Curbside Consult with Dr. Jayne 8/6/12

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 7/30/12

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 7/23/12

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 7/16/12

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

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

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

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

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

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

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

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

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

The IS Department

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 7/9/12

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 7/2/12

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 6/25/12

I maintain staff privileges at a hospital where I almost never admit. Even with my non-existent volume, I still have to attend training, so I wasn’t surprised a few months ago when I received the postcard saying that it was time to talk about finally going live on CPOE.

It’s kind of funny, because more than four years ago I served on the selection committee for this particular product. I remember at the time being shocked that we were even considering it because the user interface was so buggy at the hospital where we did our site visit. Meanwhile, I had moved on to greener CMIO pastures, but I still keep those privileges out of nostalgia (or maybe out of fear that one day I might have to go back into traditional practice.)

Luckily the final training blocks coincided with a couple of comp days I had already scheduled. I wrote about my recent Meaningful Use upgrade training a few months ago and I hoped that this would be a similar experience. However, I think I could use it to write a case study in how to alienate the medical staff.

Being a veteran trainer, I arrived 15 minutes early because I knew I’d have a logon / password issue since I rarely go to that facility. The training room was dark, so I poked my head into the room next door to make sure I was in the right place. The training team was sitting around and barely noticed me. In fact, they were talking about another physician – making fun of one who had arrived half an hour early because he was cutting into their break time. I pretended I didn’t hear them and asked if I was in the right place. I was told they’d be in the room shortly.

I went to the room and found a seat at a folding card table (no, I’m not kidding) with actual damp coffee on it. They finally walked in five minutes after training was supposed to start and began passing around a coffee-stained sign-in sheet for continuing medical education credit. That was a plus – I hadn’t expected to receive hours and it’s always good to have some “live” credit since I do most of my CME online. But the coffee was a turn-off.

Additionally, since the last time I rounded, the facility had gone to proximity badges. I didn’t have one, which created much hubbub, although none of the trainers could tell me who to talk to in order to get one. Surprisingly, my ancient logon and password were not expired.

After dealing with the sign-in sheet and the proximity badges (I wasn’t the only one without one – the other doc who had arrived 30 minutes early didn’t have one either) they finally decided to fire up the projector and went through a whole “how do I adjust the keystone” saga. My new Twitter BFF, @MeetingBoy, would have been proud.

Training finally started about 15 minutes late. To my chagrin, they not only accommodated late arrivals, but stopped class and rehashed everything that had been covered to that point.

I was given a cheat sheet with some patient names, one of whom was a 14-year-old male named “Samantha,” which added realism to the scenarios. The class moved at a glacial pace to allow for one of the more senior members of our class (whom I know to be at least 85 years old) to keep up. I felt so sorry for her – she is very sweet and is a fixture at the hospital, and they really should have offered her an individualized class.

About an hour and a half into the class, everyone was kicked out of the application. The trainers explained that the build team was still creating order sets and had a tendency of uploading their work several times a day “to keep the environment fresh.” I don’t know about you, but I’m pretty sure we didn’t need their recent (probably untested) build work to make it through class.

I was surprised to see that the version being deployed was the same version we looked at four years ago. I know this product didn’t make its vendor’s “go forward” list, but I’m pretty sure there’s been another release since then. I’m not sure about the rationale for taking outdated software into a live environment.

All the bugs and UI glitches that we had seen during selection were still there. Some orders were in alphabetical order when it would have made more sense to have them sorted by frequency of ordering or grouped by body system. Others were arranged by the order in which they were added to the database rather than being in alphabetical order. You could see what the “oops, forgot that one” tests were because they were at the bottoms of the lists. Seeing “do not use” abbreviations is always a treat as well. Several screens had such inconsistent use of color that it looked as if a bag of Skittles had been upended on the screen.

I was pleasingly surprised to see that the system had a button for logging bugs (really a glorified e-mail launch) and the other docs in the room got a kick out of that too. Docs were told to log anything they thought should be added and that it would be placed in the system. There was no mention of change control, governance, or peer review of the suggestions.

Laughs were had over the trainer’s warning that we shouldn’t try to use the embedded help files because the system had been customized so much that they weren’t relevant. The trainers took great pride in telling us how many hundreds of hours it took to build some screens vs. others and the hours quoted were really quite unreal.

Several common acronyms were used in the order sets, but unfortunately some elements were out of order and others were missing, making it hard to recognize the acronyms. With as many thousands of hours as were allegedly spent building, it didn’t appear that there was much clinical oversight. No surprise – the hospital in question does not have a CMIO and I’m not sure there were medical informatics experts involved in system planning and design either.

This was the fourth training session of the fourth week (only a few days prior to go live) and at least three of us noticed a major patient safety defect that had not yet been discovered. On some screens, patient demographic and vital signs data rounded up and/or down without reason. I’m not sure about you, but when a patient is documented as weighing 78 kg in the base clinical application, I don’t expect to see him rounded down to 70 kg in the CPOE module. Other areas of the system simply had garbage in the build (the ubiquitous ZZZZ added before pick list items to push them to the bottom) which always drives me crazy.

The doc seated next to me said she couldn’t believe we were forced to attend the class live. It could easily have been given as a 90-minute webinar instead. I didn’t disagree. I did receive two hours of continuing education credit for my four-hour tour, so it wasn’t a total loss.

The hospital went live on CPOE over the weekend. From what I hear, things went well, all things considered. I wish them the best, but hope the next rollout has not only better software but better training.

Have a training horror story? Does your system remind you of colorful candy? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 6/18/12

Yesterday was Father’s Day. I hope all the dads out there were able to spend time with their loved ones.

This is the first time in many years that I wasn’t able to spend it with my dad. I knew my summer schedule would be quirky, so I made a point of getting back to my roots a couple of weeks ago.

My dad always has a way of reminding me that no matter how hard I think I’m working, there’s always more work to be done. Nothing drives that home like spending time on a farm. In addition to having the opportunity to do lots of “farm things” (aka “work”) the best thing about being on the farm is that cell service is spotty. It forces you to spend time in the moment and focus on concrete tasks. I spent some quality hours behind the wheel of a tractor, which is always good for reflective thinking.

Everything on a farm is about cause and effect. Preventive maintenance is key. In a lot of ways, it reminds me of healthcare. (Farming also reminds me of healthcare in that I’ve learned I can handle anything as long as I have gloves on, but that’s a story for another day.). When you neglect something on a farm, it almost always comes back to haunt you. It’s important to pay attention and do the right thing the first time. Not just because someone told you to do it, but because it’s the right thing to do.

Doing the right thing is good for the land, your neighbors, and the community. You don’t do it because the government mandated it, but because you should.

Another key piece of learning on the farm is that when something needs to be done, everyone needs to pitch in. I check my MD at the door (well, actually when I turn off the paved road onto the gravel road) because higher education doesn’t exempt anyone from brush hogging, hauling wood, or any number of exciting activities. It does guarantee though that you’re the first person approached when there is a deer tick that needs to be removed.

One of my dad’s mantras is that if a job is worth doing, it’s worth doing well. Anything less than your full effort is unsatisfactory. I see a lot of people in healthcare IT that look like they’re just going through the motions, forgetting that we have people’s lives at stake. I try my best to model that work ethic for my team and to encourage them to practice it as well.

My dad also taught me that when things go wrong, the best thing to do is to stop, get your wits about you, figure it out, and fix it. And if you can’t fix it, at least come up with a solution that doesn’t make it worse while you find someone smarter to help you fix it.

Whether it’s the hydraulic line on the front-loader that decides to spray fluid all over you or whether it’s a complex laboratory interface that suddenly spews data where it doesn’t belong, neither overreacting nor being paralyzed by fear leads to a good outcome. I know about both of these first hand, and both require teamwork and careful thought to get things flowing back where they should.

Most days on the farm leave me dirty, tired, and generally achy. But there’s nothing quite like crashing in a lawn chair under a 70-year-old tree and watching the sun set over the fields. No matter how fast technology moves, when ICD-10 gets implemented, or what the Supreme Court decides to do, the corn’s going to keep growing. In the morning, there will still be plenty of work for everyone.

Can you name the ideals of 4-H? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 6/11/12

As a physician, I sometimes have to make the last note in the patient chart, officially “pronouncing” the patient to be dead. Regardless of how many times I’ve done it, I don’t think it is something I ever will get used to. Depending on my relationship with the patient, I sometimes receive the death certificate to sign a few days later, formally documenting the cause of death. It’s a very concrete reminder that the sacred trust given by our patients is real and enduring.

No matter how heart-wrenching, it’s good to have these reminders from time to time. Many of us in healthcare are so beaten down by the absolute enormity of what we are trying to do and how fast we are supposed to do it that we forget why we went into this business in the first place.

In many departments at my hospital, people seem to be increasingly pressured to check boxes, complete projects on time, and adhere to the almighty budget. This is particularly acute in the IT department of late.

Because physicians planned poorly for Meaningful Use and are now demanding that the hospital purchase their practices, we’re doing a massive fire drill to try to install them, train them, and help them attest before the end of the year. Our hospital has never been known to say no to a physician acquisition regardless of the circumstance. As long as you can be credentialed by payers, you’re in.

Our teams are being driven in a way they’ve never been driven before. Leadership keeps voicing how high the stakes are and how we must continue to deliver the impossible – again and again. Resources are being diverted away from the practices that have been moving towards actually using an EHR meaningfully (rather than achieving Meaningful Use.) For example, rather than building new reports for our long-adopted practices who want to tackle new quality challenges, the data analysts are spending their scarce time obsessively running MU reports for the latecomers.

We’re continually reminded how much money is at stake with MU. I don’t disagree that it’s millions of dollars for our health system, but really, it’s a small amount for the individual providers. Divide $44,000 by five years and we’re reminded that it’s $8,800 per year. (Yes, I know it’s an offset against future penalties, etc. and as a CMIO, I get it and don’t need the lecture.) But as a physician, it seems like too small a price for which to sell the heart and soul of medicine.

For the extra time that most of my physicians spend clicking boxes and delivering interventions that are largely irrelevant to good patient care, they could have seen two more patients a day. That’s a revenue boost, but what’s more important is that volume boost equates to almost five hundred patients per provider per year that could have been served in our community. These are patients who need care and still have long waits to receive it, even in a major metropolitan area.

Physicians are constantly distracted – by pseudo-quality initiatives, MU, and demands by marketing teams that they have an online presence and know how to use the media for promotion. We’re doing more paperwork than ever (even in the electronic world) and spending less time with patients. The essence of medicine is being lost.

We’re forgetting why we went into this business in the first place. For many of us, it was not to receive Most Wired awards, Top Hospital trophies, or write-ups in US News. It was to help people, cure disease, and reduce suffering.

I’d like to challenge those who are leading the initiatives and formulating the rules of this new game. For each new measure you add to Meaningful Use (and for the existing measures too), I’d like to see concrete evidence that jumping through the hoops you’re holding in front of us will actually help patients in a truly meaningful way.

When the FDA is considering a new drug, proof is demanded and studies are performed. When payers decide to cover a preventive service, they determine how many patients have to screened vs. treated in order to make it cost effective. However, when we upend the healthcare delivery system, our interventions are not held to the same standard.

Are you in favor of evidence-based Meaningful Use? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 6/4/12

Being an anonymous blogger, I never know when an idea is going to drop into my virtual lap. When I’m not in the healthcare IT trenches, I like to embrace certain summer pastimes – drinking mint juleps on the porch, gardening, and making the occasional trip to see some minor league baseball.

I was seated behind first base enjoying some Cracker Jack when the conversation turned to healthcare IT. A particularly tech-savvy friend of mine was talking about iPad apps. Knowing I’m a physician, he mentioned that his old college buddy recently showed him an electronic health record app that he’d been working on.

Turns out Joe College works for a major HIT vendor. My curiosity got the best of me. I asked my friend what he thought of the app. This was his response:

Well, he kept trying to show me a bunch of features that weren’t coded yet. It looked like something that was designed by an IT guy who may have talked to a doctor once and really didn’t have any idea how to do a good user interface.

Knowing the vendor in question, I’m not sure if I should be surprised or not. I didn’t have details on whether the app was for hospital or ambulatory scenarios so I don’t have a lot to go on, but it got me thinking about the role of physicians in software design.

Working for a major health system I’ve been exposed to many vendors. There is significant variation in whether they have physicians on staff, let alone physicians who participate in the design process. Some are very open about the docs on their teams and will connect clients with them for doc to doc conversations. I’ve found those valuable, especially when implementing new software and those “what were they thinking” questions arise from end users.

Others rarely mention whether they have physicians on staff. If you push them they may trot out one of a variety of archetypes:

• The physician who hasn’t practiced in decades but is great with software
• The physician who is a highly-trained informaticist but doesn’t understand office practice
• The physician who really knows what he or she is doing, but is far too busy to interact with clients.

After talking to a couple of my CMIO buddies, I think it’s time to have a little industry conversation about the role of physicians in design and usability testing.

Much like when Mr. H poses “state of the industry” questions to the leaders of the vendor space, I’m giving an opportunity for companies to speak up about how they use physicians and other clinical experts in design, implementation, and support. Here’s the hitch though – I’m not going to come begging for information.

This opportunity is for companies with staff that are loyal HIStalk readers. Let me know how your organization leverages licensed providers and at which stages of the game. I’ll feature the responses in an upcoming Curbside Consult. Priority placement will be given to companies with witty submissions. Extra credit will be awarded for photos of your physician team in action.

Got docs? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/28/12

Just when you thought it was safe to go back to the office, Big Pharma is at it again. I’ve never been a fan of direct-to-consumer advertising. I’d rather spend the few minutes I have with each patient in careful discussion of health promotion and disease prevention rather than discussing those “ask your doctor if Brand X is right for you” drug ads. My primary care patients learned over time that I’m a big fan of generics. If I recommend a drug, we’ll have a pro/con discussion of all the alternatives, not just the ones with great TV commercials.

Takeda Pharmaceuticals dropped this little number in my inbox – an app called Tummy Trends that allows patients to track their bowel symptoms, chart and graph them, and e-mail reports. The e-mail encourages me to let my patients know “that tracking symptoms can be convenient and discreet.”

I tried to get more information on the app, but found that the top five sites that my search engine served up were actually outlets for maternity clothing. Kudos to the marketing team for their excellent research of the name. Additionally, I’m not sure how many adults really refer to their digestive system as their tummy. I did finally track it down and ultimately downloaded it to my iPad to check it out.

I was disappointed. It wasn’t optimized for iPad, running in the tiny iPhone-shaped window instead. Data collection was minimal. I’d expect that if a pharmaceutical company was going to slap their name on it, they’d give it lots of bells and whistles.

I decided to see what other apps were out there for the same patient group  and found Bowel Mover Lite. It not only seemed to have more features, but even more important in my book, was pharma-free and the kicky logo was an added bonus. Really – don’t patronize patients with names like Tummy Trends (which is a little too close to the tummy time we recommend for infants anyway.) Bowel Mover displayed nicely on the iPad and also introduced me to Habits Pro and a couple of other apps. One was quite interesting – not appropriate for mentioning in mixed company, but check out Track & Share Apps, LLC and you might find it.

I haven’t had too many patients bring in smart phone diaries other than calorie trackers and exercise apps. When you’re in the primary care trenches, however, every day is a new adventure. I’ll keep you posted if I see anything sassy, humorous, or awesome. If you see one that fits any of those categories, e-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/21/12

Mr. H posted the results of a recent poll asking whether it’s OK to ask emergency department patients to pay before treating them for non-emergent problems. The vast majority of HIStalk readers responding thought it would be OK.

Since I’ve spent the better part of the last week working the ED, I have to say I agree. Normally I don’t work this many shifts, but the combined stresses of recent changes in our nursing ratios that resulted in some “blue flu” among the nursing staff seems to have inspired an unusual number of call-ins among the medical staff as well. (Either that, or my partners just want to get a jump on their summer vacations.)

Most of my shifts were on the lower acuity side of the ED, which suits me just fine. The full-time docs can handle all the gunshots, “fit for confinement” exams, strokes, heart attacks, and major trauma, thank you very much. I’m perfectly happy to handle fractures, asthma exacerbations, lacerations, and minor trauma. This week, however, we had a boom in patients who simply should not have been in the ED.

This was a bit of a bummer from an electronic documentation standpoint. Our recent upgrade brought us the ability to have condition-specific defaults, and I had spent a fair amount of time building out my personal templates for the conditions I typically see. I did not, however, spend any time building templates for problems that might be best handled at home with a wet paper towel and a nap. The highlight reel:

• A teenager with an insect bite. His mother wrote a note giving permission for a neighbor to bring him in. He noticed the bite in the morning before school when it wasn’t bothering him at all, but mom decided at 10 p.m. that she wanted to know what kind of insect it was that bit him. Unfortunately, I am not an entomologist.
• A high school senior with mild sunburn who wanted to know what she could put on it to make it go away before graduation (which was the next day.)
• An adult male with a 0.5 cm lump on his arm that had been there for six months. That prompted him to arrive at 1 a.m. “just to get checked out,” although he couldn’t say why he was coming in NOW.

I’m pretty sure that if someone in the waiting room would have told them it would be a minimum of a two and a half hour wait and a $200 charge, these three musketeers (and the dozens like them) would probably have chosen to go home. I wish we could have a seasoned registered nurse stationed in the waiting room, administering simple first aid and counseling patients to follow up with a primary physician or a walk-in clinic in a day or two rather than using scarce ED resources. While I was dealing with them, we had an elderly woman with a complex fracture of her upper arm, several patients with lacerations, and a chap with a knee the size of a grapefruit that needed my attention.

Unfortunately, fallout from the Emergency Medical Treatment and Active Labor Act (EMTALA) makes it difficult for us to employ creative strategies to reserve the ED for appropriate use. Becoming law in 1986 as part of the COBRA legislation, EMTALA seemed like a good idea at the time. Although EMTALA was intended to ensure that patients presenting with emergent conditions were not turned away for inability to pay or other discriminatory reasons, the unintended consequence is a generalized fear of saying “no” to anyone who walks in the door.

The Code specifically defines an “emergency medical condition.” More than half of my patients this week failed to meet that standard, yet they had full visits anyway. We had to document each visit in detail, including a full review of systems, counseling on advance directives, nutritional screening, and more. (We also had to arrange transportation home for the mom who brought her daughter by ambulance for a splinter, but that’s another story entirely.)

I wasn’t in practice prior to 1986 so I can’t say what it was like, but I can’t imagine it was as chaotic and soul-sucking as it is now. I was, however, in the trenches when E&M Coding appeared on the scene, and I experienced first-hand the ridiculous make-work that ensued.

Looking at the track record for federal meddling in health care, it’s hard for me to think that the changes occurring as a result of Meaningful Use will turn out well in the long run. I may have Certified EHR Technology and full command of the Meaningful Use program. I can cite all the measures verbatim even after a couple of glasses of wine. I have more timely access to old charts (which are now actually legible) and better drug interaction checking, but other than that, the benefits still seem elusive.

How do you think we’ll feel in 25 years when we look back at Meaningful Use? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/14/12

Over the last several months, there have been quite a few articles and studies about the growing phenomenon of mobile device distraction. Smart phones, tablets, and other devices have become ubiquitous. It’s almost unusual to see a group dining in a restaurant without devices littering the table. I don’t need to mention the danger of distraction while driving or otherwise being on the street and using a mobile device.

I wasn’t surprised then to see four Tweets in the last 24 hours that addressed the issue. There’s quite a buzz around psychologist Larry Rosen’s book iDisorder: Understanding Our Obsession with Technology and Overcoming Its Hold On Us. Some of his ideas are pretty common sense, such as the recommendation that families should have dinners where technology is not allowed at the table. I do agree with his point that technology might be making us dumber – the “Google effect” may make us less able to remember facts when we know that they are at our fingertips through search engines. His acronym for wireless mobile device (WMD) is accurate when you consider its other meaning: weapon of mass destruction.

Maybe having been required to be accessible 24×7 during my medical school and residency years jaded me, but until the last year or two, I had never been one of those people to compulsively carry my cell phone. Even now I don’t always answer it. Definitely not during a meal or a social event unless I’m on call or waiting for a specific return call.

The advent of the smart phone has made it easier to be in touch, though. I find texting or e-mailing to be less disruptive than taking a phone call as long as it’s self limited. However, when you open your e-mail to send a quick note to your staff or a colleague, it’s awfully tempting to troll through your account(s) to see what else is in there, and down the rabbit hole you go.

Like any other dependency, some have an easier time returning to real-time socialization than others. Some also have a hard time switching from texting-based communication to the traditional written word. This becomes apparent when I work with young people who can barely write grammatically correct sentences, but can text like crazy. In addition, despite having vast social networks, many are isolated when it comes to the skill of face-to-face communication.

An opinion piece in The Wall Street Journal proposes that, “We ought to group these machines with alcohol and adult movies.” I’m not sure I disagree. I’ve had to conduct interventions with parents who can’t seem to understand that their 11-year-old children shouldn’t be playing with an iPhone while I’m trying to take the child’s history and perform a physical exam.

Often, the phone belongs to the child, not the parents. That still baffles me given the cost of a data plan. I’ve had to explain more than once that when parents complain that children are spending too much time on the phone or with video games, it’s the parents’ job to put limits on those items.

What do you do, though, when the offenders are adults? It doesn’t seem like we have collectively developed the skills to police ourselves. I can’t imagine using a Bluetooth phone to make personal calls while performing surgery or surfing the Internet while administering anesthesia. We know it happens, however. I’ve had physicians complain that the EHR makes it to difficult to complete their documentation, one of them as she sat doing holiday shopping on her phone.

Do we need to put device behavior clauses in our medical staff bylaws along with rules about documentation deadlines and appropriate interpersonal behavior? Should facilities create WMD-Free Zones to allow us to decompress? Or do we just throw up our hands in defeat?

Have a suggestion on the wide-open field of WMD etiquette? E-mail me. I’ll try to read it in between surfing the net for animal-print crystal phone cases and signing charts.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/7/12

Have You Been Meaningfully Used?

I recently attended a continuing medical education seminar. On breaks, people normally stand around tables of stale baked goods and institutional coffee, complaining about the twin threats of Medicare and Medicaid. Sometimes we gripe about the venue (in this case, a hotel which had smooth jazz versions of “Like a Virgin” and “Personal Jesus” playing in the lobby – the horror, the horror.) This time, every conversation seemed to revolve around Meaningful Use.

I felt like I was back in medical school again, with everyone standing around the Dean’s office wanting to look at the posted exam scores in hopes of determining who was the smartest in the class. Instead of comparing microbiology vs. pathophysiology it was:

• Have you attested yet?
• When did you attest?
• How much money did you get?

Surprisingly some attendees were still in the process of transitioning from paper to EHR. Almost half of those that I chatted with still planned to attest this year in hopes of assuring their full MU payouts. At least two-thirds of those people were completely oblivious to what it actually takes to be successful when implementing an electronic health record.

Having been in the CMIO trenches for some time, I’m fully aware that the risk takers and early adopters are long gone. What we are left with are large numbers of physicians who are only going to EHR because (a) they want the MU money; (b) their health system or employer is forcing them to change; or (c) they’re afraid of future penalties.

In my experience, the early adopters really wanted to transform patient care. Their goals were to improve quality and patient outcomes and the EHR was a tool to that end. These users are now reaping rewards with quality recognition and have the ability to demand higher levels of reimbursement from third party payers.

Many of the users we now see implementing EHR are merely trying to meet the MU requirements. It’s the healthcare IT equivalent of sitting in class and only taking notes when the teacher specifically says something will be on the test.

Most disturbing were the physicians I spoke with that were acutely aware of the fact that other than a few things, they didn’t even have to use the EHR to meet Meaningful Use. Their staff members would do pretty much everything other than the CPOE requirement. While meeting the letter of the Rule, they certainly aren’t meeting the spirit or doing any great service to their patients.

Interestingly, I was not only an attendee at the conference, but also a speaker. My nametag, though, didn’t give that fact away, allowing me to gather lots of interesting anecdotes before speaking on Day Three of the conference. My topic was practice transformation through EHR adoption. It was great to see some of the looks on the faces of those who had previously admitted they didn’t care about anything other than achieving MU.

True meaningful use (the non-capitalized variety) involves transforming the practice of medicine to better serve our patients rather than doing the bare minimum. It’s not about a federal program or a software package. Until we reach that understanding, we just feel used and not in a particularly meaningful way.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/30/12

I wrote a couple of weeks ago about the pending EHR upgrade at one of the emergency departments I cover on a part-time basis. The witching hour for go-live has come and gone – or at least I think it has, or might have, but who really knows because I have received no communication whatsoever from the project leadership or from my department chair.

For those of you who may have missed my previous post, here’s the scenario. I moonlight in the emergency department at a hospital that is unaffiliated with my primary employer. They have been preparing to upgrade the ED information system for the better part of a year, with several previously scheduled upgrades being canceled at the last minute. I’ve been eagerly waiting upgrade of the system, which was less than optimal from a provider perspective. Since I’m just a contractor, I have no say in the design, implementation, or support of this product, so it’s a unique opportunity to see a system from the same perspective that my own physicians see the system I manage. I know I’m hyper-critical since I do this for a living, but some of the things that occurred were pretty unbelievable.

In the Pro column, the hospital provided plenty of notice on the training sessions. We were e-mailed approximately six weeks before and asked to schedule a slot. Opportunities were offered at two locations over a three-day period, with plenty of seats available to cover the number of providers in our department. The downside of that approach would be that if a physician was on vacation that week, he or she would not have a training opportunity. Advice for the future: split your sessions over two different calendar weeks to better accommodate vacations.

The first Con was readily apparent when I couldn’t find the training room and there was no signage – another easy fix for next time. After 15 minutes of wandering, I eventually made my way to an obscure IT office on the top floor of a physician office building. They had 20 computers set up. Since I was still early, I settled in and started checking e-mail. Apparently only some of them were actually usable for training, so when the instructor arrived (late), I was forced to move and go through the whole painful log-in cycle again.

Another Con (is this only two, or are we at three with having to move workstations?) was that the copy of the production database used to create the training database was so old that none of the users’ previous three passwords would work. Unfortunately, this led to the instructor having to use his personal log-in for all five of us, resulting in many fun adventures as we documented all over each other since we were on the same log-in.

A considerable Pro was that our instructor was clearly a grizzled vet of the IT wars. He handled all of the issues with a sense of humor, which although warped, was truly appreciated and made a difficult situation tolerable. He started his preamble with an apology; as we were the second training session of the day, he already knew that the deck was stacked against him. Our training sessions were scheduled to be four hours, and apparently the IT staff had asked our department secretary to send out a notice that the scope of the upgrade had changed dramatically and training would only be an hour long. Needless to say, none of the physicians received this message (Con) and apparently he got an earful from the 8 a.m. session. The preemptive apology definitely helped mitigate the ire of my group.

Upon making it through the log-in screen (now boldly decorated with the “Meaningful Use Certified!” enthusiasm of the vendor) the first change we noted was that our beloved grey inbox was now shaded a delightful salmon color. I’m not sure exactly why a vendor would want to do that, but salmon isn’t exactly a crowd pleaser, and I found it more distracting than the relatively vanilla grey tone we had previously.

In the Pro column, the IT staff had built test patients for each provider to train with. As a Con, however, none was built for me, “because you’re just part time – but don’t worry, since we’re only giving you part of what you need, I don’t mind if I only get part of your attention.” This instructor was really on his game – deflecting the negative vibes and making us laugh. He also gave us fair warning that the morning class identified some elements of the system that were less than stable. Maybe it was good that training only took one of the projected four hours, because that gave him time to call the mother ship to request that they stop tinkering with the system while training was in progress.

One of the major upgrades to the system was the addition of templated patient visits, a big Pro in my book because of the ease of documentation. No one wants a beautiful flowing narrative in the ED – they want what we call the bullet: “This is a 43-year-old Caucasian male with a gunshot wound.” We do not want to know that this is a 43-year-old male of Germano-Irish descent who was walking along Elm Street two blocks south of Chestnut, minding his own business on a bright and sunny day, when two guys game out of nowhere and he heard a “pop.” I found the templates extremely intuitive and the system very responsive. In hindsight, however, after writing my recent piece on ICD-10, maybe I will need to know what street he was on and what the atmospheric conditions were at the time of the injury, as well as whether he heard a “pop” or a “bang” etc. For now, however, I’ll leave those questions for the police report.

The other docs in my class didn’t like the templates much, but I think that’s largely due to the fact that they’re full-time docs who don’t have any other vendor experience for reference and who have been allowed to use voice recognition in lieu of the painful “visit builder” native to the application. (As part-timers, we are not allowed to use voice recognition due to licensing costs. Go figure.)

I was pleased to see that the patient education module had been completely overhauled (big Pro) and replaced with a third-party component that allowed creation of physician-specific macros as well as those available for sharing across the department.

Unfortunately, the biggest Con is that the much-hated prescribing system received no updates at all. When I mentioned this disappointment and how I loathe not being able to prescribe exactly what I want, one of the other docs in the class was happy to demonstrate some “undocumented functionality” in the system that allowed me to do exactly what I wanted despite the constraints. Although it’s not officially sanctioned (the instructor actually covered his ears and said “la-la-la” while we were doing this) I’m ecstatic and can’t wait to try it out.

One Pro/Con was the lack of training material given to us. Good because a lot of people don’t read it anyway (can you say Sanskrit?) and it kills fewer trees, but bad for those of us that might actually want to look at it. Apparently they didn’t print anything, because even the morning of class, they were debating the scope of the upgrade. Promising to e-mail it made sense (although I have yet to receive it.)

I mentioned a few weeks ago that I was concerned that the support staff wasn’t aware of the upgrade. Apparently this is because other than the salmon-colored inbox, all of the changes were on the provider side. Assuring us that the team would e-mail us with instructions on downtime and the final preparations for the upgrade, he sent us on our way. The instructions never arrived, but I’m putting that blame on the department secretary rather than holding it against the IT team.

Totaling the score, that’s six Pro and seven Con, a mixed bag by any standard. I hope the upgrade went well (if it went at all) but I really don’t know since there’s been no communication. I’m scheduled to work later this week, so I’ll find out then.

Have any outstanding upgrade tips to share with the HIStalk community? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/23/12

Even before our friends at the federal level decided to delay implementation of ICD-10, I had been reading quite a bit about the different strategies health systems are planning to employ in support of the transition. With the delay, most vendors are continuing full speed ahead so that they can be sure to be ready for an eventual implementation. Although some advocate waiting for ICD-11, many feel it’s a foregone conclusion that ICD-10 will happen.

Most articles I’ve read have been about preparing your practice, ensuring coders are trained, and ensuring software is updated. There hasn’t been much talk out there about how to actually train physicians (who will continue to ultimately be responsible for the diagnosis and coding as they have always been) on the new system. For those of you who not playing along at home, the change from ICD-9 to ICD-10 gives providers approximately 138,000 additional ways to miscode a diagnosis.

I don’t think many people realize that providers are going to have to change the way they interview patients in order to obtain all the information needed to accurately assign a code. A recent article in Medical Economics points out some specific examples:

• ICD-9 has a single code for a closed femur fracture. ICD-10 has 36 and it’s difficult to see how physicians or payers will really benefit from that level of granularity.
• Histories will have to include information which isn’t relevant to most physicians, such as the part of the home in which an accident occurred.
• When that information isn’t collected at the point of care, staff will either have to call patients to gather the details or risk lower reimbursements from perceived lower acuity when non-specific codes are used. Additionally, the article reminds us that in many practices there is high staff turnover, meaning that staff that are incurring training costs now may be working elsewhere in the future.

Some of the articles out there are oversimplified cheerleading. As much as I liked the article about why waiting is an option, another Medical Economics piece just made me aggravated. The nauseatingly titled “ICD-10: You can do it with these pointers”  offered such highly useful tips as these:

• Overall, the types of medicine that will be most affected by ICD-10 include cardiology, cardiothoracic surgery, emergency medicine, general internal medicine, neurology, obstetrics, oncology/hematology, orthopedics, psychiatry, and vascular surgery.
• Of the disease processes typically encountered by internists, the ones that are most affected under ICD-10 are cardiovascular disorders, cerebral infarctions, diabetes, gout, musculoskeletal conditions, neoplasms, respiratory disorders, and underdosing.

I don’t know about you, but those little “pointers” don’t make me think I can do anything but contemplate how long I have before I can actually retire. I think many of us are pinning our hopes on software and technology vendors – hoping that notes can be parsed and prompts constructed to ensure all necessary information is gathered during the patient encounter.

Often, however, the patient doesn’t even know the information required. For example, was the myocardial infarction inferolateral or basal-lateral? Did it involve ST segment elevation? In order to ensure coding accuracy, it seems like there will be much time spent in hunting old records lest we risk being “dinged” for poor coding.

Just to make things more interesting, I noted that the infographic provided in the “it’s OK to delay” article has an error in it:

My other handy-dandy coding reference at ICD10Data.com lists the codes a bit differently:

I’m sure it was easy for some non-medical proofreader to confuse “subsequent” with “sequelae,” but whenever coding is at play, the devil really IS in the details.

I want to invite each of you to share your favorite ICD-10 codes. I’ll run the funniest in upcoming posts. Until then, I leave you with a challenge:

Say I was at the Pike Place Fish Market and I was struck in the left shoulder by a mackerel. How would I code that? And would it make a difference whether it was a mackerel or a shark? What if the mackerel wasn’t flying through the air, but was being swung at the time? Does it really matter? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/16/12

I cover the emergency departments of different hospitals. One of my facilities (part of a large health system where, thankfully, I have no responsibility for any of the IT decisions) is about to upgrade its ED information system.

Working there has driven me to near madness. The medication prescribing system is atrocious. It not only contains “do not use” abbreviations, but also doesn’t allow you to prescribe any medications that are not pre-built in the hospital-centric medication database.

Being spoiled by other vendors that use high-quality third-party medication content, it’s definitely a challenge. There’s no ability to free text notes to the pharmacist and no e-prescribing either. Half the time I end up taking the computer-printed prescription form and handwriting comments on it to avoid pharmacy callbacks (most of the patients I see have no insurance and pharmacies are constantly calling to substitute things due to cost — I like to give the pharmacists flexibility to substitute when needed.)

Because I’m a part-timer, I rarely work with the same nursing staff repeatedly. While challenging, it’s rewarding because I’m guaranteed to learn something new on every shift.

Last night, Nurse Tina introduced me to what I can only categorize as forbidden fruit. The drawer under the counter where the physician’s PC sits contains more than just pencils and paper clips — there are (gasp) pads of prescription blanks! Yes, Virginia, there IS a Santa Claus and he just brought me something good. Better than dark chocolate.

I gleefully spent the rest of the shift hand writing prescriptions whenever I ran into an issue with the software, something I hadn’t done in years. Because of the limitations of the prescribing system, not only was hand writing the prescriptions faster, it was better for the patients. I could write exactly what I wanted rather than trying to hijack a poorly built “default” medication selection. I had to find a suitable notes field in the system so that my handwritten scripts were documented and I did sacrifice allergy and interaction checking, so it wasn’t a perfect solution.

The system is due for a much-needed upgrade, which has been postponed twice previously. I hope this time it actually occurs. I will attend training in a couple of weeks and I hope there are good things in store.

I’m a little concerned, however, because I learned from Tina that the non-physician staff haven’t received any notification of the upgrade, nor have they been scheduled for training. That should make things interesting.

Because I’m just a hired gun providing clinical coverage, no one gives a hoot about my IT opinion. That’s frustrating,  but refreshing. It allows me to see the systems as the rest of the physicians do. I’m just  someone just trying to do her job and care for patients. This gives me greater perspective on how my own systems should operate and whether our communication plans, training, and upgrade preparations are adequate.

I’ll know more in a couple of weeks about whether we’ll really have improvements. Hopefully provider-specific medication favorites are coming, or maybe even an actual comprehensive medication database. I’m crossing my fingers and will keep you posted.

E-mail Dr. Jayne.