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.

Curbside Consult with Dr. Jayne 10/1/12

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/24/12

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/17/12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Boil-Lanced.

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/10/12

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/3/12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 8/27/12

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 8/20/12

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 8/13/12

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.