Curbside Consult with Dr. Jayne 4/9/12

The hot news around the non-virtual water cooler this week has been the call by many physician professional organizations to reduce unnecessary medical tests and procedures. The move is aimed at lowering health care costs and improving decision making. The campaign, called “Choosing Wisely,” hopes to engage doctors and patients in a dialog around the procedures and tests.

In my experience, even the most educated patients are reluctant to go along with guidelines and evidence-based medicine, frequently demanding tests “just to make absolutely sure” that a problem doesn’t exist, or even worse, “because insurance will pay for it.”

I have had countless arguments with patients over all manner of tests and treatments. It’s difficult to help patients understand that medical testing isn’t entirely harmless. There is always the risk of a false-positive test that can result in further unneeded testing, stress, and potential harm. Radiation exposure is cumulative. Tests aren’t necessarily indicated just because a cardiology practice that owns a CT scanner is running radio ads that offer discounted cardiac risk scoring.

Many of the tests on the list are obviously questionable, yet patients consistently demand x-rays for low back pain. I have many colleagues who order colonoscopies every seven years for low-risk patients.

I’m sure many think this list will be helpful to stimulate discussion with patients, but I’ve tried the literature and data route before. Patients have accused me of trying to ration care when I’m simply following evidence-based guidelines.

Every patient has a story about something that “the doctors missed” and is afraid it will happen to them. There is also the subset of providers who don’t want to get caught on the wrong side of a lawsuit should something be missed.

A glance at my local newspaper today revealed four of five reader comments along the lines of, “The doctor didn’t want to do the test, but I demanded it and it saved me from a life-threatening situation.” I appreciate these individuals’ stories, but ordering every test on every patient every time is not only poor patient care, but a recipe for economic collapse.

The participating physician groups are partnering with Consumer Reports and AARP to get the word out, but I’m not sure it’s going to make a difference. As long as payers continue to cover some of these items (such as annual EKGs for low-risk patients without symptoms) it’s going to be an uphill battle.

Additionally, hospitals still often require some of these tests – such as a preoperative chest x-ray for all patients regardless of risk – making it difficult for physicians to just say no. The entire list of 45 procedures (each of the nine participating specialty groups identified five procedures that are overused) can be found online at Choosing Wisely.

From an EHR perspective, figuring out how to work clinical guidelines into real-world workflows and ensure truly usable clinical decision support is tricky enough when the guidelines are clear cut. When they’re not so clear (especially when you have multiple bodies recommending strategies which are contradictory, such as the mammography guidelines) it’s nearly impossible.

I’ve been asked by individual physicians to re-code clinical decision support during EHR go-lives because they don’t agree with the national standards. Indeed, we are in America, but as long as providers continue to have cowboy attitudes this will be a struggle. Similarly, the transition from “patients as patients” to “patients as consumers / customers” has also created difficulties. When physicians are graded on patient satisfaction scores, the decision to deny unneeded antibiotics or a requested test becomes more difficult.

I’m interested to hear how these recommendations have affected you. If you’re a physician or provider, are your patients hearing any buzz on this topic? And if you’re in IT or software support, are you receiving requests to modify clinical decision support to reflect constantly changing guidelines? Let me know what you think. E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/2/12

Last week the Supreme Court heard an historic number of oral arguments as it considered challenges to the Affordable Care Act. Unlike other portions of the federal government, those responsible for the transcripts move at the speed of light. Some of them can be fairly enjoyable – the Justices have well-developed senses of irony, sarcasm, and humor.

Monday was essentially the challenge to the individual mandate provision requiring insurance coverage. One of my favorite exchanges involves Chief Justice Roberts, who says:

The idea that Congress has acquiesced in what we have said only helps you if what we have said is fairly consistent. And you, yourself, point out in your brief that we’ve kind of gone back and forth on whether this is a jurisdictional provision or not. So, even if Congress acquiesced in it, I’m not sure what they acquiesced in.

Is everyone clear on that? It just goes to show how complex this issue is and how the eventual ruling will involve the splitting of more than a few hairs.

Another great example is Justice Alito speaking to Solicitor General Donald Verrilli Jr. saying,

General Verrilli, today you are arguing that the penalty is not a tax. Tomorrow you are going to be back and you will be arguing that the penalty is a tax.

The challenges have certainly put the government in as many different positions as an advanced yoga class.

My favorite quote of the session is from Robert Long, arguing his case to the court and stating,

Not all people who litigate about federal taxes are necessarily rational.

I wonder if he includes himself in that assessment?

The hearing continued Tuesday with some interesting discussion comparing people’s need to enter into the healthcare market with their need to enter into the market for police, fire, or other emergency services. Chief Justice Roberts:

Well, the same, it seems to me, would be true, say, for the market in emergency services: police, fire, ambulance, roadside assistance, whatever. You don’t know when you’re going to need it; you’re not sure that you will. But the same is true for healthcare. You don’t know if you’re going to need a heart transplant or if you ever will. So, there’s a market there. In some extent, we all participate in it. So, can the government require you to buy a cell phone because that would facilitate responding when you need emergency services? You can just dial 911 no matter where you are?

The Solicitor General argued that it was different and what followed was a great exchange with Justice Alito asking Verrilli if he thinks there is a market for burial services. Alito went on to ask:

All right. Suppose that you and I walked around downtown Washington at lunch hour and we found a couple of healthy young people and we stopped them and we said:  you know what you’re doing? You are financing your burial services right now, because eventually you’re going to die and somebody is going to have to pay for it and if you don’t have burial insurance and you haven’t saved money for it, you’re going to shift the cost to somebody else.

With arguments like that, how can you not love these guys and gals? It’s like being on rounds with the Meanest. Attending Physician. Ever. At one point, Justice Scalia compared the individual mandate to forcing people to buy broccoli.

As the day progressed, Justice Breyer discussed the ability of Congress to regulate interstate commerce and used this example:

And I look at the person who’s growing marijuana in her house, or I look at the farmer who is growing wheat for home consumption…

Where in the world did THAT come from and what does it have to do with anything? It gets better:

I say, hey, can’t Congress make people drive faster than 45 – 40 miles an hour on a road? Didn’t they make that man growing his own wheat go into the market and buy other wheat for his – for his cows? Didn’t they make Mrs. – if she married somebody who had marijuana in her basement, wouldn’t she have to go and get rid of it? Affirmative action?

I tried to decipher the meaning but couldn’t. I’m not sure what Breyer is growing in his basement, but I think I want some of it. He did return to coherence a few paragraphs later:

So what is argued here is there is a large group of – what about a person that we discover that there are – a disease is sweeping the United States, and 40 million people are susceptible, of whom 10 million will die; can’t the Federal Government say all 40 million get inoculation?

The transcript is full of aphorisms that would make Ben Franklin proud. Justice Kagan asked one speaker whether his argument was “cutting the baloney thin.”

Arguments continued Wednesday morning around severability, or the premise that if the individual mandate is unconstitutional, then the rest of the Act has to go as well. Justice Kagan asked whether Congress wanted half a loaf and whether half a loaf is better than no loaf. I think that’s somewhat debatable, depending on the loaf. If it’s Nutraloaf, I’d personally rather have no loaf at all.

At one point Justice Scalia also referenced “cruel and unusual punishment,” asking a petitioner what happened to the Eighth Amendment when it was suggested that the Justices might want to look at all 2,700 pages of the Act to determine “what the text and structure mean with respect to severability.”

The non-stop action continued later Wednesday afternoon with the discussion of Medicaid expansion. The first 20 pages were pretty dry, until it came to the point where Paul Clement, representing 26 states, was asked by Justice Scalia,

Mr. Clement, I didn’t take the time to figure this out, but maybe you did. Is there any chance that all 26 states opposing it have Republican governors, and all of the States supporting it have Democratic governors? Is that possible?

There was laughter in the court as Clement admitted the correlation.

I met up with some colleagues over the weekend and had the chance to hear different opinions on where the Court might land. The only consensus reached was that although none of us can predict which way it will go, we were unanimous in feeling that it will be a 5-4 decision. Regardless of the outcome, it will be interesting to see how Congress responds and how the Presidential candidates respond. The summer promises to be anything but dull.

Have a question about legal precedent, jurisprudence, or what you have to do to file an amicus curiae brief? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 3/26/12

I’ve been having a hard time sleeping lately. Maybe it’s the recent time change, or maybe there’s just too much going on at work. Maybe I’ve got spring fever or just a touch of unfulfilled wanderlust. I’ve enjoyed taking some long walks in the evenings and sitting out on the patio listening to mellow David Gray tunes as I deliberately wind down from the ever-lengthening days.

I suspect it’s the proverbial “too much going on” because I also developed a touch of writer’s block. A friend of mine works in the industry, so I asked him for inspiration with this question: as a person in the trenches, what kinds of things keep you up at night?

What he came up with was a question for me: will Meaningful Use really decrease the cost of healthcare and increase continuity of care, or is it just additional overhead where no one really knows how to administrate the benefit it could provide?

I’m going to take off my politically savvy “plays well with others” hat and put on my “doc in the trenches” hat for a bit here. The answer is I really don’t know. Many health systems have been practicing what Meaningful Use preaches for years prior to the incentive program. They’ve implemented patient portals, obtained unified data, and achieved transparency of the medical record. They conduct group visits, run non-traditional schedules, and encourage both patients and employees to use personal health records.

IT systems are in place which support evidence-based care and encourage disease prevention and health promotion. Providers are graded on the care they deliver and are presented with opportunities to intervene where care can be improved. Providers in these health systems are discouraged from ordering unnecessary tests and ineffective treatments through both payer and quality initiatives. In many organizations which are true integrated delivery systems, referrals are closed loop and carefully controlled as well.

Despite these efforts, many are not seeing overall costs come down. Patient insurance premiums definitely aren’t decreasing. We know that certain episodes of care can be made more cost effective and we can leverage technology to prevent many harms. We’ve all watched the recent debate over the Health Affairs article that showed that access to prior results didn’t decrease ordering of tests. We understand that test volume alone isn’t a reliable indicator of whether we’re successful. I have seen data on primary care practices whose ordering volume spiked after EHR implementation, but when you drill down, a large number of those tests were preventive. That seems to indicate that clinical decision support is working.

If you watch those practices over a few years or so, however, the ordering tapers off. It’s almost as if providers are playing “catch up” for the tests they missed while they were too busy addressing acute illnesses and complex chronically ill patients. If you look at labs that are ordered to diagnose illness or monitor chronic conditions, we didn’t see as many spikes. I wish hospitals and provider groups would have had the resources to do better prospective studies as they implemented, but unfortunately, most of us were focused on system build and implementation. It would be nice to look at it other than through the retrospectoscope.

I do think advances in healthcare IT have significant potential to increase continuity of care, but it is unclear whether MU is really a driver. Over the last decade, we’ve seen RHIOs fail despite significant clinical potential. I’ve seen the accessibility of information increase dramatically in both the ambulatory and acute spaces as well as between them. We have data at our fingertips instantly that would have taken hours or days to obtain previously.

We have the potential to avoid duplication of tests and therapies, with one caveat – caregivers have to be allowed the time to intelligently process the burgeoning amounts of information relevant to each patient and his or her care. Unfortunately, our payment system is still largely volume driven, often resulting in fewer and fewer minutes for each patient contact. Patients in the hospital are sicker and they’re going home sooner, making the task even more difficult.

Meaningful Use is certainly additional overhead. Of that there is no question. The cost to implement certified technology is significantly higher than the payments received. I hope anyone who actually believes differently is willing to share whatever psychotropic substance they’ve gotten a hold of.

Hospitals and providers are simply running to catch up and to make sure they avoid the payment penalties that are coming. Meaningful Use has derailed other initiatives as budgets have shifted to accommodate timelines which are faster than some groups were prepared to implement. I know that’s the point – to speed things along for laggards – but some groups and hospitals were simply proceeding at a more deliberate pace relative to their own goals and priorities.

I wonder how many people at ONC have visited a practice that has cut back on improvements to the physical plant, supplies, or clinical equipment due to the increasing IT budget? I know I’ve been to quite a few. I’ve seen state-of-the-art computers sitting on decaying countertops that can’t be properly sanitized. I’ve seen budgets for continuing education and clinical in-services eliminated in favor of application training and time spent in endless debate about the validity of various order sets.

I’ve seen much more, but it’s too depressing to put into words. The amount of money spent on MU consulting alone is absolutely staggering.

Physicians seem increasingly susceptible to burnout, and the cost of that unintended consequence can’t be readily quantified. This also applies to nursing staff, pharmacists, ancillary staff, and pretty much anyone who works in support of patient care. IT staff are also under increasing stress. We all know stress and burnout diminish productivity and put patients at risk.

Only time will tell whether Meaningful Use will be truly effective in changing the way we deliver healthcare and how much it costs. In the mean time, we’re all going to work longer and harder and get by with less in some respects. We’re going to do some amazing things, but not without a price. Fasten your seat belts, folks. It’s going to be a wild ride.

And for those of you who know your Disney history, remember this: Mr. Toad was only a C-ticket ride.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 3/19/12

I spent the better part of today taking a tree down. It might surprise some of you, but I do know my way around bow saws and chain saws as well as scalpels. Unlike the delightful specimen above, mine was extremely close to the house and required yearly maintenance. It also had some other unsavory features, and since today was a beautiful spring day with a light breeze and not too much sun, it was time to get it done.

It would have been easier if the tree were ugly or diseased, but unfortunately this particular tree was in full spring bloom. Most of the trees I’ve been involved with taking down were diseased, in wooded areas, or part of a service project where everyone understood why they needed to be removed. I’ve never had to do one right next to the house in full view of the neighbors and everyone else who passed by walking dogs or enjoying the spring weather.

Not surprisingly, people had things to say about the tree coming down, and I started to question my decision. To the casual observer, a beautiful tree was being removed. The casual observer, however, didn’t ever have to deal with the messy fruit that it dropped, staining the driveway before being tracked in to create a nasty gelatinous mess in the kitchen. He or she also wouldn’t have to deal with the birds that liked to congregate in the tree, eating the fruit and creating an additional level of mess that prevented anyone from ever parking in the driveway or walking on it during the better part of the year.

Passersby also wouldn’t know about the lovely herringbone brick walkway that was installed by the previous owner, and which the roots of the tree destroyed. They also wouldn’t realize the hazard that the now-uneven walkway caused to anyone who tried to visit in the winter – the destruction of the walkway made it impossible to clear snow or ice.

Initially the neighbors just thought this was a routine trimming, but after large limbs started coming, down it was obvious that this was more than that. I started feeling guilty. After all, it was outwardly a very good-looking tree. I had to remind myself that it was also a species that tends to split in high winds, and due to its size and proximity, if it split (as many trees of the same age in my area already have) it would likely come through the house. That certainly wasn’t anything I wanted.

As the work progressed (thanks to some strapping young men who offered to help) and I looked at all the blossoms littering the yard and the street, I choked back my guilt by remembering that had the tree remained, nearly every one of those would have turned into a piece of messy fruit. I also had to remind myself that the tree was in the way of a pending construction project on the house, which includes revising drainage to ensure that the foundation stays dry and the yard ceases to be a muddy pit.

Working on projects like this always makes me contemplative. This particular project went on for hours, giving me plenty of time to think about what I was doing as well as the parallels to my work life.

Dealing with this tree reminded me of dealing with a particularly difficult employee who ultimately had to leave the organization. From the outside, he appeared to be a solid worker. Gregarious and outgoing, co-workers found him likeable. His outgoing nature often proved to be an issue, however, when he couldn’t complete assignments due to excessive socialization. He needed frequent reminders to stay on task.

Unfortunately, early attempts to correct his behavior resulted in friction with other members of the leadership team who only saw the beautiful tree and discouraged his direct supervisor from formal corrective action. This worker frequently took credit for his colleagues’ work and directly reported these successes to those above his supervisor, putting the supervisor in an awkward spot. Maybe it’s all the time I spent studying human behavior, but aside from his direct supervisor, I felt like I was the only person seeing through his showy exterior.

As time progressed, our little tree dropped his proverbial fruit throughout the department, creating messes that others had to clean up. His roots grew into other departments, resulting in complicated entanglements with female staffers that created additional instability. We pruned and we pruned, but as much as we tried, he grew.

We began to carefully document every action taken because his twisted roots threatened to undermine his supervisor and his peers. Only when his continued presence threatened the future of several key projects could we muster the support to finally remove him.

I felt guilty throughout the process, but like today, had to remind myself of the current dysfunction as well as the potential for future damage and the ways in which he was impeding progress.

Once he was gone, I was pleasantly surprised. Other co-workers grew into the void and supported his replacement, like sheltering trees protecting a young sapling. The team regained its cohesiveness. Some members who had been in his shadow were finally recognized for their achievements.

Like dealing with my former employee, I know that taking down the tree was hard, but it was only the beginning. There’s plenty of work coming – branches to bundle, a stump to remove, French drain to install, and more. Once those things are stable, the new tree (non-fruiting of course) will arrive to be planted and nurtured, ultimately providing shade and beauty. The effort will be worth it and I’m looking forward to the future.

Have a question about arborists, making your own compost, or what’s the best way to store a face cord of wood? E-mail me.

E-mail Dr. Jayne.

Curbside Consult by Dr. Jayne 3/12/12

I’ve been wearing my faculty hat more than I’m used to lately. It’s a little sad but not surprising that increasing numbers of medical students are questioning their career choices. Although I historically precepted students in traditional medical rotations, I’ve more recently led electives in practice management and health informatics.

For those of you who aren’t in academic medicine, this week is “Match Week,” which is the time when the National Resident Matching Program (NRMP) spits out residency program offers to medical students who have spent the better part of the last year filling out applications, traveling to interviews, and generally trying to one-up each other on important clinical rotations.

The truth comes out on Friday the 16th at 1 pm ET. Across the country starting at noon, fourth-year medical students will participate in a variety of events (from formal ceremonies to all-out keggers) and receive a sealed envelope that tells them their fate.

Think of sorority / fraternity rush on steroids. These students have spent tens (if not hundreds) of thousands of dollars on tuition then several more to go through this process, where they rank residency programs and the programs in turn rank them. That hopefully results in a match that allows students to pursue their post-graduate training program of choice. Most of them will move to another city, then embark upon three to seven years of additional training (some moving again between the first and second year due to residencies that don’t have integrated internship programs) and ultimately be able to join the rest of us in the trenches.

For those students that don’t match, there used to be an aptly-named “scramble” process where lots of phone calls were conducted to try to find an open slot. This year there’s a new process called SOAP – the Supplemental Offer and Acceptance Program. Students who are eligible for SOAP received e-mails last Friday night and now will have to go through eight “offer rounds” starting on Wednesday. Hopefully the process ends with a match by Friday at 5 pm. Each round will have fewer offers available, so potential residents are encouraged to accept a first-round offer if it is satisfactory. The offers are essentially binding contracts.

The entire SOAP process hinges on brand new software that, hopefully for the students’ sake, has been well-tested. I know more about this than I probably should due to this year’s increased number of students showing up on my doorstep to discuss their options. Many of the students who have rotated with me are thinking about going the administrative or informatics routes with their careers. They tend to stay in touch since there aren’t a lot of mentors out there and other faculty members tend to try to shame those students to some degree about “wasting” their training.

A number of them have decided (against my better advice) to not even do an internship or residency. There’s a growing sentiment that it’s just not worth it and that medicine has gone into what one termed “the death spiral.” One recently said, “If I’m going to wind up not being able to control my life, at least if I go into administration or to the pharma industry, I’ll be well paid.” The downside of not doing an internship is that you can’t be fully licensed, but some industries don’t care, and schools of business and law definitely don’t mind.

Looking at this year’s graduating class, there are nearly a dozen headed to business school, law school, or straight into the workforce. The number of students choosing careers in primary care is low – family medicine is almost a curse word at my institution. We’ll have to see what Friday brings. Over the last two years, the number of students matching to family medicine programs nationwide was up, but if the nation looks anything like our current student body, we’re in trouble.

It’s also interesting to look at the demographics of specialty matching. Last year in family medicine, 94% of available slots were filled, but only 48% of those by US grads. As a physician staring down the barrel of an onslaught of aging baby boomers, seeing that US grads don’t find family medicine attractive is concerning. Not surprisingly, NRMP data shows that some specialties continue to be filled with high numbers of US grads: anesthesiology (80%), dermatology (93%), emergency medicine (79%), neurosurgery (90%), orthopedic surgery (93%), otolaryngology (95%), plastic surgery (93%), radiation oncology (94%), diagnostic radiology (80%), general surgery (81%), thoracic surgery (92%), vascular surgery (97%). I’ll let my very intelligent readers climb the ladder of inference and figure out where these specialties fall on the pay scale compared to primary care.

So here’s to The Match – one more third-party hoop for physicians to jump through in preparation for a career containing many more. But even better – here’s to a Friday afternoon that allows those of us who are not on call to start drinking at lunchtime, officially sanctioned, with the Dean picking up the tab.

Have a question about residency programs, the challenges of subinternship, or which pumps look sassiest with your interview suit? E-mail me.

E-mail Dr. Jayne.

Curbside Consult by Dr. Jayne 3/6/12

The League of Extraordinary Gentlewomen

A few days ago, I had lunch with some friends. Anyone walking by might have thought it was simply a table of ladies who lunch, but it was much more than that. The reason – three of the five women at the table were, at one time or another, my boss. I’ve written before about bad bosses and bosses who don’t know what to do with CMIOs but today I wanted to talk about bosses who do it right.

I haven’t always been a CMIO – I’ve been an EHR pilot (read: guinea pig) as well as the nebulously-named Physician Champion. I’ve been a Department Chief, faculty member, and front-line physician depending on which hospital I was rounding at on a given day. I’ve also been a teacher, worked retail, and changed my own oil. The point is that many of us come to the table with a variety of experiences. A good boss will recognize the way in which experiences shape employees and draw from those experiences. They will seek to get to know their employees and what they can bring to the table besides title and credentials alone.

All three of these extraordinary bosses saw different things in me. One saw a fairly-green but passionate physician who had a vision and passion for technology. Choosing me over other ‘safe’ choices to provide clinical oversight for my first major IT project could have been a career limiting move for her (and more than once I pushed it to the limit, I’m sure.) Still, she cared enough to get to know me as a person as well as in the capacity of being her employee. Understanding what made me tick and how I reacted to change helped her advise, counsel, and mentor me and increased my value to her team.

She taught me how to dig in when the going got tough as well as how to quickly assimilate huge quantities of data into something useful for physicians to evaluate. I learned about process and methodology, how to work with consultants, and how to recover after getting one’s posterior handed to one by other physicians. She taught me how to leverage those difficult physicians and involve them in the project so that it became “our” project rather than the loudest physician’s idea of what things should be.

With different management styles, different bosses can motivate people to achieve in different ways. My second boss was able to build on what her predecessor had done – taking it to the next level with lessons in political strategy and operational tactics which have been invaluable to me as a CMIO. Although I was familiar with physician to physician politics, when hospitals and payers are involved there is an entirely different level of gamesmanship needed. She taught me to be confident in what I knew to be right as well as how to stick up for it without being obstructive.

She also taught me how to survive when being forced to do things I absolutely didn’t want to do or didn’t believe in – skills which have been critical when dealing with certain kinds of disagreeable organizational strategies that we all face. She gave me space when I needed it and didn’t micromanage, letting me find my own groove and set my own goals.

The other extraordinary gentlewoman at the table was my peer before becoming my boss, which happens to many of us at least once in our careers. We learned together how to swim in the choppy waters of health IT and having shared that experience she knew how thoroughly I would be willing and able to back her up when things got tough. She understood the way physicians make decisions and our ability to take multiple pieces of complex information and quickly arrive at a conclusion that balances patient safety, quality, and efficiency. She understood that I saw the applications we supported as patients and that I was constantly assessing their new ‘aches and pains’ and integrating new discoveries and features to try to come up with the best diagnosis and treatment plan. With that background, she was able to help others in the IT department understand that although it may have seemed like I was just throwing out an answer quickly, it was well-reasoned and also helped me learn to better explain my thought process so that people weren’t spooked.

(So help me, though, if you ever show up as a trauma patient in my Emergency Department, don’t expect me to explain what I’m doing in gory detail just so you can feel better about how quickly I arrived at a conclusion. When you’ve got a chest wound, I guarantee you want the doc to be rapidly processing the situation at the same time she’s giving orders and executing a well-thought and rehearsed plan. There’s no consensus-building when someone’s bleeding out and my reflexes are going to take over and get things done. I do promise though that I’ll explain it to you when you regain consciousness.)

Besides leadership styles and management skills, I learned another key lesson from these extraordinary women – that work/life balance is essential to avoid burn out. We worked in extremely complex situations, short on budget and resources and long on demands and expectations. They taught me how to care for myself so that I could continue caring for others (and also so that I could continue working my tail off for them, which I happily did.)

I truly wish that each of you has, at some point in your careers, one boss that you would walk through fire for. When you do, you’ll understand what I mean – someone who so totally inspires confidence and motivates you, that you’d do anything they ask. And if you’re really lucky and the stars align – you might just be lucky enough to have three.

E-mail Dr. Jayne

Curbside Consult with Dr. Jayne 2/27/12

Over the past several years (and especially with Meaningful Use) there has been a fairly significant shift in the attitudes of ambulatory physicians who are making the leap to electronic health records. The hospital-based physicians (and ambulatory physicians who see patients in the hospital) are a different story. They’re a captive audience who has always been subject to hospital control and who has a long-standing history of adapting to things imposed by various Big Brother entities: the Joint Commission, the hospital’s formulary team, insurance and hospital case managers, etc.

Those physicians have done pretty well adapting to electronic documentation, computerized order entry, and the like while in the hospital. Hospitals have also tended to phase their implementations over the scope of years – deploying in a modular fashion with lab, nursing documentation, CPOE, and provider documentation all done as separate initiatives. Ambulatory docs who dislike the hospital’s conversion have been able to escape back to the relative safety of private practice and cling to their paper charts.

As ambulatory physicians transition to EHR, though, they tend to deploy more rapidly – wanting to get rid of all the paper immediately, but also with a strong drive to keep the revenue stream steady. When I started deploying EHRs some time ago, we worked with early adopters who believed in the promise of electronic recordkeeping and were more willing to staff up, reduce patient load, or work longer hours to realize their goals. These physicians are now mature users who are leveraging their EHRs to achieve advanced Patient Centered Medical Home designations, increase fee schedules through demonstrable quality, and improve patient satisfaction.

On the other hand, there are now thousands of physicians who previously found the idea of the EHR distasteful and feel forced to make the transition. Whether by peer pressure, payer requirements, or the threat of government-related penalties, they’re now implementing and with a significantly different strategy than may be prudent.

More often, I hear of physicians that want to implement a system fast, cheap, and easy. The rest of us who have done this for a while know that it’s very difficult (if not impossible) to do all three. Often these late adopters refuse to follow vendor advice, consultant advice, or frankly anyone’s advice. Convincing them to cut schedules or hire staff is a challenge. Ultimately, it’s the patients who suffer.

As the healthcare market consolidates, hospitals and health systems are looking to “align” (one of my least-favorite buzzwords) with community physicians to ensure profitable referral, ancillary, surgical, and inpatient revenue streams. Many are offering subsidies and other incentives to bring these providers onto EHR systems.

Often these practices don’t actually want to align, but are feeling cornered and desperate. Some have previously turned down acquisition offers from the same hospital and see taking a subsidized EHR as a way to be somewhat protected from burdensome federal requirements while maintaining at least some degree of autonomy. Others simply can’t afford an EHR without the subsidy. A last group is providers who’d like to be acquired but for various reasons aren’t suitable candidates, but hope that alignment (and sending a steady volume of referrals which of course cannot be spoken about) will result in being ultimately asked to the dance.

These physicians often deploy on an existing system-wide EHR. Since they’re late to the game, though, they haven’t been stakeholders in any of the decision-making that’s already occurred and often have less buy-in to the idea of group goals than those users who are actually part of the group.

Another angle is that even though subsidized, these physicians are paying customers with different expectations than employed physicians and different ideas about governance. Of course, this would have been true even if these subsidized physicians were early adopters, but the differences are magnified by them being late in the EHR game and feeling pressured to demonstrate Meaningful Use as quickly as possible.

I still go out on implementations and perform physician training on a regular basis. Until recently, most of the physicians I have worked with have treated me as a respected colleague who could assist them through the difficult transition. Some have even looked at me as some kind of EHR shaman, able to smooth their journey to the other side with mystical wisdom. Of course, there have always been a few docs who were borderline (or overtly) hostile, but they were few and far between and usually we could leverage their partners or peers to moderate their behaviors.

Lately I’ve run into more and more angry physicians who are completely resistant to the idea of the EHR transition even though they’ve agreed to go paperless. Some are passive-aggressive, but others are openly abusive. This manifests in a variety of ways – disruptive behavior, inappropriate comments during training (think middle school students with a substitute teacher), or refusing to be trained at all. I find the latter group the most frustrating because then they can’t figure out why the system is so hard to use and scream the loudest about lack of support.

Looking at the data on how many physicians are actually using EHRs in practice (let alone being robust users) we’re just approaching the midpoint. If what I’m seeing in the field is any indication, it’s only going to get tougher as the last-ditch adopters come through with increasingly unrealistic expectations and correspondingly difficult implementations.

I feel bad for the vendors and for the teams who have to support these folks (mine included.) I feel bad for the physicians who don’t want to transition to EHR and the staff members that have to work with them every day. But most of all, I feel bad for the patients who entrust them with their care. Regardless of what they think about the EHR, the IT team, or the government, I hope the angry docs remember that after all, it IS all about the patient.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 2/13/12

Care and Feeding of the CMIO

I frequently receive calls, e-mails, and LinkedIn messages from recruiters looking to fill CMIO positions. This might be a good thing – a sign that hospitals and health systems are figuring out that they really do need a CMIO after all and are looking to fill newly-created positions. A wise man once told me that it’s a good idea to spend 10% of your time looking for your next job, so I do read or listen to everything that comes my way. Who knows? Someone could be offering a CMIO position in a tropical location with excellent benefits and an assistant to deliver a slushy adult beverage every day at 5pm.

Unfortunately judging from many of the position postings I see, not all of them are new positions. In fact, some of them have been vacant for a long time and the postings have remained unchanged despite being unfilled. Some employers are just not understanding what CMIOs are looking for as far as scope of work, compensation, and job satisfaction. Let me give you a few examples.

Ability to continue practicing medicine. This is important for a variety of reasons. Credibility is often linked to actually using the systems that we’re advocating for our colleagues. Being an actual user of the system is important in understanding the reality and magnitude of issues raised by physicians. I’ve been able to shoot down the “it takes 17 clicks to do this” rhetoric spouted by some of my colleagues because I’m a user – and I know for a fact it’s a gross exaggeration or an example of a provider not following the best practice workflow.

Additionally, requiring a current active medical license of applicants can also screen out physicians with drug problems, failure to pay child support, failure to pay taxes, criminal records, and other undesirable employee attributes. I recommend that potential employers offer this as an option rather than a requirement, though. Keep in mind there are a lot of good candidates out there who don’t have licenses – many never thought they’d practice again and let their licenses lapse – so don’t use it as an absolute yes/no test. On the other hand, watch out for resumes that show people were in practice until recently and or have unexplained gaps in their work histories.

Travel and after-hours commitments, meetings, etc. One recent job description I saw stated that the job involved 50-75% travel – mostly regional, but some national. Considering that most employers are looking for people that have not only a medical degree but also either an advanced degree (MBA, MHA, etc.) or an informatics certificate, plus three to five years clinical experience and three to five years CMIO or medical director experience, this could be a problem. You’re talking about a potential applicant pool that will be in their late 30s to mid-40s age-wise at a minimum. These are going to generally be people who have families, often with small children, and your position may not be very attractive to them.

Continuing education and meetings. This should be part of the offer. It’s extremely helpful to be able to have not only the time (either on the clock or as dedicated continuing education time) but the budgetary resources to travel to a couple of meetings a year. Although we’re all increasingly good communicators in the virtual world, there is still value in face-to-face interaction with colleagues and peers, especially if your organization is in a town where there are only a handful of CMIO types. An offer I recently considered had not only less vacation than my current package, but I was explicitly told that as an IT employee (rather than a physician employee) I was not entitled to continuing education days or funding because “only the physicians get that.” I decided right away that they didn’t “get” what a CMIO was all about, and that was the end of my looking there.

Administrative support. With everything your CMIO is going to be tackling along the lines of Accountable Care, Meaningful Use, and the acronym soup that is our lives, he or she is going to need some help. Even if it’s just a shared administrative assistant, it can be a huge benefit to not have to spend time each day juggling calendars and handling daily office “stuff.” At a minimum, I’d expect some of the same things I’d expect from a good practice manager – opening / sorting / prioritizing mail and phone messages; ensuring regulatory compliance (completing license renewals and credentialing if those are required for practice); coordinating support resources, and handling other ad hoc requests. I would never consider a position without some kind of administrative support. The ability to tackle spreadsheets, flow chart software, project management software, and the ubiquitous slide shows is almost mandatory as well.

Benefits and salary. If you’re committed to finding an experienced CMIO who can hit the ground running, you’d better be willing to pay for it. Someone with ten years’ experience is not going to settle for an entry-level physician wage. The same group I mentioned above was offering a salary that was barely commensurate with the guaranteed salary they were paying new physician grads who were joining practices. When asked for the rationale, this was the answer: the CMIO doesn’t see as many patients or generate as much revenue. Again another indicator of an organization who doesn’t “get” the CMIO role. We may not be seeing 95% of the MGMA statistics for patient volume, but what we do can allow your physicians to reach that level in a much more efficient fashion as well as to assist in increasing the quality of care provided. Government and payer requirements are increasingly complex, and if you expect your CMIO to be able to bob and weave along with the myriad of changes, you better be willing to pay for it.

Culture and autonomy. CMIOs may report to a variety of people – CIO, CEO, or someone else entirely. Some organizations have complicated dual-reporting structures. Yet others have a clear chain of command but a parallel network of “informal” governance that makes it difficult to get things done. The best way to alienate a new (or potential) CMIO is for them to feel they’re in a place without clear direction or support for their initiatives. Making them obtain approval for every little thing is another good way to disenfranchise your CMIO. For those organizations that refuse to use the CMIO title, making your director of medical informatics (or whatever you want to call it) feel like a second-class member of the leadership team because they don’t have the title is another good way to encourage your CMIO to leave.

I worked for a group like that for a while. It was unpleasant, and each day I felt like I had just played 20 rounds of Whac-A-Mole. Because there was no real organizational culture, there was little room for strategy and great need for firefighting skills. Everything was a crisis that had to be dealt with and the leadership was constantly in transition. It seemed like I had five different bosses at any given time and everything was a priority. Initially I thought it was just me trying to adjust (I was a Padawan Learner then rather than the Jedi I am today) but it turned out it was a vacuum in leadership and culture.

If you have a handle on these things, you’ll probably do pretty well trying to hire your first CMIO. If you’re an organization where that role is well established, it might be worth taking a little time to see how your CMIO thinks you measure up in these areas. The CMIO is still a relatively new addition to the corporate team and it’s certainly OK for the position to change and evolve over time.

I’m pretty happy in my current role. But if you do happen to be located in a tropical or otherwise fabulous place and can provide the aforementioned fuzzy drinks, e-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 2/6/12

The past week has been crazy, and unfortunately the crazy spilled into the weekend as well. I had visions of the perfect thought-provoking topic for this week’s Curbside Consult, but every time I tried to flesh something out, it escaped me. Instead, I found myself musing on what I planned to do at HIMSS and which vendors I wanted to be sure to check out. Mr. H and Inga are hard at work on their “must see” vendor list and I’m working on my personal CMIO hit list.

For the CMIO (or anyone involved in evaluating new products or making purchasing decisions) it can be a great way to sort the proverbial wheat from the chaff. Many products look great in brochures or on the Internet but pale when you see them in person. Last year one of my “hot items” (sad that I think this is hot, isn’t it?) was wall-mount swing-arm brackets for monitors. The true test of quality and sturdiness is being able to check them out in person rather than trust a marketing slick.

You may ask, why does a CMIO care about brackets, and should she? The answer is yes. If I have to use it every day, I want to make sure it’s going to work for me and for the hundreds of physicians I represent. That’s not to say that the CMIO should be out personally investigating everything that needs to be purchased. Generally I prefer that the engineering and purchasing folks work their magic first, culling the herd down to their top choices, then allow a small group of providers to make the final call.

This year I have a laundry list of things to look at. Some are a bit gadgety (washable keyboards, COWs), others are more esoteric. I want to see how vendors are progressing with natural language processing and where they stand with clinical decision support. Are they going home-grown, or incorporating third-party solutions? How are the attendees responding to them? Who has incorporated Medicomp’s Quippe product that blew our minds at HIMSS11?

Like last year, I hope to have some time to cruise the exhibit hall with Inga, but I will also have some time to peruse the booths with a few other CMIOs and share their opinions and thoughts. One of my friends is a first-time attendee, so watching his expression as he sees some of the people out there will be interesting. A note to ChipSoft: I see you’re exhibiting again. If you’re giving away the clog slippers this year, please stash some for Inga and me because we’ll be looking for them and you ran out last year.

The marketing materials from exhibitors are arriving much more slowly than I remember from last year. So far, my favorite marketing piece is from CDW Healthcare, with their “What happens at HIMSS definitely won’t stay at HIMSS” tagline and accompanying poker chip. Although I like the idea of taking home things I learn, based on the potential for Inga and Jayne to have a good time, I’m sure some things will be staying well within the 89109 zip code.

Speaking of marketing, I received quite a response to my comment on why the soles of Christian Louboutin shoes are red. One reader shared his shame:

I must know. During a Battle of the Sexes trivia contest, I and my fellow male panel of knowledge brokers failed to identify the maker of the famed red sole shoe. It was the tipping point in a tight contest that found us falling to the gals. I now must know why the soles are red…

A certain savvy reader provides the answer:

Just a quick comment to say I thoroughly enjoy your commitment to giving your readers a well-balanced education. Not just what’s up in healthcare, but why CL shoes have their distinctive red sole! A mundane process turned into a brilliant marketing differentiator. I’ll be looking out for them!

In short, it’s all about branding. Louboutin trademarked the red-soled look in 2008, fighting to protect the distinctive look when Yves Saint Laurent came out with a red sole in 2011. YSL claimed in court documents that red soles existed long before Louboutin trademarked them:

Red outsoles are a commonly used ornamental design feature in footwear, dating as far back as the red shoes worn by King Louis XIV in the 1600s and the ruby red shoes that carried Dorothy home in The Wizard of Oz.

There’s your fashion moment of the day, and hopefully some of you can leverage this newfound knowledge to win the hearts of your lady-friends who might have a thing for shoes, not to mention to triumph in the next battle of the sexes trivia night.

Have a favorite HIMSS (or other show-related marketing piece) to share? Does it belong in the Hall of Fame or Hall of Shame? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 1/30/12

Don’t Take Me Out of Context

Depending on the size of the communities they live in, CMIOs can sometimes feel isolated. Some may work in cities with multiple hospitals and health systems and have easy access to peers (and getting together over drinks is certainly fun!) but many work in towns with only one hospital. For the latter, finding and collaborating with peers can be a challenge.

I belong to a virtual community of CMIOs that contains a mix of big-city and small-town CMIOs. There are a couple of former CMIOs and a couple of young pups just starting out in informatics thrown into the mix as well. It’s been a great resource for idea sharing over the last several years and has helped me preserve my sanity on numerous occasions.

We recently got into a discussion about single sign-on options. Even those hospitals with single-database systems often have legacy systems with which clinicians need to interact. They also need to access a variety of homegrown and interfaced applications in order to care for patients and manage clinical data. Many hospitals have tackled this with single sign-on, proximity badges, or other strategies to reduce the need for clinicians to manage multiple passwords.

I’ve used several of these solutions and they are undoubtedly cool. However, they lack the ability for clinicians to rapidly access a single patient across multiple systems. Providers end up searching for the patient in multiple applications while they try to mentally create a unified view of the patient. This is less than ideal. One of the young pups in the group mentioned that he was looking at context-sharing solutions in an effort to remediate this problem. Luckily we have a few CCOW aficionados in our group. For best-of-breed shops, this can be essential to efficient access by clinicians.

For those of you who don’t know where I’m going with this, let me introduce you to CCOW. CCOW stands for Clinical Context Object Workgroup, which is an HL7 standard that allows clinical applications to share information. Through this standard, applications can participate in both user context sharing and patient context sharing.

From a practical standpoint, this means that when the clinician accesses a patient chart, all other applications that the provider is accessing synchronize to that patient. When user context is also included, it may also facilitate reduced sign-on into applications which are subsequently accessed. CCOW can go deeper than just user and patient context – encounter context can also be included.

CCOW (thanks to Health Level Seven, Inc. for the graphic) is often misunderstood by clinical and IT people alike. Although many vendors create their applications to be CCOW compliant, this does not mean that just installing two of them will “automagically” link them together. Context management is required. When the systems lack a shared master patient index or a common patient identifier, an intermediary mapping agent may also be necessary. Dedicated context management software may also need to be installed locally or on servers to help synchronize client-server and Web-based applications.

CCOW also doesn’t magically move data from one application to another. It simply allows users to access information on a single patient across disparate applications with a minimum of fuss and bother. Depending on the setup of the environment, CCOW may not work the same for users accessing from home or from non-network devices.

The use of CCOW also creates additional testing requirements during application upgrades in order to ensure that functionality remains unchanged. I know of at least one major vendor whose CCOW functionality has been negatively impacted by an upgrade, causing much consternation to the numerous hospitals live on its product.

There are multiple context managers out there, including Microsoft’s Vergence product (formerly of Sentillion) and Carefx Fusionfx. The fate of the Vergence solution is one reason that the recent Microsoft / GE Healthcare joint venture (first reported by Mr. HIStalk back in December) makes a lot of people nervous. Customers were already twitchy after Microsoft acquired Vergence from Sentillion in 2009, with reports of a decline in customer service and support.

Quite a few significant players in the hospital industry are customers, so hopefully that will be incentive enough for the as-yet-unnamed entity to resist making a mess of it. (Any idea on that name? I’ve been keeping my eye out, but haven’t seen anything, and there’s nothing on the Microsoft Health Web page yet, either.)

Most of the big vendors are CCOW compliant, but there are still some who don’t understand the value proposition to clients. Far from a gimmick or a “nice to have” feature, for organizations such as Mayo Clinic, Johns Hopkins, and many more, it’s essential. Once again, I was grateful to my CMIO coffee klatsch for a good discussion and plenty of humorous anecdotes. I’m looking forward to catching up with y’all at HIMSS12 in just a few short weeks!

Have a question about virtual networking, best-of-breed systems, or what the new Microsoft/GE entity should be called? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 1/23/12

I was inspired by Ed Marx’s post last month, Transformation Through the Written Word. He talks about doing book studies with his direct reports, which then expanded throughout the workplace. The thing that most fascinated me about Ed’s piece was his book list. Having been the victim of a boss who tortured his team with 17 Irrefutable Laws of Teamwork, I was surprised (and quite pleased) to find books on his list which didn’t scream “teamwork!” or “leadership!” or “business!”

I’m a voracious reader, although lately I’ve been reading some fairly insubstantial fluff in an attempt to reduce stress and achieve relaxation. One of my best friends keeps recommending things like The Mathematics of Life or The Omega Theory,  but I just can’t seem to get into the mode for deep thinking.

I liked the fact that Ed’s list is eclectic – it includes James and the Giant Peach and Disney psychology along with the classic management and leadership-themed works. One of my personal favorites is The Checklist Manifesto: How to Get Things Right  by Atul Gawande. This book should be required reading for everyone who does anything which remotely impacts patients or other living things. I’ve liked Atul Gawande since reading his first book, Complications: A Surgeon’s Notes on an Imperfect Science, years ago. It helped to make sense of the things I encountered during training and in understanding the psychological complexity of events physicians are exposed to.

Speaking of psychological complexity, I’m already tired of the run-up to the November elections. One of the hot topics is healthcare reform. I’m not convinced that any of the candidates is qualified to actually speak to the issues. The general public gets pulled into the rhetoric as well. I end up discussing healthcare politics with a patient at least a couple of times a day. I recently ran across a book that should be required reading for anyone who thinks they are educated regarding the delivery of healthcare in the United States.

I don’t want to turn into Oprah, but I’m throwing it out there as the first “Dr. Jayne’s Book Club Challenge.” Some talking points from my friend Doug Farrago (of Placebo Journal fame) really sum it up:

• Our society has warped our perception of true risk. We are taught to fear vaccinations, mold, shark attacks, airplanes, and breast implants when we really should worry about smoking, drug abuse, obesity, cars, and lack of basic hygiene.
• Somehow we have developed an expectation that our health should always be perfect.  We demand unnecessary diagnostic testing, antibiotics for our viruses, and narcotics for bruises and sprains. And due to time constraints on physicians, fear of lawsuits and the pressure to keep patients satisfied, we usually get them.
• The bottom line is that most conditions are self-limited. “Our best medicines are Tincture of Time and Elixir of Neglect.”
• There is tremendous financial pressure on physicians to keep patients happy. But unlike business, in medicine the customer isn’t always right. Sometimes a doctor needs to show tough love and deny patients the quick fix. A good physician needs to have the guts to stand up to people and tell them that their babies gets ear infections because they smoke cigarettes. That it’s time to admit they are alcoholics. That they need to suck it up and deal with discomfort because narcotics will just make everything worse. That what’s really wrong with them is that they are just too damned fat.  Unfortunately, this type of advice rarely leads to high patient satisfaction scores.

It’s available now from Amazon, although not yet in Kindle format, which I know will make some of you sad. If you’ve read it, let me know what you think. And if you know anyone in politics, feel free to leave copies on their desks.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 1/16/12

Jayne Gets Her Tweet On

During a recent e-mail exchange, a friend of mine repeatedly chastised me for not being on Twitter. He failed to see why someone who lives in the land of blogging and social media wouldn’t want to Tweet with the rest of the world. To be honest, I’ve been more than a little scared to take the plunge. Knowing all too well what an outrageous time suck Facebook can be, I didn’t want to get into something else that had the potential to further unmask certain addictive personality traits.

Nevertheless, I took the plunge. Signing up was deceptively easy, although I’m having a hard time deciding who to follow. I don’t want to overdo it with too much information. So far, I’m following HIStalk (of course), my BFF Inga, and my very public secret crush Farzad Mostashari (and his dashing bow tie.) You can follow my shame spiral @JayneHIStalkMD .

While I’m feeling social, I decided to share some reader correspondence. It goes back a bit, as you can imagine my inbox usually looks something like the hallways of a New Orleans emergency department during Mardi Gras (which incidentally is just a month away for those of you who plan to get your party on).

From Miami, My Amy: “I was at a physician office this week and they couldn’t get the right patient into the right room. They took me back twice and reseated me in the reception and did the same thing to another person. Made me wonder whose medical record they were viewing. I find I am becoming a “difficult” patient, bristling with all the paperwork to fill out time and time again… with the same provider.” I agree, this sounds pretty annoying and it’s also a significant patient safety issue. I do hope your physician apologized though. I that was happening in my office,I would expect my staff to make me aware so that I could say something to patients.

From Bama Bubba: “Your Curbside Consult today really charged up my growing OCD. Public restrooms never have commode lids, plus they often flush with a great torrent of surging water, not the home-based gentle swirl. This flushing surely raises huge clouds of nasty water droplets perfect for deep lung deposition. I had a remembrance of the huge toilet complex at McCormick Place in Chicago and literally dozens of commodes in narrowly separated stalls, used by folks from all over the world, being flushed at the same time. Whoa! Talk about a toxic cloud of international viruses. Excuse me, I have to go wash my hands again.”

From HealthNut: “Re: shift work food options. I worked 11-7 for a stretch and our food options consisted of coffee, colas, cigarettes, and vending machine staples of sandwiches with greenish mystery meat/cheese, lukewarm canned chili or Beanee Weenee, peanut butter crackers, candy bars, and gum. The only thing that kept us from morbid obesity was bring broke all the time because we were students.” Yeah, that and the fact that we had to run arterial blood gas samples to the lab in styrofoam cups of ice chips and run to radiology to look at actual x-ray films all night long. At my hospital, our vending machines were just updated with a new item: White Castles.

From Golfing Great: “Regarding your recent post on technology as the new scapegoat. It’s not only the users who operate the systems, but also the folks who create and maintain the systems, the training they receive, their proficiency, and their ability to anticipate — or at least understand — the needs of those users (which I try to do by subscribing to HIStalk, so thank you very much!) When problems occur, there is usually more than enough blame to go around. It’s a shame the time spent deflecting isn’t devoted to planning, training, and coordination instead. It is important to keep in mind that systems are comprised of technology, people, and processes, all of which must function properly for the system to succeed. I’m not sure that any system will ever be able to address the intentional ignorance demonstrated by people in some of the scenarios you quoted, certainly technology alone cannot. I couldn’t agree more that culture is key, particularly when, even in spite of best efforts, systems are inadequate.” Thanks for that feedback. If I could convince organizations of the need to do one thing prior to and during implementation of any health IT system, it would be this: change management.

From Mr. Clean: “What is the evidence base on best way to sanitize tablets and (especially) keyboards? Inquiring minds want to know!” There’s not a ton of data on this. Personally, I use the same wipes that we use in the emergency department, which are a healthcare-grade sanitizing wipe for hard surfaces. Low-level cleaning requires keeping the surface wet for at least thirty seconds; higher-level disinfection requires keeping the surface wet for at least three minutes, which is a little harder to do with a keyboard.

Just a few days ago, the FDA cleared a self-sanitizing hospital keyboard with the bargain price of $900. The solution uses UV light to eliminate bacteria. Another reader suggested the WetKeys Washable Keyboards, which actually look pretty cool and have much more accessible pricing. It would definitely be easier to keep those wet for three minutes than a traditional keyboard. I really like the looks of their washable flexible keyboard. Too bad Santa has already come and gone — he could have rolled one up and left it in my stocking.

Have questions about ICD-10, the most common injuries seen during Mardi Gras, or whether you should order your White Castles with double pickles? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 1/9/12

The New Year is ringing in slowly from a news perspective. Maybe everyone’s just a little saggy from the holidays. I did manage to find some thought-provoking tidbits for the week.

Almost 40,000 new laws have recently gone into effect, now that 2012 is here. The biggest changes involve immigration, civil rights, budget woes, abortion, and other hot-button issues. Some less-reported but no less interesting legislation:

• Georgia will require those who drive golf carts on the road to have brakes, back-up lights, and a horn.
• Illinois allows motorcyclists to run red lights if they don’t turn green (the lights, not the motorcyclists) in a reasonable amount of time.
• Nevada is requiring fire performers and their apprentices to register with the state fire marshal.
• Utah nixes happy hour.

Congressman Edward Markey has asked HHS Secretary Kathleen Sibelius to tackle the issue of alarm fatigue. Specifically, he requests that the Institute of Medicine look at the issue and recommend solutions.

The New York Times reports on a new Medicare study that claims hospital workers only recognize and report medical errors and accidents one out of seven times. Daniel R. Levinson, inspector general of the Department of Health and Human Services, also notes the following:

• More than 130,000 Medicare beneficiaries experienced at least one adverse event in a hospital during a one-month timeframe.
• Although hospitals have systems to report adverse events, staff failed to report most of the harmful incidents.
• Hospital administrators are aware of underreporting by staff.
• Hospitals fail to connect adverse events with systemic quality concerns, resulting in few changes to policies and procedures.

I’m trying something new this year. My goal is to complete all of my required Continuing Medical Education and Maintenance of Certification activities at the beginning of the year rather than waiting until December is halfway out the door. I’ve been doing pretty well so far, plowing through piles of journals and article links that people have sent.

The Journal of Hospital Infection publishes a study on the hazards of lidless toilets, especially in spreading pathogenic bacteria like Clostridium difficile, one of the nastiest hospital-acquired bugs. In my hospital, the only commodes with lids are those little space-shuttle style ones found in the ICU patient rooms. Now that I think of it, you don’t see too many staffers wearing full protective equipment when helping patients in that way. Something to think about. Kind of makes my kvetching about dirty keyboards less relevant.

PLoS Medicine publishes some interesting thoughts on a topic dear to most health care workers and an increasing number of IT workers: “Poor Diet in Shift Workers: A New Occupational Health Hazard?” It cites data (including some from the Nurses Health Study) linking shift work to type 2 diabetes in women. Potential underlying mechanisms include poor diet and exercise, poor sleep, and disruption of circadian rhythms. Knowing the differences between day-shift menus and night-shift menus in most hospital cafeterias, brown-bagging it is probably the safest option if you’re looking at interventions.

David Blumenthal penned the recent A Piece of My Mind column in the Journal of the American Medical Association. It’s titled, “A Physician Goes to Washington… and Safely Returns,” which actually encouraged me to read it, unlike most of the pieces in JAMA which sound like something to read with a glass of warm milk when you have insomnia. I was hoping for some juicy revelations or HITECH wisdom, but it’s mostly about what it’s like to spend time in government service.

I’ve finished my stack of mandatory reading for the day, so am heading to lounge with a bit of fluff – Explosive Eighteen by Janet Evanovich. I can’t believe they’re finally making a movie of her first book One for the Money – it’s due out the end of this month and I’m counting down.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 1/2/12

What Gets Measured Gets Managed

During the last five years, we have seen significant shifts in how healthcare is delivered and in the way in which different healthcare services are valued. Most of us have realized for quite some time that fee-for-service medicine is clinging to life. Pay-for-outcomes is going to be the order of things from here on out.

Hospitals are no longer going to be paid to ameliorate hospital-acquired conditions or to deliver care to patients who were impacted by preventable harms. Physicians are going to be judged on their patients’ lab data and biometric information rather than the number of visits they bill.

Care will be transformed regardless of how we feel about it, whether it’s by the name Accountable Care, Shared Savings, or Pay-for-Performance. It’s something we all need to get used to.

My colleagues were ringing in the New Year this morning in the time-honored tradition of complaining around the coffee pot. (Most of us were rounding a bit later than usual and I did see a couple of bloodshot eyes.) It seems that many independent physicians, particularly those in small practices, don’t know where to start. (Employed docs are generally confused too, although to a slightly lesser degree.)

I decided to introduce them to Peter Drucker, whose famous statement, “What gets measured gets managed,” should be well understood by now. But let’s just say I was more than surprised by the blank looks in front of me.

Several of the docs didn’t understand that Meaningful Use is going to get trickier as time goes on. Although there are some metrics for Stage 1, many of them are easily achievable with a minimum of work. (Apparently though not as easy as people might think – I’m still stumped by the phenomenon of people unsuccessfully attesting. If you don’t have the numbers, why would you attest? Still waiting for someone to shed light on this.)

Although we don’t have final metrics for Stage 2 and beyond, it’s virtually guaranteed that the bar will be higher and the hoops smaller. In talking with the docs in the lounge, though, many of them don’t have a clue how to approach care metrics – even those with sophisticated software. I’m seeing far too many physicians who are barely using their certified EHRs, who are confused by some of the terminology, or who are hung up on wanting flash and sizzle.

I felt like I was giving a Grand Rounds presentation because our friendly chatter turned into a lecture that I probably could have given CME credit for. Docs don’t seem to understand that you have to know what you’re looking at in order to drive change. It’s not going to drive itself. You have to figure out what you want to work on, then measure it, then work on it, then measure it and work on it some more. Lather, rinse, repeat.

It seems pretty straightforward, but maybe it’s not, so allow me to share some other “secrets” that your docs may not know.

First, don’t get hung up on the fact that your EHR vendor may or may not have a registry or dashboards. Maybe they do and it’s just called something else, or maybe they don’t. One doc I was chatting with was caught up in the fact that he didn’t have his vendor’s dashboard product live yet. He was either under the impression (or in denial – it’s debatable) that he couldn’t start managing care until he had the pretty charts to back up the data. He didn’t like it too much when I called baloney on that one.

Most certified EHRs have at least some minimally decent ability to do reporting. That’s really all you need to start. If you have discrete data, you can report on a wealth of conditions. Prostate cancer screening? Check. Blood pressures? Check. Documentation of advance directives? Check.

You don’t need pie charts to tell you how to care for patients. When your report has blanks on it because you haven’t documented an item for a particular patient – that, my friends, is an opportunity for care.

Second, don’t get baffled by the metrics. Looking at some of the NCQA or NQF or MU measures and how they’re calculated makes my head spin as much as yours does. If you’ve never tried to do quality improvement before, start with something basic.

If it’s important to you to make sure every patient over 50 has a documented cholesterol test, start there. Don’t get hung up in the numbers and managing everyone down to an LDL of 70 or figuring out complicated exclusions. Start with something manageable, such as actually testing everyone. Run reports, do outreach, give it a month or two, then run those reports again and see if you’re making a change.

Third (and this is one of those points where I’m glad I’m anonymous – my CIO is probably spitting his coffee as he reads this) you don’t even have to have an EHR to make a difference. (I think I heard a few vendor gasps out there, perhaps the hissing of the word “heresy,” but it’s true.) You can make tangible gains in patient care without even a single chart pull. If you have a practice management system (that’s a “billing system” to some of you docs) with even rudimentary reporting capabilities, you can find opportunities to deliver care.

How so, you ask? Take an all-too-common diagnosis like diabetes (250.xx in ICD-9 terms.) Run some claims reports. Run a report of patients seen in the last three years with that group of diagnoses codes on a claim (or pick a single one like 250.00 if you’re scared at what you might find) and the date of their last billable visit. Presto! Anyone who hasn’t been seen in the last six months is an opportunity for care. This, of course, assumes that you actually bill the codes you’re addressing at the visit and not just cloning the last visit’s codes, which may or may not have included the diabetes. Primary care physicians are notorious for under-documenting the work they do.

Calculate the percentage of diabetics who haven’t been seen in the last six months and you just created your first metric. (If you passed epidemiology and biostatistics, which you must have to have graduated, you can calculate this. Trust me.) Send some postcards and make some calls (HIPAA-appropriate of course) and get those patients to come to your office for an actual billable visit. Report again in two to three months and see how you did. If you need a graph to show you the results, allow me to introduce you to my friend, Microsoft Excel. But I’m betting the numbers will speak for themselves.

Finally, it’s not just enough to have the data. You have to make it visible to make it actionable. Post your goals and action plans in a visible place in the office. Post monthly outcomes numbers. Celebrate those victories. When the numbers aren’t in your favor, take some time to figure out why and how you can do things differently. Involve everyone in the office. Even if you’re only focusing on a single metric each month, you WILL make a difference in the lives of your patients.

If you don’t believe that what gets measured gets managed (especially if you’re posting it publicly for everyone and their cousins to see) think again. I used to think I was pretty decent with my exercise habits (although it truly is difficult to hit the treadmill with a martini, so I wouldn’t recommend it.) In 2010, I did about 870 miles, which wasn’t totally shabby.

However, a double-dog-dare by some of my staff led to the public posting of our activities, with technical validation courtesy of our friends Garmin and Nike+ to prohibit cheating. (I suppose I could have paid the neighbor kid to jog around with my Garmin on, but that wouldn’t have been very sporting.) We have some serious running junkies on our team, and although I wasn’t delusional about keeping up with them, I felt pretty strongly about being able to beat most of the 20-somethings that populate the cube farm we call home. (Yes, they’re young. Yes, many of them are liberal arts grads. No, we’re not an Epic shop.)

Everyone had to share his or her numbers Saturday night. I almost forgot, so I was frantically uploading with a glass of Bailey’s in hand. I finished respectably with over 1,200 miles, but there’s always 2012:

Just Measure It. Just Manage It. Just Do It.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 12/26/11

Technology: The New Scapegoat?

I’ve always been a bit of a tech junkie. If I wasn’t afraid of revealing my age, I could tell some pretty good stories. To me, technology is exciting and invigorating, but also something to be respected. Technology at any level can run amok – think about Lucy in the chocolate factory as a basic example of what can go wrong. And who wants the artificial intelligence to run amok like HAL 9000? 

In conversations with providers, hospital administrators, and end users, the problem is always “the EHR” or “the system” or “the computer.”

Having lived in an electronic practice for nearly a decade and having used computers in the hospital for almost a decade before that, I can say with a good level of confidence that it’s not always the technology that’s at issue. Systems are only as good as the users who operate them, in conjunction with the training they receive and the proficiency they demonstrate. A recent situation at UC Irvine Medical Center illustrates this.

Although the headline screams “drug pump issue,” a close reading of the Statement of Deficiencies document (it begins on Page Five) yields some interesting factoids:

• The hospital deployed new infusion pumps without hospital-wide training.
• No policy and procedure document was developed (let alone approved) for the safe use of the new pumps.
• A physician overrode a “soft stop” alert on the pump, leading to a patient receiving a high dose of medication. (I agree that the fact that there wasn’t a “hard stop” alert programmed in, but let’s remember a physician did override the alert.)
• The hospital was “unable to ensure that MD… was competent in accurately programming the medication infusion pump.” The pump didn’t have a drug library and was programmed with a dose over 30 times that of the prescribed dose.

After two patient-related incidents, the hospital took corrective action, including:

• Only allowing trained RNs who have documented competency to program the pumps.
• Ensuring that dose, concentration, and flow rates are chosen from a current drug library appropriate to the care area.
• Restricting the ability for users to enter dose/rate for non-library medications unless a second user verifies the programming.
• Requiring re-verification of orders and programming when soft limits are overridden.
• Instituting hard stops which cannot be overridden for certain medication doses.
• Instituting independent double check for programming of pumps that deliver certain high-risk medications

These seem like no-brainer fixes to me. I’m glad the hospital put policies in place that should have been there all along (regardless of the newness of the brand of pump, model, etc., these are just good patient safety procedures).

The document goes on to list several other fairly horrifying behaviors, including a director of pharmacy who admitted knowing that no policies were in place and that no one was overseeing pump safety. “We will in the future, but the pharmacy department needs to be trained first.” He/she also stated that the vendor provided inadequate training for monitoring of pump-related events. Blaming the vendor is always easy – it takes a steadfast leader to halt a go-live when adequate training has not yet taken place.

Other scenarios mentioned in the document:

• A resident physician involved in a pump-related incident that involved infusing a medication over one hour instead of the recommended six hours was “unaware or unwilling to accept the hospital pharmacy directive to infuse the medication over six hours.” The resident’s anesthesia record stated that he was aware that he dosed the medication to infuse over one hour. The resident also violated Department of Anesthesia rules by not paging his attending physician to be present for the end of anesthesia as was required. Oh yeah – he also “overlooked” the patient’s low oxygen level and didn’t take corrective action. When the attending arrived after the resident finally paged, the attending called a Code Blue because the patient “had poor color and was not breathing.”
• Residents examining patients but not writing progress notes (even after a nursing supervisor notified the attending physician) on several occasions.
• An oncology staff nurse (whose job duties included validating chemotherapy doses) who was unable to calculate the dose when given a patient’s weight in pounds and a dose in milligrams per kilogram.
• Contract nurses allowed to operate infusion pumps without training (one with an ungraded proficiency exam in the personnel file — if you made him take it, why not grade it?)

I had to quit reading after a while because I’m extremely compulsive about patient safety and it was just making me increasingly agitated.

Despite the potential harm involved in the pump-related incidents, I’m actually glad they happened. Why? Because the incidents acted as a trigger to expose some significant issues and deficits in patient safety. Patient safety is a culture that requires education and support. It doesn’t happen in a vacuum.

I wouldn’t let an adolescent operate a lawn mower independently without appropriate training, safety gear, and close supervision. We don’t allow teenagers to drive cars (aka operate deadly weapons) without proving a minimum level of proficiency. Yet in this situation, users were allowed to operate equally dangerous machinery without training. The documentation doesn’t mention whether the nurses were forced to operate the pumps over their objections, but the point is they shouldn’t have been asked to use potentially lethal equipment they weren’t qualified (by training and demonstrated competency) to use.

I hope this case serves as a wake-up call for some institutions. I hope end users continue to speak up when they’re asked to do things that are unsafe and that someone listens. Lives depend on it.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 12/19/11

I really struggled with what to write about for this week’s Curbside Consult. I thought about being witty or trying to come up with some clever HIStalk version of “Twas the Night Before Christmas,” but the things I saw today top anything I could ever come up with. So listen, dear readers, to the cautionary tale of why each and every one of you who work in health IT can never forget the importance of your role, whether large or small.

As you may have picked up from my columns, when I’m not in the CMIO trenches, I work in various clinical environments. I don’t have to (it’s not part of my contract,) but I discovered during a year-long sabbatical from patient care that I really did miss taking care of people. I missed the simple joys of being able to make a new parent confident that their baby will eventually sleep through the night or helping patients come up with a plan to manage chronic health conditions. I missed the patients who came to me with lacerations because they knew I could patch them up faster than the local emergency room.

I did not, however, miss dealing with insurance companies, RVU compensation models, and administrators who didn’t know beans about running a medical practice.

When I was ready to see patients again, I had to find opportunities that wouldn’t interfere with my CMIO duties and that were flexible enough for me to still have plenty of time to cultivate my hobbies (can one really consider martini drinking a hobby?) I chose to be a non-employed physician. Sometimes I work for a staffing company, covering urgent and emergent care facilities. Sometimes I work as a locum tenens to cover docs who are on medical or family leave. Today was a little of both and to compound the “perfect storm” that was brewing, it was a place I hadn’t worked before.

You know you’re in trouble when you pull up to the designated employee parking garage and it’s essentially a chain link cage with a badge-swipe entry portal that looks like a sally port. As a last-minute fill-in for a physician out on leave, I didn’t have a badge, so I had to phone a security guard, who had to find my name on a list. Of course they didn’t have me on said list, but I must have looked fairly non-scary, so they buzzed me in.

I parked (next to a Corvette and a Jaguar, safe in their cage – go figure) and headed in. The staff was friendly and I had enough time to get fully caffeinated before the patients started rolling in, both of which are usually good signs.

The Emergency Department Information System (EDIS) was one I had worked with before, so I was pretty confident that I was going to be able to roll along without incident. Boy, was I wrong. Today was a veritable textbook of “lessons learned” on what can go totally wrong with software, hardware, and workflow. As I mentioned, this is why it’s so important for everyone who works in health IT to take their jobs seriously. Information Services leadership take note and hold on tight, because here we go:

1. I was given a stock password and told to change my password the first time I logged in. Unfortunately, my security classification doesn’t permit password changes, requiring me to call the help desk, which told me I could tell them what I wanted and they’d load it on their end. Really?
2. Better yet, the PACS system has a generic login and password left on a sticky note taped to the monitor. When I asked about this, I was told they had gone to a generic login because the doctors couldn’t remember their passwords. I can’t imagine what their HIPAA audit policy looks like for figuring out who viewed what data with generic logins.
3. To make things more exciting, the IT team scheduled a planned upgrade of the financial and registration system during the day shift. There were no printed downtime procedures available for staff and no clear communication plans. We were alerted to upgrade status by random people who would walk through the ED shouting “it’s back up” or “it’s down again.” Eventually we figured out that the patients whose names appeared in mixed case were registered using the integrated system, and patients whose names were all lower case were manually registered in the EDIS. That might have been nice to know since those manually registered patients had no outbound orders stemming from their accounts. We figured this out after radiology never showed up to do films on our patients – apparently we were supposed to call radiology to schedule those manually registered patients.
4. I’m usually obsessive about hand hygiene before and after touching patients. Today I actually felt an uncontrollable urge to wear gloves to touch the keyboard. You may have noticed I said “keyboard,” as in singular. There was one computer for me to use in a 10-bed emergency unit and it was a fixed desktop. That means no documenting in a patient-facing manner, thereby leading to rework, possible memory errors, and potential transcription errors. The nurse also had a single fixed workstation. Interestingly, the registrar had a really nice new computer on wheels (wireless) to go with their spanking new financial and registration system. So much for enabling patient care.
5. The software had not been updated to a Meaningful Use-compliant version. Not that being MU certified has anything to do with usability or efficiency, but it has become at least a minimum standard for software to meet. Basic demographic information is required to meet MU and this system had some major holes. I know the vendor has a MU compliant version (I’ve used it before,) but this was not it. The users were unaware of any planned upgrades.
6. I’m fairly certain the EDIS was not JCAHO compliant or remotely adherent to the precepts of the Institute for Safe Medication Practices, either. For prescribing, it was almost entirely hard-coded with physician “favorites.” Unfortunately, many of these favorites included “do not use” abbreviations as well as medications that have been off the market for several years. Users told me the prescribing system was hand-built and doesn’t import data from any of the respected formulary vendors. It was pretty clear no one was updating it, either. There was no appropriate way to prescribe current weight-based pediatric prescriptions. In order to get a non-ambiguous medication order for the pharmacy, I had to find the closest “canned” medication I could then print it on safety paper, finally crossing out the confusing parts and handwriting a traditional script below to clarify the confusing computer-ese. To the pharmacists on the receiving end – mea culpa, I didn’t know what else to do.
7. There was no ability to save any kinds of defaults or templates when documenting patients. I had the choice of either a “brief” history/ROS/exam, which was basically a canned jumble of findings (which I’m sure some committee somewhere worked really hard to agree on, rendering it individually useless) or the ability to check each individual finding box individually. After a full complement of ED patients, I’m seeing individual checkboxes when I close my eyes.
8. Customizations had been placed into the system without logic, resulting in duplicates and user brain fatigue. Most of the follow up clinics were listed as “Clinic – Specialty” but every now and then I’d see a rogue like “Derm Clinic” (even though Clinic – Dermatology was in there) but there was no consistency.
9. Clicking for Spanish patient education materials occasionally printed documents in a language which was distinctly not Spanish. Thank you, Señor B for gently educating the gringa that the discharge instructions were muy mal, because you’re right, I didn’t look at them before I handed them to you or I would have known. Shame on me and my apologies to those who taught me during eight years of Spanish classes.
10. Printers were non-configurable. I could print the discharge summary for the patient, but when I wanted to print additional information (such as sources of free medication for uninsured patients), my only choice was “print to file.”

I could keep going but I won’t. Hopefully you get the point.

As an outsider, the confluence of all the various decision streams at work here created a veritable maelstrom in which we tried to deliver care. It would be tempting to refuse to go back if I’m ever asked to staff that facility again. What’s interesting, though, is that I probably won’t refuse if I’m called. Why? Because the patients were genuinely needy, the care provided was solid despite the challenges, and the staff worked their tails off as a team to get through the shift. Everyone did his or her part and then some.

By the end of the day, it was like we had worked together forever. Hugs were exchanged (as well as recipes for Christmas cookies and empanadas – thanks for introducing me to things I never thought possible with chocolate and coconut) and high-fives given. I learned a nice trick for removing the proverbial rusty nail from the bottom of a foot, courtesy of a provider who shoes his own horses in his spare time. I did a little bit of education on Meaningful Use and information security.

Last, but most important, I helped some people. And that, my friends, is what it’s all about.

Feliz Navidad, próspero año y felicidad.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 12/12/11

This is always a busy time of year, so I’m a little late reporting on something that could have a profound impact on health care. Last month, the United States Supreme Court agreed to hear challenges to the 2010 Patient Protection and Affordable Care Act (PPACA).

The briefing schedule was just released last week. It looks like briefs are due throughout January, February, and March. We can anticipate oral arguments before the Court shortly thereafter.

Although there is no way to predict when the Court will hand down any given decision, all cases argued during a particular term are decided prior to the summer recess, so we should have a decision by the end of June. The timing of this is interesting because it means there will be a decision right around the time the 2012 presidential campaign heads into its final months.

In announcing its review of the case, the Court is consolidating two pending lawsuits. Both seek to overturn the Act, with the primary question being whether the law is constitutional – in particular, the mandate for individuals to obtain health coverage.

Specifically, an appeal from the United States Court of Appeals for the Eleventh Circuit in Atlanta is aimed at reversing the decision that a three-judge panel made to strike down the mandate. The panel felt that Congress did not have the authority to do this despite their constitutional power to regulate commerce and levy taxes. This particular appeal dealt only with the mandate, however, and left the rest of the Act intact.

The other appeal attempts to overturn a decision in the Eleventh Circuit that ruled against Florida and other states on a challenge to the law’s expansion of Medicaid. The states also argued that Congress exceeded its reach by expanding Medicaid eligibility and coverage thresholds that states must adopt. Under the Act, states must meet new conditions or lose all federal Medicaid funds.

There are several different actions the Court could choose: upholding the law, striking down only that provision, striking down other elements, or striking down the entire law. In a bit of a twist, they are also considering another issue coming out of the Fourth Circuit (Virginia) which could delay a final ruling until 2015 when penalties take effect and the ability of individuals to challenge the individual mandate becomes timely.

There are a total of 26 states challenging the law. Given the polarization the law has caused, this is sure to be one of the more electrifying cases heard this year. In anticipation of the significance of the issue, the Court scheduled more than five hours of oral arguments instead of the usual one-hour argument. They will hear two hours of argument on the issue of overstepping constitutional authority, an hour and a half on whether the mandate can be separated from the rest of the act, an hour on the Medicaid issue, and an hour on the issue of whether it is premature to decide the case.

Regardless of the outcome, it will be interesting to see how the presidential candidates react, not to mention how those battling on both sides of the aisle of Congress will react. For those of you who have a hankering for primary source material, briefs and orders are posted on the Docket page of the Supreme Court website.

Have a question on the branches of government, touring Washington DC, or where Associate Justice Ruth Bader Ginsburg gets her kicky jabots? E-mail me.

E-mail Dr. Jayne.