription to mail to the patient or for the patient to pick up. These chains are still not enabled to receive DEA-compliant controlled substance prescriptions, yet they continue to send these refill requests that cannot be processed.

When I first saw this years ago, I called the pharmacy and asked why this was happening. I was told that the prescription management software couldn’t tell the difference between controlled and non-controlled substances, so they couldn’t block the inappropriate refill requests. They didn’t think their vendor would be willing to make a change. Flash forward and it’s still happening. I have to wonder why. Have systems not evolved in nearly a decade? Can vendors really not fix this?

It makes me wonder — where are the Meaningful Use requirements for all the other software systems with which my EHR has to interact? Why aren’t the pharmacies required to document the numerator and denominator for “percentage of refill requests sent that are actually legal to refill?” Why are only the providers and hospitals eligible for penalties?

If we’re going to have de facto regulation, let’s treat everyone the same – from the pharmacy to home health to post-acute care. When only some of the players are jumping through hoops and we’re just passing the meaningless work from one part of the industry to another, we’re not transforming medicine — we’re just being wasteful.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/29/13

Mr. H posted a question in the Monday Morning Update about the decision-making habits of healthcare IT leadership. It brought in a fair amount of reader comments and I thought I’d contribute my two cents.

First, to the original question/comment:

Healthcare IT leadership seems unable or unwilling to take meaningful actions that would benefit their organizations … In a corporate world, leaders who don’t act on revenue opportunities or cost savings don’t last long. Is it asking too much for healthcare IT to make responsible decisions to avoid wasting money?”

Many of the so-called leaders I work with suffer from analysis paralysis. It’s not just IT leaders – it could be finance, revenue cycle, practice operations, or just about anyone. They spend so much time thinking through various options that they ultimately miss the opportunity to make a decision that would make a difference. There’s no understanding of the concept of opportunity cost.

I tend to see this more in so-called non-profit health systems where the business just isn’t run like a business at all. Sometimes I think altruism or the thought that everyone is “trying to do their best” becomes a smoke screen for failure to lead.

It’s not just analysis paralysis, but there are quite a few healthcare leaders I’ve worked with who are simply ineffective. I’ve worked for and with people who range from passive-aggressive to missing in action. One group I worked with in a consulting relationship had an EHR project head who was missing in action. His favorite pastimes included casino gambling and hanging out at the local coffee klatch with a group of wealthy retirees. He’d come to steering committee meetings completely unprepared and expected his subordinates to bail him out. His direct reports were rewarded by having their one-on-one meetings canceled and receiving performance evaluations that were written by other division directors because he was unable to meaningfully assess their performance.

Inept leadership isn’t the only thing that contributes to poor decision making. Awkwardly constructed team structures can be a factor as well, where different verticals end up unknowingly (or intentionally) confounding the needs of other teams. Teams where leadership obviously doesn’t like each other or share any kind of mutual respect can lead to bickering and efforts to block others just do be difficult. When teams don’t get along, it’s up to the next level of leadership to demand cooperation and congeniality or let people go.

Although I agree that the level of involvement (read: interference) of government in medicine makes it difficult to say ahead of the curve, that often sounds more like an excuse than a reason. I’ve seen more than enough healthcare organizations that have no concept of the true cost of the care they’re delivering, and instead of focusing on the bottom line, spend their time whining about payers. Physicians underestimate the value of their time and shift resources the wrong way, taking on additional work rather than “burdening” their staff members. I see too many administrators who are penny-wise but pound-foolish, trying to do complex projects in-house due to perceived cost savings when a team of experienced consultants could have delivered higher quality product with fewer errors, delays, and cost overruns.

Another major problem that leads to ineffective (or no) decision making is failure to understand the value of active change management within an organization. Sometimes unpopular decisions need to be made, but rather than using a formal change management program to smooth the transition, leadership elects to make no decision at all. Guess what, folks? This isn’t high school. You’re not here to be liked — you’re here to do a job and improve patient care. It’s not a popularity contest.

I also see a fair number of “leaders” who don’t understand their core business or its needs. My favorite corporate “stupid human trick” is the lateral outplacement move, where you take someone who is ineffective in your vertical and move them to another vertical in the organization where they may know even less about the business line. Just because someone knows the inpatient setting doesn’t mean they know beans about ambulatory care, and vice versa.

In the same vein, I also see too many people that place stock in certifications and degrees over experience. I’ll take an experienced CMIO who has had to work with the DBAs to resurrect an enterprise app in the middle of the night, whether they have fellowship papers or not. In my neck of the woods MBAs are a dime a dozen and I continue to watch hospital administrators hire people with no healthcare experience at all, then feign surprise when failure occurs.

Is it really that much worse than other industries, though? I’m not sure. Having worked in healthcare most of my career (unless you count a string of fascinating summer jobs), I don’t have a lot to reference against. My friends in non-healthcare IT seem to have managers and decision trees that are as crazy as those I deal with every day. Sometimes running away to become a rodeo clown looks pretty good – until I remember that’s what I already do every day.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/22/13

It’s a little strange having a secret life as an anonymous blogger. Although I’ve gotten used to hearing colleagues talk about things they recently read on HIStalk, I’m still not entirely used to them talking about my personal posts. I think that will be a bit easier now that I’m apparently a “non-anonymous” celebrity, courtesy of cable TV.

Our hospital has had a “Focus on Your Health” outreach program for several years. It shows on the local public access channel and each episode runs intermittently throughout the month. I did a women’s health feature when I first started practice and it brought an interesting mix of new customers to the practice. I had just opened and needed the business, but the influx of people was challenging enough that I wasn’t too excited about doing it again.

Last month, the hospital was looking for a piece about summer health emergencies and asked me to help out. I figured that since I now work mostly in the emergency department, it might be fun. I dutifully prepared my segment on all the various “things that can get you in the great outdoors” and prepared to film. We covered all the staples: dehydration, sunburn, noxious plants, heat-related illness, venomous snakes, and more.

Most of the conversation was around prevention and the basics. Drink plenty of fluids, avoid being outside during the hottest parts of the day, wear a hat, use sunscreen. Wear long sleeves, pants, and sturdy shoes when working in the yard, woods, or garden. Not exactly hot topics.

What I wasn’t prepared for, though, was the magic of video editing. While we were filming, there was a flat screen with the “Focus on Your Health” logo in the background positioned between the interviewer and my chairs. After filming, the screen was replaced with gory pictures of our discussion topics – rashes, bites, snakes, spiders, and more. Some of the footage seemed right out of a National Geographic “animals eating animals” special.

I was surprised to be a hot topic in the doctor’s lounge. Apparently some of my colleagues thought I had prepared the video clips myself and wondered exactly what I do in my free time to have all those pictures.

I’m self-conscious about being on film, so it wasn’t easy to hear what colleagues thought about my performance. I fretted over that for a day or two until I had my first celebrity encounter at the supermarket. I heard a little voice say, “Hey, mom, it’s the Snake Lady!” and looked around to see who he was talking about. Turns out it was me. His mom said he loved the show and recorded it.

I suppose having one’s performance critiqued is worth it when you see the smile of a child meeting his TV idol. Got a story about public access television? What do you think of it as health information technology? E-mail me.

E-mail Dr. Jayne.

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.