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.

Curbside Consult with Dr. Jayne 12/3/12

There’s been a lot of chatter (via Twitter and other social media) about the hospital battle going on in Boise, Idaho. More than half of the physicians in town are employed by St. Luke’s Health System or a competitor. Independent physicians have shared allegations of skewed referrals, rising patient costs, and other unfair practices.

I’ve never been to Idaho, but after reading several articles about the situation, I find it not much different than what I’m seeing in my own market. Certainly there is some degree of this going on just about everywhere, regardless of whether health systems are non-profit or for-profit. Some control over referrals stems from value-based care initiatives and contracts where providers and their sponsoring institutions assume financial risk. Other moves seem to be merely profit-motivated.

In addition to demanding referrals, health systems are demanding that their member physicians refer exclusively to hospital-owned laboratory and ancillary services unless the patient refuses. Patients are left holding the bag, as they may have separate co-pays and/or deductibles for hospital-based (as opposed to reference lab) services.

I’ve personally had issues with hospital-based radiology departments whose cumbersome processes take complex registration and billing inefficiencies to a new level when they try to merge the hospital way of doing things with an ambulatory patient’s expectations. The hospital where I am on staff charges a screening mammogram at more than three times the charge of the freestanding radiologist-owned imaging center (which also provides private waiting areas and on-site immediate results as well as being a bargain). Since I’m on an insurance plan where I have a fixed amount of money to spend on preventive services, guess where I’m headed?

Let’s also talk about provider-based billing, where the hospital assumes control of a practice, names it a “hospital outpatient clinic,” and starts billing a facility fee in addition to the fee for provider services. I experienced this recently when a minor dermatology procedure (for which my ambulatory practices charge about $100) showed up on my bill as several hundred dollars because it was performed by a member of the medical school faculty. Practically speaking, her practice is no more a “hospital department” than mine is – despite the hospital’s assertion that Joint Commission accreditation and being part of a monstrous bureaucracy merit a different charge structure.

Unfortunately, overcharging individual procedures and services is just the tip of the iceberg. CBS ran a story this weekend on Health Management Associates. The story alleges coercion of emergency department physicians to admit patients who didn’t require admission. An interesting component includes the use of a software program to order extensive panels of tests on patients based largely on their ages rather than their presenting complaints or histories. It’s a fair bet that other organizations could be accused of the same thing.

Although my hospital’s emergency department intake process contains numerous wasteful components (like performing suicide screening on every patient who walks through the door – even a three-year-old needing stitches from tripping into a coffee table) I’ve never been pressured to increase admissions. Frankly, I’m not sure where we’d put them, as we’re constantly waiting for beds upstairs and end up boarding patients in the ED hallways. In my opinion, our major source of waste is the practice of defensive medicine, which results in overuse of tests and imaging because physicians are afraid they’ll be sued if they miss something.

Earlier in my career when I was in full-time primary care practice, I experienced a lot of pressure. The first few years it was personality-driven: the chief of staff complained I wasn’t referring enough to him. In fact, I was referring to one of his junior partners who started at the hospital at the same time I did and with whom I had better rapport. The hospital continued to reinforce that they wanted to earn our business and our referrals, even to the point of purchasing a high-quality competitor specialty practice to whom most of our primary care practices referred. Once they were in the corporate fold, however, referrals were expected and even demanded.

Back in the day, we knew our hospital tracked referrals for imaging services. A couple of times, I received cards thanking me for my referrals when my volumes had increased. I didn’t mind that so much, but now our hospital sends detailed reports to providers comparing their referral volumes to that of their peers. I find that extremely distasteful. The provider group’s administrators also mine data in the EHR and distribute referral reports that highlight which providers are referring out of the system and which are “loyal.”

No matter how recently we completed training, this certainly isn’t what any of us signed up for. I’m not delusional enough to think that Marcus Welby is still out there somewhere, but there has to be something better than this.

Have a story about a health system that earns its referral business rather than demanding it? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 11/26/12

Last week Mr. H took a break from compiling the news, which meant that I took a break as well. Baking is one of my hobbies, so I used the free time to turn out a couple of “oldie but goodie” recipes. I’ve been making one of them since I was in junior high school but hadn’t done it in a couple of years and it was a nice treat. I find working in the kitchen to be therapeutic. The steady rhythm of knife work and the stress-relieving properties of making pastry are good reminders of getting back to the basics.

I’ve been doing more traveling lately than usual, so the downtime this week was much appreciated. The perfect storm of my specialty society meeting, a tech conference, and MGMA hit entirely too close together. Although tiring, the upshot of hitting three meetings in two months was being able to see (actually in person!) a lot of people that I typically only interact with in the virtual world. In this age of emerging communications tools, I think that the concept of friendship has evolved as well.

Although I have plenty of local friends, some of my best friends are those that I may only see once or twice a year. It’s easy to stay close when you’re only a few keystrokes and a mouse click away. The things you previously had to wait to hear in the annual Christmas letter are now presented real time via Facebook. When you meet in person, it’s almost like no time has passed since your last get-together and that is a wonderful thing.

I find that I’m closer to work friends because we interact through social media. Although I don’t like my News Feed clogged with pictures of what people ate for lunch or which beer they’re drinking tonight, I enjoy seeing what colleagues are up to when they’re not at work and seeing their children grow up. I’m thankful to be able to keep in touch with people who have moved on to new challenges or to other parts of the country.

Our HIStalk readers provided some extra special Thanksgiving moments by reaching out to say how much they appreciate our team. Sometimes it still seems a little unreal that we do this every week – IT workers by day, bloggers by night. It’s good to hear that you think we’re making a difference.

My favorite e-mail of the week was one asking me for a favorite Christmas punch recipe, and I’m excited to be thought of as the Martha Stewart of the health IT world. Let’s face it, I’ll never keep up with Inga as the fashionista, so I’ll settle for being the happy homemaker.

Since Thanksgiving seems to be the official start of the holiday office party season, I offer up Dr. Jayne’s Holiday Recipe Guide. Having spent most of my career in non-profit healthcare, I’m used to partying in the potluck style. Since HIStalk is your virtual water cooler for IT news and gossip, we’re happy to be part of your office potluck as well. Choosing something from the list below will allow you to avoid another year of shame after being labeled as “that guy who brought the case of White Castle Hamburgers.”

Appetizers

Hot buffalo chicken dip

Best made in a small crock pot on your desk since I’ve never worked in an office that has an oven.

Super-lazy cheese and crackers (perfect for purchasing on the way to work)

Unwrap a block of Neufchatel cheese (might be labeled as “light cream cheese”) and place on a rimmed serving dish. Pour Bronco Bob’s Roasted Raspberry Chipotle Sauce liberally over the cream cheese and around the dish. Serve with Wheat Thins or similar crackers.

Main Dishes

White Chicken Chili

Cranberry Cocktail Meatballs

(thanks to Mr. Z. – and I totally appreciate the notes on how you actually make them vs. what the recipe says)

2 pounds lean ground beef

1 cup cornflake crumbs

1/3 cup finely chopped parsley

2 eggs, lightly beaten

¼ teaspoon pepper

garlic powder to taste

1/3 cup catsup

2 tablespoons thinly sliced green onions and soy sauce

Thoroughly mix all ingredients. Roll into balls (about 1 to 1 ½ inches). Bake on cookie sheet at 500 degrees. It says five minutes, I think I do about seven. They are great as is for spaghetti.

Sauce

1 can whole cranberry sauce

1 12 oz bottle tomato based chili sauce

1 tablespoon each brown sugar and lemon juice

Warm in pot, drop in meatballs. I make my meatballs ahead of time and nuke them on medium to bring to room temp and drop in.

Desserts

Libby’s Pumpkin Roll 

It’s a little tricky to make without it cracking, but it looks (and tastes) like a million bucks. And yes, a seventh grader can make it.

Insanely Good Chocolate Cake

It goes by a variety of names and with subtle variations.

Bake a dark chocolate cake in a 9×13 pan according to package directions. Before it cools, poke holes all over the cake (using a serving fork or a bamboo skewer) and pour on a 14 oz can of sweetened condensed milk, then pour on an 8 oz jar of caramel topping. Refrigerate overnight. Immediately before serving, cover with whipped topping and sprinkle with crushed Heath bars.

Drinks

Christmas Punch

Martha Stewart Style and not for the office party, unless your office lets you have vodka.

Christmas Punch

Cooks.com style.

Sherbet Punch

Good for when you have to throw an office baby shower, too.

Place ½ gallon of sherbet in a punch bowl – I like raspberry personally. Slowly pour over 1 liter ginger ale and ½ liter of Fresca or Sun Drop. You can change the colors by changing the sherbet, but know that rainbow sherbet turns an unappealing color if you try to use it.

If you have favorite office party recipes, be sure to share. I’m always looking for something new and delicious. See you around the water cooler and in the buffet line.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 11/19/12

Penny Wise and Pound Foolish

Working for a large health system, I’m no stranger to procurement policies whose complexity rivals the best Rube Goldberg machines. This has been made worse by consolidation among hospitals and their various service lines when administrators demand a tightly-controlled list of preferred vendors.

On its face, a preferred vendor list sounds like a good idea – make sure vendors are well-vetted, reputable, and have the all-important Business Associate Agreement squarely in place. It can also be helpful to ensure vendors reps play by the rules and behave themselves in the hospital. Vendors on the preferred list may also have a better grasp of the needs of large health organizations and can ensure contractual pricing is delivered to all parties that should receive it, whether they are part of the mother ship or merely affiliates.

This makes sense when dealing with items that are truly commodities – linens, transcription service, uniforms, furniture, medical supplies, and technology hardware. It makes less sense when dealing with emerging interoperability needs, especially when third-party interventions are needed to improve workflow or make clinicians’ lives better.

A little over a year ago, my group (which is owned by the hospital) decided to shutter the moderate complexity lab that we had hosted in our office for years. Although convenient for patients, it was a declining source of revenue and an increasing source of aggravation due to unreliable equipment and staff. When the hospital offered to place a draw station in our practice (complete with staff that we didn’t have to pay for) it was an easy decision to shutter the lab.

What we didn’t anticipate were workflow issues caused by the lab interface the hospital provided. When we owned our lab, results were printed out and scanned. We reviewed these in our EHR work basket and acted on pages of labs with a single message to staff.

Once we went live with the hospital lab interface, result flowed real-time into our work basket. This sounded like a good idea, but as primary care physicians ,this was inefficient and annoying. Rather than having all labs back together, they returned piecemeal, which meant we might have to touch a patient’s chart three or four times trying to figure out if all the labs were back and ready for us to act.

I explained this to one of my CMIO pals, who immediately recommended some middleware that he had used to solve the same problem. Even better, the solution was cheap in IT terms (barely the cost of an off-the-shelf interface project) and readily available.

The hospital agreed to pursue the solution for us since competing local labs already had a solution in place and would have been happy to have our business. We were initially enthusiastic, but work quickly ground to a halt since the vendor was not on the hospital’s preferred vendor list.

Instead of pushing to have them on the list, we have had to watch the hospital slog through its vendor identification, request for proposal, and endless review process. Ultimately they chose a vendor from the preferred list who said they could build the same type of solution, but unfortunately had not built this particular flavor before. Having my colleague’s experience to draw from, I wanted to make sure we addressed several key areas of functionality in the contract. This caused the contract to be “nonstandard,” which is apparently a euphemism for “something which will never be signed in your lifetime.”

We were in negotiations with the vendor for nearly four months. The slowness was mostly on our side, which was easy to figure out based on the many painful conference calls I attended. Once the contract was in place, the vendor began building the solution and we had to beta test it for them in their environment. Then we had to deploy it to our full-blown test environment, followed by more configuration and a couple of enhancements. After several more months, we’re finally ready to take it live.

Our physicians and staff have aged in dog years during this process. Staff has created a new process to try to reconcile what has returned with what was ordered so that providers don’t try to address a patient’s results before they’re all back. When we added up how much money this has cost (both in lost productivity and in incentives/bribery to keep the process working), we could have purchased the upstart vendor’s solution five or six times over.

For those of you who have recently joined the ranks of employed physicians or are contemplating a hospital’s purchase offer, get ready. You get to share the joys of the ubiquitous preferred vendor list.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 11/12/12

Bianca Biller and I recently traveled to a continuing education seminar out of town. Although the trip started out as a lot of fun (the flight attendant actually asked me for ID before allowing me to have an adult beverage), it quickly turned dark as we began discussing the challenges faced by ambulatory physicians.

Once again, there is a looming Medicare pay cut. Although Congress has overruled this annually since 2003, it’s nerve wracking to face the medical practice equivalent of the Fiscal Cliff. Based on our recent election cycle, I don’t have a lot of hope for a permanent fix any time in the near future.

Providers who haven’t yet gotten with the program are starting to see their e-prescribing penalties become reality. Although this shouldn’t be a surprise, physicians are still grumbling and generally behaving badly.

Bianca is seeing an increase in prepay audits for high level visit codes – claims are processed and denied (who doesn’t love a zero payment?) with a reason code that requests records. For physicians who don’t have savvy billing staff paying close attention to the reason codes, this could be a problem. Payers have different time limits for receiving the supporting documentation – the clock is ticking, so it’s key to be aware of the different requirements.

This is almost certainly fallout from the transition to HER. At least in our organization, providers are actually billing for the work they do and document instead of under-coding as they have been for more than a decade. It’s sad that this is perceived as potential fraud instead of a move to capture more accurate billing.

Although we’ve started to see some recovery in office visit numbers (which have been nationwide the last several years) the holiday season is upon us, which usually results in a downturn in productivity. Although patients have met their deductibles they’re busier and have less time to be seen for non-emergent issues. This is also the time when physicians and staff tend to take vacation, which can lead to increased charge lag. It’s important to make sure documentation is done and charges are billed to keep cash flowing into the New Year.

The “usual suspects” of ACO, PCMH, and ICD-10 continue to be wolves at the door. Hopefully your house is made of bricks rather than straw and you have your plans shored up to be compliant with the different nuances of each program.

There is one ray of sunshine on the horizon. Medicaid rule CMS-2370-F increases Medicaid reimbursement rates to equal Medicare for key specialties: primary care, general internal medicine, family medicine, and pediatrics. Although positive, it’s both a slap and a kiss in some markets where Medicare payments lag far below commercial.

Ultimately the trip was good, the weather was sunny, and we actually learned quite a bit at the conference. We also had time to discuss our projects and goals for the next year, which we never get to do at the office despite being in countless meetings together. Here’s to good friends, strong teams, and another year in healthcare.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 11/5/12

I’ve written before about the difficulty I sometimes have reconciling the high-tech tools I’m responsible for with the low-tech situations that physicians deal with on a regular basis. Many of us are confident we live in a wondrous age where innovation and technology are both the means and the end. Stories coming out of areas devastated by Hurricane Sandy, however, tell a different tale.

In New York City, the decision was made (based on storm predictions) to evacuate several hospitals prior to the storm, but not all. I don’t doubt that there was a lot of deliberation involved and careful weighing of the risks of evacuation vs. sheltering in place. New York has experience from Hurricane Irene and used that knowledge to inform its decision. Sometimes even the best plans go awry, as detailed in a New York Times article about the hospital situation.

As a physician (and as a first responder before medical school) I’ve been through my share of disaster drills. We don’t have hurricanes where I live, but we do have more than our fair share of fires, tornadoes, earthquakes, and floods. (Last year we even had locusts, but I digress.) I know in the event of an emergency what I’m supposed to do. I also count on hospital administrators and others to make good decisions.

Despite significant preparation, there were some misses in Bellevue’s disaster plan:

• Although fuel pumps were in flood-resistant housings, they were in the basement, which flooded. Residents, nurses, and administrators ferried fuel up 13 flights of stairs to the backup generators.
• Electrical control systems were also in the basement.
• Elevator, oxygen supply, and water systems failed.
• Disaster drills did not include actual practice of the scenario of carrying patients down the stairs to evacuate.

I cannot even fathom the conditions that caregivers and patients endured this week. And it wasn’t just at Bellevue. Speaking with some of my colleagues, conditions at several facilities were horrendous, with sanitation issues, sewage problems, and more. When evacuations were finally ordered, patients were carried or dragged down 10-15 flights of stairs, often with someone manually ventilating those patients who could not breathe on their own.

The Times article details the conditions at other hospitals. Patients were given minimal dialysis because private dialysis centers were closed. Facilities were only prepared to be on backup power for days rather than for a week or more. Food supplies ran low. Communication plans failed.

Due to a quirk of scheduling, I happened to be in the New York area this weekend. I am shocked by not only the devastation, but by the disparities across the region. New Yorkers are being urged to return to business as usual even though hundreds of thousands of people are without power and bodies are still being recovered. The devastation that occurred is a life-altering event for those affected. Psychologically, people need to grieve and come to terms with the past week rather than launch back into “business as usual.”

Not all of New York City was affected equally. Staten Island was hard hit, yet parts of Manhattan were relatively unscathed. A controversial decision was made by Mayor Michael Bloomberg to go ahead with the New York Marathon. Community advocates worried that emergency workers were already stressed by evacuations, fires, and rescues and that their efforts should be focused on rescue and recovery rather than recreation. Residents were furious that generators (albeit privately funded ones) were powering media tents when nearly half a million people were without power. Ultimately, Bloomberg responded to criticism by canceling the race Friday evening.

When this decision was announced, I was on a flight with a mix of marathoners and people who were returning home to the devastation. Conversation topics included everything from “what kind of generator should I buy for next time?” to lamentations of the race cancellation. I was surprised by the lack of empathy from runners/tourists who felt that New Yorkers had bullied the mayor into canceling. I hope their tone changed when they left the airport, because what I saw when I hit the roads was dramatic. Lines at gas stations were two to three hours long with significant power outages, lack of traffic signals, and many people who are still in shock.

It’s not over yet, however. This weather event and the subsequent tragedies will add to the healthcare burden not only in exacerbation of existing illness, but in a short term surge of respiratory, gastrointestinal, and other infectious complaints. In addition, there will be longer-term cases of post-traumatic stress disorder, anxiety, and depression.

Regional health authorities, hospitals, and disaster preparedness experts need to carefully learn from the events of this week and prepare their teams with careful planning and practice. Plenty of people were touting the benefits of HIEs to assist with natural disasters this week, but an HIE doesn’t do you a lot of good when you lack food, water, and basic sanitation. Does it really matter if the servers fail over gracefully if generator failure causes a hard stop a few hours later?

It seems that despite all our technology, people have become less prepared for events like this, as well as less resilient when they occur. In our post-Katrina world, people need to be ready to help themselves and not rely on government agencies. I urge each of you to use this as an opportunity to revisit your own personal disaster plans as well as those for your workplace. Emergency preparedness isn’t just for doomsday preppers, but should be for all of us.

No matter where you live, make an effort to have a week’s supply of food and water on hand (if nothing else, invest in some energy bars and a case of bottled water) and have a plan for where to go if you’re displaced from your home. You don’t have to be a secret agent to keep a “go bag” with a few clothes and essentials packed and in the closet or under the bed. Be aware of chronically ill or elderly relatives and neighbors. Ask them what their plans are and know whether you are willing to assist if the time comes. Know what your role would be if you are at work and disaster strikes. Be willing, be able, and be prepared.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 10/29/12

Trick or Treat.

I’m not sure if it’s a trick or a treat, but there’s no question that we’re seeing some interesting cooperative partnerships among hospitals and health systems. Last fall Sentara Healthcare, Novant Health, and MedStar Health united to form MNS Supply Chain Network, LLC. Although the groups are in reasonably close geographic proximity (Maryland, the Carolinas, Virginia) they’re not in significant competition in their respective markets.

The press release highlights the purchase of more than $3 billion in supplies and services across the new organization as motivation. Even the name indicates a focus on supply chain efficiency and volume-based contracting. On the face, this would seem to make sense in almost any industry, particularly one with decreasing margins and increasing regulation.

The announcement in June of a similar collaboration in Iowa had a slightly different tone – a healthcare alliance to advance care in addition to group purchasing power. The addition of buzzwords in the coverage such as “clinical integration” and “streamlined and coordinated care” put a different spin on things, although the groups were clear to state their plans to maintain their independence.

This makes a bit more sense since all the member organizations are located in a single state, particularly one that has a reputation for close-knit communities and a stable population. Over 70 percent of Iowa residents were born in Iowa. Anecdotally, my med school friends from Iowa assure me that there is some kind of force field that only allows them to leave for four years before they are pulled back to the heartland. Given the growth in Medicaid rolls across the country, this could be a very strategic move.

The Iowa plan specifically calls out plans to share “expertise and operational costs associated with development of ‘accountable care’ initiatives.” It also mentions “sharing the high costs of the information systems and experts needed to analyze clinical data and convert it into information that can be used by physicians and others to improve care and better manage populations of patients with chronic diseases.”

That surprised me a little, especially since at least one of the four organizations is part of a larger multi-state health system. Although a larger group would certainly be able to negotiate better deals on hardware, I’m not sure what the implications are for software.

Buying software isn’t like replacing a fleet of PCs or negotiating a better deal on linens. Especially when you’re dealing with health systems that are already the result of multiple mergers, there are tons of legacy systems to deal with. Looking at their histories and missions, these groups are not likely to be flush with cash or ready to rip and replace.

I hadn’t thought about these cooperatives much until this week when a colleague sent me notice of a deal in the Midwest that seems to be a hybrid of the previous two approaches. Four hospital systems in Missouri and Illinois have announced formation of The BJC Collaborative LLC. Participants include BJC HealthCare (St. Louis), St. Luke’s Health System (Kansas City), CoxHealth (Springfield, MO), and Memorial Health System (Springfield, IL). One system’s CEO explained the somewhat geographically disjointed arrangement: “It’s hard to do that with systems in your own community because they’re each working for their own advantages.”

There could be more to this partnership as well. St. Luke’s competitor Ascension Health is negotiating to sell two hospitals in Kansas City to HCA Midwest. BJC competitor Mercy is making some interesting moves in Missouri and Arkansas, one of which is to sell St. Joseph’s Mercy in Hot Springs to Capella Healthcare. Perhaps the collaboration is an attempt to shore up the walls against a for-profit incursion.

They’re clear to say it won’t impact how hospitals deal with insurance companies (no one likes to be accused of collusion or restraint of trade). Talking points again included supply chain, but information technology was also called out – there is a mix of Epic, Cerner, Allscripts, and McKesson in play among the participants.

One CEO stated that “backup servers, data warehousing, and disaster recovery systems” could potentially be shared. I’d love to see the architecture schematic of a backup data center for an organization like that, but I wouldn’t want to see the legal fees for the governance documentation it would take to make it a reality.

The increasing frequency and size of these arrangements certainly counts as a trend in my book. If you have information on who might be next, you know how much Mr. H, Inga, and I adore rumors and juicy tidbits. If you’re an insider at one of these collaboratives and want to share your thoughts, we’ll keep you anonymous. If you’re an outsider, what do you think? Are these arrangements good, bad, or indifferent? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 10/22/12

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 10/15/12

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 10/9/12

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

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

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

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

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

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

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

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

How does your organization allocate incentive payments?

E-mail Dr. Jayne.