Curbside Consult with Dr. Jayne 12/5/11

For those of you who are my Facebook friends, you may have noticed that I’m at the National Finals Rodeo this week. (And if you’re not my friend on Facebook… well, you know what you need to do to keep up with all my travels and adventures.) Despite my love of all things technology, I really am a cowgirl at heart.

For those of you who are not rodeo fans, NFR is in Las Vegas. I’m amazed at how the city transforms itself for different constituencies. The casinos of the headquarters hotels are filled with the sounds of country music. Shopping areas are featuring cowboy boots in the window instead of rhinestone stilettos (although there are plenty of rhinestones on the boots.) The cocktail waitresses at one bar I’ve been to several times in the past have given up their leather bustiers and miniskirts in favor of tight jeans and white cotton shirts. If there’s any place on earth that’s a triumph of marketing, it’s Las Vegas.

So what does this have to do with healthcare and technology? A couple of things.

First, let’s talk about marketing. We always think about vendors when we think of marketing. Nearly every vendor’s ad campaigns these days prominently feature the twin terrors of Meaningful Use and Accountable Care. If those aren’t mentioned, then it’s revenue cycle or other financial aspects of health care.

I think we forget about the sheer amount of hospital marketing that goes on, however. Just like the casinos marketing to the cowboys (many of whom have wallets the size of their belt buckles – and trust me, Jayne and her crew have been checking out some jeans pockets on this trip) the hospitals, surgery centers, and physicians are heavily marketing towards whatever demographic they feel has the fattest wallets or deepest pockets.

Driving around most cities, you see plenty of healthcare-related billboards. One hospital I passed recently boasts a Heart Hospital. What does that mean? Do they do more heart cases than anyone else? Are their outcomes better than others? Or do they just want the perception of being specialized to try to garner business when their volumes are the same as the hospital across town?

Everyone is tweeting their emergency department wait times. I’d like to see them tweeting their nurse-to-patient ratios or their infection rates instead. That would really create some interesting discussion in the community about which facility is the best.

Physicians and other providers aren’t much different. Going after high-paying patients is an art form. Medical buildings (and some physician offices, too) are installing complimentary coffee kiosks to go with their waiting room check-in kiosks. Ancillary services including cosmetic and convenience offerings are proliferating faster than Medicare Wellness exams. Availability of after-hours physician access at premium prices is becoming more commonplace. Concierge-type practice models such as MD VIP are going mainstream. My travel companion noticed a special advertising section in the Southwest Airlines Spirit magazine this month that featured not only concierge medicine, but other specialty and alternative practices.

Hospitals and physicians have their own internal marketing campaigns as well. It may be as simple as signs in a primary care office reminding diabetic patients to take off their shoes prior to seeing the physician or as complex as a multi-hospital multimedia hand washing campaign (complete with Big Brother surveillance, as we’ve seen recently) or promoting desired behaviors such as vaccine compliance through viral videos.

The medical establishment is increasingly marketing technology to patients. Not only emergency wait times, but also patient portals, secure messaging with providers, lab results online, bill pay, and a host of other services. Many of these offerings not only add value to patients and families, but also have the potential to significantly increase the bottom line for healthcare organizations. Payers are in the game as well as employers, with many offering health promotion and disease prevention as well as online enrollment, updating, and claims management features.

Many agree there are health benefits to increased patient education and empowerment. But the jury is still out on some of these marketing efforts. I’m interested to hear what HIStalk readers think about marketing – on the vendor, client, and patient sides. Have an opinion? I promise to read your comments just as soon as I’m finished watching the action. Tonight is “Tough Enough to Wear Pink Night.” I’ll let you guess what color my boots are.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 11/28/11

Now that Thanksgiving has come and gone, we’re officially in that nebulous zone called “The Holidays.” For many, this includes hectic family gatherings, school programs, and travel to see relatives. College students return home to agitate parents and siblings.

For physician offices, it marks the beginning of cold and flu season. For IT teams, it often it signals a lull in the implementation of projects because no one wants to deploy new technology when physicians and staff are alternating time out of the office with packed schedules (usually required to accommodate said time out of the office.)

I officially boycotted Black Friday by purchasing nearly nothing, despite needing to pick up a new external hard drive. I was happy to see my municipality issuing tickets to big box retailers that opened at midnight, citing laws preventing 24-hour operation of retail enterprises. I’m not the neighborhood Grinch by any means, but I am glad to see someone countering the steady pressure of rampant consumerism. I did buy some coffee (a delightful peppermint mocha) while visiting with a friend, but I’m sure that didn’t make a blip on the Black Friday cash register.

One good thing about The Holidays is that travel often brings people to town that I don’t get to see too often. I had the rare chance to sit down with my longest-standing friend. We started our healthcare careers together at the tender age of 13 as hospital volunteers, aka Candy Stripers. Cecilia always wanted to be a nurse and I always wanted to be a doctor, so it was a friendship forged of common interests with a sprinkling of adventure.

We started volunteering on the mother/baby ward (yes, they were called wards back in the Cretaceous period,) refilling plastic pitchers with ice chips and answering the nurse call light system. My favorite part was using the Addressograph machine to stamp paperwork when new patients arrived, assembling charts in large plastic three-ring binders. I guess that means my interest in health information goes back to the very beginning (or maybe I just liked the smell of mimeograph ink).

After a while, I tired of being the ice chip police and transferred to being the “checkout girl” at the gift shop. The computerized cash register made the job fun. I enjoyed the tally reports that it created for the end-of-day close. Maybe that’s where my interest in technology comes from.

Being Candy Stripers gave us unlimited access to the hospital (in the pre-HIPAA era, things were very different.) I still can’t believe they let teenage girls do the “pharmacy run,” driving a cartful of drugs to every ward including the locked psychiatric ward (at my hospital, robots now do that work). We saw the hospital from the ground up – from central stores to sterilization to food prep to pharmacy to nursing and beyond. It gave you a solid understanding of all the different people needed to make patient care possible. It allowed you to be close to the action, but not too close (thankfully, we weren’t on duty the night that a baby was delivered in the lobby bathroom.)

Cecilia and I thought it would be cool to work together when we grew up. I could have a private practice and she could be the office nurse. Although I did ultimately end up with that practice (at least for a while,) she specialized in cardiac nursing and prowled the telemetry and post-surgical step-down units. The hospital where we started faced a declining census and was torn down to make room for outpatient offices. I still have a brick from the demolition. Ironically, a decade later they’re thinking about building a bed tower there due to rising hospitalizations among the increasingly aged population of our home town.

Being a nurse on the front lines, Cecilia really has seen the transformation of healthcare delivery first hand. She has nearly a decade more experience than I do, working in the trenches while I was still slogging through medical school and residency. She has worked through every buzzword you can think of. We always commiserate about having to deal with patient-focused care that’s actually profit-focused, centers of excellence that really aren’t that excellent (but the administrators think that if you call it that, it makes it automatically great,) and goofy regulations and policies.

Spending time in major hospitals throughout the country, we’ve both found that the more hospitals think they’re unique, they more they really are the same. Clinical care has been commoditized. 

It’s a bit humorous, but we both wound up in the same situation for clinical work. Although she works for a major health system just a few miles from her home, they don’t employ her – she’s staffed by an agency hundreds of miles away because the hospital doesn’t want to spend the money to employ full-time nurses. I’m in the same boat because my hospital doesn’t actually employ any of the hospital-based physicians either, relying on a staffing company to insure us and administer our schedules. It’s a long way from what we thought we were getting into way back when.

I can’t complain, though. Being a mercenary doc from the clinical perspective allows me to indulge my IT passions and still see patients. It does make one wonder, though,what’s next in healthcare. When the majority of workers at a hospital aren’t actually employed by the hospital, what’s that going to mean? How do you ensure training and consistency? How do you handle an ever-changing and increasingly complex environment? How does it impact patients? We’ll just have to wait and see.

So here’s to The Holidays. I hope you have the chance to connect with friends and colleagues old and new. Stay safe, stay sane, and take some time to recharge. If what we’ve seen this year is true, it’s only going to get busier in 2012.

Have a question about eggnog recipes, call light systems, or making the perfect ice pack out of a rubber glove and paper towels? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 11/21/11

As the newest member of the HIStalk team, I’m continually amazed at how Mr. H and Inga keep up with the constant barrage of press releases, announcements, news, information, and gossip that circulates around everything related to health information technology. I try not to feel bad when I realize an interesting tidbit has slipped past. Hopefully at HIMSS I can meet with Inga for a mind-meld to learn how she does it (and also to absorb some of her sartorial style.)

The issue at hand is relatively small potatoes in the overall federal funding bonanza – a $1.24 million contract awarded by ONC to APP Design, Inc. The goal of this contract is to help patients better understand choices regarding sharing of health data.

Specifying, building, and deploying a health information exchange have been a major part of my career for nearly half a decade. As a physician, the concept of HIE solves a myriad of problems. Consult letters don’t get lost in the mail; labs don’t wind up being double-ordered because the results aren’t in the chart; and medical misadventures can be prevented through timely sharing of pertinent clinical data.

As those of you who have been down this road know, it’s often unpaved and riddled with pot holes, poor lane markings, and uneven shoulders. For many of us, the road trip has been halted by the barrel monster called “Consent.” This is ironic because our patients think that simply by virtue of the fact that we’re documenting using computers, that all their providers are already fully sharing patient information. I’ve had patients yell at me in the exam room because I don’t have a particular piece of data on my screen.

As long as data sharing is within a physician group (especially if they are all under the same tax ID and within a single state) it seems relatively uncomplicated. But add non-employed physicians, independent providers, multiple health systems, and (heaven forbid) multiple states and you have a real mess on your hands.

When we sought to add providers outside our large employed physician group, the recommended consent language created by outside counsel was over five pages long and was totally unintelligible to the average person. Remember all those carefully crafted patient education handouts that have to be at the fifth-grade reading level so that patients can hopefully understand them? Think again. I have multiple graduate degrees and couldn’t follow this one.

Days of revising turned to weeks and then months as we struggled to get the consent document to even a single page. What felt like years of my life were sucked away on endless conference calls with our in-house attorneys and outside counsel. I jokingly proposed the following:

Check one below:

a) I want my physicians to share all information available so they can treat me the best way possible

b) I don’t want my physicians to share information and am aware this could possibly hurt or maybe even kill me

c) I don’t want to share my information because I am a drug seeker and am afraid you will no longer treat me if you find out

Not surprisingly, the attorneys didn’t find it funny. Most of my physician colleagues however found it hilarious.

Regardless, I’m looking forward to the outcomes of this exercise. The E-Consent trial being funded by ONC has several goals, including finding new ways to educate patients about data sharing as well as finding ways to move from paper consent to electronic consent.

The trial will take place at four sites in western New York that use the HEALTHeLINK exchange system. APP Design plans to create a new user interface to inform patients about data sharing and their choices, and also to document the patient’s permission. Looking at the timeline for deliverables, by now the project kickoff meeting should have occurred as well as creation of the project approach and work plan. APP Design will have 48 weeks to deploy a pilot, then an additional 32 weeks to evaluate patient understanding and satisfaction. Biweekly status meetings with ONC and monthly progress and financial reports will occur throughout the project.

Let’s hope they do well and avoid the potholes. May the construction barrels steer them to smooth pavement, slow gradual turns, and well-lighted parking.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 11/14/11

Dear Dr. Jayne,

Is our current EHR paradigm dated? Docs practiced for years with paper. Pencil evolved to ink, both inscribed on compressed wood. Housed in manila folders, stickers provided the index and retrieval involved sight-based interpretation based on patient names. Then, we introduced computers. Initially similar to the paper paradigm, full summaries in ANSII or images are stored in a paradigm that still resembles folder-based paper storage.  From the images and full ANSII summaries came discrete data points. Ink on paper had now evolved to data capture as unique field based database storage. Over time, these discrete data points will become much more comprehensive.   

With all the technical advances where is the industry going? Will the paradigm shift from practicing medicine on discrete data points to something else, and when? Will medicine be able to shift? Is multimedia the next frontier? Just like the initial paper to electronic chart paradigm shift, when will computer science convert images and video to discrete data points? We all know the value of discrete data.

Fan of Dr. Jayne from the Deep South

Dear Southern Fan,

You pose some interesting questions. Given the fact that physician recordkeeping didn’t change much for hundreds of years, the relative pace of records evolution at present is staggering. We’re already becoming fairly adept at converting spoken language into discrete data, allowing physicians to document patients’ stories not only with codified data points, but with the rich narrative that frames individual patient circumstances and situations.

In my opinion, the biggest barrier to the kind of documentation that can be envisioned is unfortunately the proverbial hand that feeds us. The regulations, policies, and requirements of CMS are still stuck in the paper paradigm. And as we all know, as CMS goes, so go the rest of the payers. Despite federal mandates to take the technology forward — such as HIPAA and HITECH — healthcare providers are still being scored based on documentation standards that have not evolved in more than a decade.

Physicians can’t get “bullet point” credit for documenting a cancerous skin lesion with a photograph. They say a picture is worth a thousand words, but in an audit, a picture is worth nothing.

I remember sitting in medical school watching a video of a child with whooping cough. No written description could ever take the place of that. When you see and hear that kind of pathology, it’s etched in your brain forever. Nevertheless, embedding a video clip of a patient isn’t worth anything, either. I can look at a photograph of a diabetic foot and tell you a lot more about a patient’s illness and status than I can glean from a multi-page nonsense note generated from a poorly-implemented EHR.

I once heard someone say that our thinking is constrained by the technology of today. I don’t think that’s the entire problem; our vision is also constrained. And it’s not the technology that locks us in, but also the auditing and payment paradigm that hobbles us.

I was initially hopeful that the rise of Accountable Care Organizations with their risk-sharing and outcomes orientation would help us move to a more modern way of thinking and documenting. It doesn’t look like the fact that providers and payers are sharing risk is going to move us away from the incessant and costly paradigm of documentation for documentation’s sake.

The promise of telemedicine and other technology ventures such as real-time electronic patient communication was exciting. However, lack of payment and increased regulatory burden continue to keep it from realizing its potential. I’d like to think the future’s so bright we’ll have to wear shades, but I’m not sure CMS agrees.

Dr. Jayne

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Curbside Consult with Dr. Jayne 11/7/11

You all know how much I love things from South Carolina, so it’s with an extra smile that I congratulate Pink Glove Dance winner Lexington Medical Center of West Columbia, SC. Their entry really does have it all – from the early morning cleaning crew to pink glow sticks at the end of the day. I’m particularly impressed because they captured parts of the hospital that some of us forget about – like the engineering department (the guys with the umbrellas) and the child care center – with plenty of other clever bits in between. In honor of the win, $10,000 will be donated to the Vera Bradley Foundation for Breast Cancer. BTW, don’t miss the biohazard ninjas at 2:23.

From my comments on shoes and finding the best martini, some of you might think Dr. Jayne’s idea of the great outdoors involves poolside cocktails at the Ritz Carlton. Big surprise though — I spent the weekend camping. Good, old-fashioned sleeping bag on the ground in tent-style camping. No electricity, no running water. The weather was chilly, but fantastic. It was great to be away from technology for at least a little bit (except for the guy in our group who was texting in his tent – I believe that’s a camping faux pas, but I wasn’t going to wriggle out of my mummy bag to tell him to quit.)

Camping can be a great equalizer. It’s hard to know whether you’re a Suit, a Doc, or IT staffer when you’re all wearing jeans and either a ponytail or a ball cap. (I didn’t go camping with work people, but I did go camping with an IT staffer, a postal carrier, and a project manager as well as other assorted folks, so it was an interesting mix.)

Watching people set up camp definitely reminded me recent IT adventures in the “you get what you pay for” category. The inexpensive vendor with the iffy support that you contracted with because you only needed them as a bridge technology? Very similar to the budget tent with the iffy instructions that took entirely too long to assemble and will never, ever go back into its stuff sack. (And a shout out to my tent provider – yes, you are correct, your tent IS the bomb, I’m sorry I ever made fun of how much you paid for it, and BTW you’re never getting it back.)

Being away from the constant electronic and political spin cycle was good and allowed for some time to think about where our tech-enabled lifestyle has gotten us and how far apart we are from the vast majority of people in the world. One of the women in my group mentioned that she had never eaten a breakfast that had been cooked over an actual fire. Considering that’s how many people in the world today still live on a daily basis, it seemed kind of sad that we’re so out of touch from what many consider true basic needs. Our near-worship of technology and making things easier and more efficient has also made us more prone to heart disease, diabetes, obesity, depression, anxiety, and stress-related illnesses, which add to the high cost of health care.

We’re spending billions on expanding, enhancing, upgrading, and turbo-charging health information technology when there are people in the world (and even in our own country) who have no access to health care. We forget that there are people who have to walk miles to access clean drinking water. Things like that kind of put some of our daily IT trials and tribulations in perspective when you’re considering that level of resource disparity in our world.

While contemplating all of this under a cloudless starry sky (after having confiscated my tent-mate’s iPhone and its fascinating but atmosphere-spoiling astronomy app) I started thinking about what it really is that I do for a living. When I left solo practice to begin my journey at the Big Hospital and in academia, I was motivated by how many patients I’d be able to impact by moving to the next level. Moving next to the Large Health System and now to my current position, the potential for impacting patients’ health should be even greater. It’s a long way from three thousand patients in a private practice to several million patients across a multi-state organization, but some days it doesn’t feel very impactful.

I know from the numbers (which I crunch daily thanks to software, reports, registries, and endless dashboards) that we are moving the needle. On a month-to-month basis however it is agonizingly slow. We’re building a better mousetrap, but is a mousetrap what we really need? Where is the true innovation? Do we instead need an ultrasonic way to repel the mice from the area, obviating the need for a mousetrap? Or maybe we’ve over engineered, missing entirely the fact that if we’re living on a farm, we’re going to have mice, and we need to be focusing on something else entirely?

The people who deal with the mice on a daily basis feel like they’re no longer stakeholders in the process. Putting it in healthcare terms, insurers, large health systems, and federal entitlement programs are driving legislation that pushes us away from individually focused care and into a widget-making mentality. Patients aren’t the same and neither are providers. Among large health systems, there are great differences (and for some, differences even within their own organizations.)

We’re exactly a year from the next presidential election and I think it will be interesting to see where we are when the big day rolls around. By November 2012, we’ll know who’s been naughty and who’s been nice in the game of Meaningful Use attestation. We’ll watch some vendors bomb and some victors emerge. The big question: will we actually be making more of a difference in the lives of the patients we serve? Or will we ourselves be mice reaching for cheese and hoping to avoid the snap of the trap? Only time will tell.

Have a question about healthcare expenditures, CPOE, or which knot to use to hang your bear bag? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 10/31/11

Today is Halloween, which is without a doubt my favorite day of the year. It’s one of those days where even adults can act like kids and playing dress-up is OK. People love to mark the occasion by visiting haunted houses, watching scary movies, and telling ghost stories.

So everyone grab a popcorn ball and some of those little peanut-buttery candies in the orange and black wrappers and turn the lights down low, because it’s time for Dr. Jayne’s Top Ten List of Horrifying and Frightening Things.

10. HIPAA compliance zombies. You know the type — those that cite HIPAA as the reason for everything, regardless of relevancy. I had a run-in with one of these who told me (as the referring physician) that she couldn’t fax me a copy of a consultation note (which was addressed to me, but had only arrived with one of three pages present) unless I sent a release signed by the patient. Reason: HIPAA. (I bet in her head it was spelled HIPPA.)

9. Physicians who demand that allergy checking and other EHR decision support be completely disabled because they “know all that stuff already.” I understand (and loathe) alert fatigue as much as the next gal, but seriously, I can’t imagine that there’s a physician who has never accidentally prescribed a medication to someone who was allergic to said medication. I know I’ve done it and you know you’ve done it at least once in your career, too. If that doesn’t scare you into leaving the allergy checking active, it should.

8. Shortages of common medications, including vaccines and chemotherapy drugs. Often these are low-profit margin generics and are made by only a handful of manufacturers. If one of them experiences production issues, the entire supply is threatened. Something to think about the next time you read about all drug makers being branded as greedy.

7. Celebrities and politicians dabbling in the public health sphere by adding to vaccine hysteria. Want to see something really scary? Pictures of vaccine-preventable diseases. I wish they’d spend their time advocating anti-drug and anti-obesity propaganda instead.

6. Patient-facing software vendors who do not have licensed physicians on staff (or at least as consultants.) I’m not sure how they evaluate usability, let alone suitability for patient care. The only thing scarier is the hospitals and health systems that actually purchase this software.

5. Hospitals and ambulatory organizations that implement patient-facing software without physician leadership or oversight. I recently moonlighted at a JCAHO-accredited facility that had an allegedly certified system. However, for some reason, the prescriptions printed without a medication route. The system also had “never use” abbreviations on the prescribing screen. I’m not sure why they were printing on paper in the first place, but with obvious patient safety and regulatory issues to address, I didn’t pick the eRx battle that day.

4. Congressional rule-making that increases health care costs in the name of balancing the budget. I’m talking about the ridiculous change that made patients obtain prescriptions in order to use flexible spending accounts to reimburse over-the-counter drugs. Let’s see, the reason they’re over-the-counter is because they don’t require a prescription. But now, to save money, I have to get a prescription for my OTC med (after paying a co-pay), take it to the pharmacy, waste their time submitting it to my insurance to get the denial because it’s OTC, then pay cash for it and submit it to my FSA overseer. If they thought this process was going to deter patients, they were wrong (I’m not sure they thought it that far through the process, though) because patients are coming in droves for these scripts and some offices are charging fees for preparing these extra prescriptions. There’s a whole lot of spending going on here and it’s your fault, Congress. Next time you’re going to do this kind of thing, can you please ask a primary care doc his or her opinion first? I’d rather be counseling the obese, hyperlipidemic, hypertensive diabetic about his cardiac risk than writing another prescription for little Johnny’s diaper cream.

3. The fact that the item above is only a teeny, tiny, microscopic piece of what Congress has done or is trying to do with healthcare. I’ve got an idea: Let’s form a Congressional HMO, enroll all the legislators and their families in it, and use it as a pilot site for health care reform proposals. Once they prove efficacy on a captive population, only then should it be allowed to see the light of day. Muahahaha!

2. The emergency department at almost any urban hospital and quite a few suburban and rural ones, too. Overcrowding is often the norm, and due to fright-inducing Acts of Congress such as EMTALA, everyone is treated regardless of the ridiculousness of their chief complaint or its appropriateness for the emergency department. I know some hospitals were (and still are) guilty of patient dumping, and that is indeed a crime, but having to perform a medical screening examination on a patient who presents with “wants to know if I’m dyslexic” at 11 a.m. on a Saturday is a waste of resources. And yes, I really did see this patient, but only after the nurse had to spend his time assessing the patient’s pain score and asking him if he had an advance directive. This was in an ED that sees about the same patient volume as that of Massachusetts General Hospital, so it’s not like we were just sitting around shoe shopping on the Internet.

1. Watching providers adapt to ICD-10. I’m hearing lots about ICD-10 readiness and how software and billing systems will handle it, but am hearing very little about how organizations are actually going to train their providers to identify the appropriate new codes for old diseases. Word in the Doctor’s Lounge is that providers think EHR vendors will just automagically map the codes for them. They apparently missed the fact that it’s not a 1:1 conversion. If your vendor is telling you they’ll do this, you should be as frightened as if you just ran into Jason Voorhees and Freddy Krueger chatting at the coffee machine.

I hope after all this you’re not too scared to open the door to trick-or-treaters tonight or to do some candy hunting of your own. Maybe you’ll stop by Casa Jayne and not even know it. I’m one of the “good candy” houses and my office at work is also well provisioned. I stocked up on Sweet Tarts and Sprees should a certain sassy sales exec decide to stop by. I’ll be in costume (of course!) but I’ll give you a clue — you’ll be able to figure me out by my shoes. I’ll bet Inga doesn’t have a pair of these!

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 10/24/11

A reader recently sent me a link to a blog by Dr. Joe Heyman titled We Can’t Fix All of Medicine with Meaningful Use. He calls out two serious problems with Meaningful Use – measurement for the sake of measurement and the introduction of unintended frustrating inefficiencies that offer no noticeable improvement in patient care.

Heyman states:

It has been my experience that most physicians involved in policy making in the health IT field are unrepresentative of people like me. They are either not practicing at all or they practice one day a week in a huge institution or network. They never do their own coding and billing and have a buffer in place when it comes to measures as well. We little people have no buffers, no counters, no billers, and no paramedical people to help with our workload. Most physicians in this country are in small practices, and most patients in this country are cared for by those physicians. So when a policy maker who has never been in our shoes sets requirements for measurements, a red light and siren should go off to remind people to be sure that the measure is so important that it is worth decreasing efficiency and making technology less attractive to the folks who take care of most of our patients.

Unfortunately, this is entirely true, not just in Meaningful Use, but in various facets of healthcare. Although there are many areas where care can be dictated based on robust study of the evidence, we have entered uncharted waters in knowing whether the dictates of Meaningful Use will actually deliver quality care outcomes. Personally, rather than a hodgepodge of measures thrown together in the guise of Meaningful Use, I’d love to see demonstration projects on each of the measures to determine whether they are indeed valid.

We see this kind of evidence in the Quality Measures portion. Many of these are well-researched disease management elements that have been shown to reduce the burden of disease, improve quality of life, and reduce health care costs. I’m all for these types of measures.

What I’m not for, however, is mindless box-clicking such as Dr. Heyman describes when having to “remember to put a check mark in place saying the patient has no problem every time I would have left the problem list blank.” Playing devil’s advocate, of course one could argue that physicians left the problem list blank because they were lazy, or thought a problem unimportant, etc. Instead, however, we’re going to make everyone check a box instead so we can measure it.

As someone who has spent a great deal of her career in process improvement initiatives, I do fully embrace the concept that what gets measured gets managed. In this case though, I fear that all we’re going to manage is to have providers leverage staff to simply check the box so they don’t have to, potentially increasing inaccuracy rather than what was probably intended, which is to make sure patient charts have accurate and complete problem lists.

He also shares his frustration with requiring collection of ethnicity on each patient, with which I heartily agree. A good chunk of patients out there have no idea of the difference between race and ethnicity – frankly, how many healthcare providers can accurately explain it? – and quite a few patients are offended that we’re even asking. This requires someone in the office (often the physician, who hears the patient complaint even after staff has tried to address it) to explain the goals are of gathering the data, wasting precious time that could have been spent on health counseling, taking a detailed history, and undertaking more clinically relevant pursuits that have been shown time and again to improve outcomes.

For many providers, Meaningful Use is too much, too fast. I know that my staff, regardless of technology, prompts, and reminders, can only focus on so many elements at a time (and we were early adopters, so the distraction of the technology itself is long gone.) In a perfect world, we’d like them to be able to spend their time focusing on issues that will really make an impact with an individual patient rather than gathering individually irrelevant data for broad population initiatives. I’d like my staff to spend that explanation time making sure the patient has resources to pay for her medication so she can even take it, rather than worrying about discerning what my patients call “where my people come from.”

Patients want us to be present in the moment – in the exam room with them, focusing on individual issues and getting to know our patients as people. That is increasingly hard to do when providers are being graded on whether those same patients actually do what we ask them to do and also whether we checked the appropriate box to correctly document it. We’re no longer paid for patient rapport, cognitive ability, or compassion. We are, however, paid for playing a game where checkboxes and regulations rule. This is sad.

I close with another great comment from Dr. Heyman:

We cannot fix everything in medicine with Meaningful Use, and we should stop trying to do so. We can fix lots of things with technology and innovation, but let’s stop micromanaging physician practices. Let’s move from Meaningless Documentation Measurement to Meaningful Care! We can be so much more innovative than Meaningful Use.

And from the back pew of my hospital’s chapel, Dr. Jayne says “Amen!”

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Curbside Consult with Dr. Jayne 10/17/11

Dear Dr. Jayne,

What’s your take on the following Medicare position?

When documentation is worded exactly like or similar to previous entries, the documentation is referred to as cloned documentation. Documentation exactly the same from patient to patient is considered cloned and often occurs when services have a specific set of limited or select criteria. Cloned documentation lacks the patient specific information necessary to support services rendered to each individual patient.

After doing cough/cold/flu clinics where patient after patient presents with similar symptoms, similar exam findings, while the HPI documentation may be different, there are only so many ways to document “nasal turbinates red, erythematous, swollen, lungs clear” and the advice to the patient nearly always remains “Rest, fluids, Tylenol, ibuprofen, return if condition worsens.”

Additionally, much documentation remains unchanged at a routine 3-6 month visit for diabetes, HTN, hyperlipidemia where a physical exam is performed thoroughly. Medicare requires the documentation for payment, but is now placing providers in a catch-22 where the documentation cannot be even similar. How different can one make an exam if little changes?

Must we now ditch those time-saving macros that document routine education in the chart, such as “Counseled patient regarding risks and benefits of medication, including the possibility of sedation and advice to avoid driving or operating power tools while on narcotics?”

Clone Trooper

Dearest Trooper,

My secret fear is that Medicare is building its own Clone Army of Recovery Audit Contractors to continue to torment and confuse physicians. If they’re now going to go after so-called cloned documentation, they’re going to have to go back to every History and Physical and every Discharge Summary that every resident has done since the invention of the Dictaphone.

I remember being trapped in Medical Records (before it became Health Information Management) with a stack of my cruel attending’s charts, dictating notes on patients I barely remember seeing. Unless they had a significant finding, everyone was “regular rate and rhythm no murmur, rub, or gallop; lungs were clear to auscultation bilaterally.”

I absolutely agree with you – there are only so many ways to say, “Patient is not a smoker.” Let’s see. PATIENT is not a smoker. Patient is NOT a smoker. Patient is not a SMOKER. Let’s try this: STOP smoking pot. Stop SMOKING pot. Stop smoking POT.

If I use the same simple sentence on every patient, does that make me guilty of cloning? Will the stem cell activists come after me too?

Frankly, I think Medicare shares responsibility for creating this kind of documentation. This isn’t a new problem with use of EHRs. It has been prevalent every since transcription services started charging by the line. Physicians learned to say the same thing in fewer and fewer words. This ultimately evolved into dictation macros and the concept has continued as voice recognition slowly takes the place of transcribed dictation. EHRs just jumped on a train that was already rolling at a good clip.

Medicare’s cousin, Medicaid, has also driven us to this. Has anyone ever seen an EPSDT form? This is a required form for pediatric well visits. It is required that providers fill out the same form (specific to age) for each patient. You are required to document mandatory anticipatory guidance by placing an X in a box. Thus, the forms look pretty darn identical when they’re done. Should I start doing cursive X on some forms and print on others? Should I alternate right and left facing check-marks? Why is Medicaid’s form OK but my own form causes cloning?

I do a lot of sports physicals, sometimes at a sports physical clinic. There is a mandated state form. Almost all of the teens I see are healthy. So what constitutes “patient specific information?” Maybe I should start finishing them up with “This blonde surfer dude in an Abercrombie t-shirt is cleared for contact sports,” or include “Patient has braces with alternating pink and green elastics” on the oral exam. Would this meet the CMS standard for unique documentation?

Then, what about the patients who have the same visit month after month? I have patients whose office visits are straight out of the movie Groundhog Day. Except for the vital signs, the visit never changes. The patient continues to be non-compliant. The murmur is identical from visit to visit (which is a good thing!) The assessment and plan are the same. I keep prescribing the same medications that the patient continues to not take correctly.

Let’s not even talk about group visits, which they want us to do as part of Patient Centered Medical Home initiatives. Of course your counseling is going to be identical for every patient – you only said it once because they were sitting there in a group, for goodness sake. If you try to change it up for the sake of making less uniform documentation, isn’t that fraud?

I think if Medicare wants to avoid cloned documentation, they should start paying physicians to document using well-crafted prose – or at least an incentive payment for complete sentences with reasonably correct grammar. For the ability to collect a higher fee, I’d even consider writing notes in the form of the Shakespearean sonnet. But with dropping reimbursements and rising costs, CMS is going to be lucky if they get a Haiku out of me.

Have a penchant for an Ode, some Tanka, the Jintishi, or maybe the anapestic tetrameter of Dr. Seuss? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 10/11/11

The bean counters in my organization are all abuzz about how we might be able to mimic the financial results of the Medicare Physician Group Practice Demonstration project. For those of you who may have been living under a pay-for-performance rock, the PGP Demonstration was the first Medicare P4P initiative and dates back to legislation passed back over a decade ago.

The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 authorized this project to encourage coordination of Medicare Part A (hospital) and Medicare Part B (outpatient) services; to promote efficient and effective care through care management and process redesign; and to reward physicians for improving health outcomes.

The five year demonstration project involved ten physician groups (approximately 5,000 physicians) who continued to be paid regular Medicare rates but also earned performance payments of up to 80% of the amount saved. The other 20% savings was kept by the Medicare Trust Fund. (Hopefully, they put that savings in the proverbial Lock Box, but I doubt it.)

Over the life of the program, quality measures were factored in and by year five, 50% of the performance payments were based on cost efficiency and 50% on quality. The 220,000 Medicare beneficiaries involved (aka patients) were tagged to a participating group “if the group provided the plurality of their office or other outpatient evaluation & management services during the performance year.” Patients averaged five visits at the group during the year.

Spending was risk-adjusted and quality was measured based on 32 indicators, starting with diabetes and adding heart failure, coronary artery disease, hypertension, and cancer screening. Groups were scored against national benchmarks and the measures were developed by CMS in conjunction with various well-respected quality organizations.

Over the life of the project, payments have varied. In performance year one, two groups shared $7.3 million. The next year four groups shared $13.8 million. Years three and four both had five groups receiving payments – $25.3 million and $31.7 million respectively. Year five had four groups sharing $29.4 million in payments.

It’s not just about the money though – the groups have also demonstrated increases in quality that should translate to increases in quality of life for the patients involved. In year five, all ten groups reached benchmark levels on at least 30 of the 32 measures with seven groups hitting them all.

Each group was able to design their own mechanism to drive towards desired outcomes. Strategies included:

• Packing as much evidence-based care as they could into each patient visit
• Protocol-driven medication management
• Increased patient education
• Streamlining transitions of care
• Leveraging technology such as automated outreach, registries, and scheduling as well as EHR

So why are the financial folks excited? They read blurbs in email blasts or in fluff journals (or possibly on cutting edge, thoughtful, and sassy websites like HIStalk) and say to themselves, “Hey, I’m sure we can do that too!” If only it were that easy.

Glassy-eyed by the thoughts of millions coming in the door, they forget that out of 50 possible group-year payment opportunities, only 20 have resulted in an incentive payment. That’s one in five. Would those same money-crunchers invest in a new diagnostic device that only had a one in five chance of breaking even?

I’d like to see data on how much these health systems spent trying to hit the benchmarks needed to achieve the quality measures. And for those who didn’t receive incentive payments, how close were they? Were there wide gaps, or in the words of Maxwell Smart did they miss it by “that much?”

Those looking to mimic these outcomes also should note that the up-front costs for this program were borne by the participants. Although they may have been able to use grant money or other funding sources, there was no pot of gold at the beginning of the rainbow. There had to be substantial organizational commitment to these projects and the willingness to take a loss and continue pressing forward.

Transforming the way we deliver care is definitely a marathon, not a sprint. Organizations need to commit to being in it for the long haul. They can’t be in it in a flavor of the month way, which we see all too frequently. Participants need to be sure they’re willing to go all-in not only financially but philosophically. The faint of heart need not apply – groups with a history of shuffling leadership every time a loss appears will have a hard time stabilizing. Groups with a history of cutting ‘expensive’ staff (aka nurses) will struggle.

Leadership needs to be supportive of the initiative at every juncture – even if it means finally dealing with those difficult physicians who refuse to use the EHR properly, antagonize the care coordinators, or fail to comply with order sets and evidence-based protocols. Substantial technology investments need to be pursued despite lack of short-term ROI. IT staff who can interact with clinicians, understand their needs, and deliver support models that work will be in high demand.

The groups participating in this project already had well-seasoned structures for looking at issues of quality, cost, and access and were able to engage and energize these teams to move forward in a coordinated fashion. They weren’t acting on a whim. They had clear priorities and direction and strategically reduced barriers to achieving that mission.

Unfortunately, I see far too many groups and providers at both the macro and micro level motivated to go after the money without understanding the hard work and resources (financial and other) needed to succeed. They also fail to understand the time it takes to properly implement programs on this scale. For those of you working in organizations like these, you have my sympathy. For those of you on the other end of the spectrum who have dynamic, engaged, and visionary leaders, you have my admiration.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 10/3/11

Last month I mentioned that the AMA had recently released its 2010-2011 Health Care Trends Report. The report’s “Science and Technology in Medicine” section includes items summarized from other sources, including MGMA data. Surprisingly, MGMA noted that independent practices were “more likely to have fully implemented and optimized EHR systems than hospital-owned practices.”

They noted that nearly 20% of EHR-owning independent practices felt they had optimized use of their systems, while another 50% had completed implementation and were moving to the next stage. In contrast, one-third of owned practices were still in the beginning stages of EHR adoption.

As far as quantifying how many physicians are using the system, only 43% of hospital-owned practices reported that all physicians used the system, where 72% of independent groups claimed that all of their physicians used the system.

I’ve spent a significant portion of my career toiling in the CMIO trenches, including oversight of ambulatory EHR implementation. Although this was largely in hospital-owned practices with employed physicians, I’ve had experience with private practices under hospital-subsidized arrangements as well as truly independent physicians. I’ve definitely noticed a difference in how the two groups do with EHR adoption and have a couple of thoughts on why they’re different.

My first theory involves the idea of free will. In a typical independent practice, the physicians have to come to at least some kind of consensus prior to purchase of an EHR. They’ve often been active participants in the selection process and in determining how a system will be implemented. Physicians may be active in system setup and customization of workflow and template screens.

In contrast, hospital-owned physicians are generally told which EHR they’re going to implement, as well as when and how. There are typically limits on how much autonomy physicians have with workflow, and customization at the provider level is taboo. It may be the system’s way or the highway. It’s always easier to get people to do what you’re asking when they think it’s their idea or when some reward is involved. It’s awfully easy to rebel when someone is trying to force change.

Speaking of reward, my second theory involves having the proverbial skin in the game. Because employed physicians typically have contracts which include the EHR and implementation as part of their employment agreements, they’re not paying much (if anything) out of pocket for the transition. Often employed groups are committed to keeping their physicians’ compensation stable as an EHR is implemented. Those physicians aren’t really incented to rapidly adopt or to change behaviors.

My colleagues who have had to pay their own IT bills (many of whom can also tell you exactly how much they paid for their EHR systems, down to the penny) have a different view of things. Trainers report that independent physicians are less likely to skip training sessions and tend to be more engaged. I’m sure those value-conscious providers know how much they’re paying for training hours and also how much they’ll be hurt if they can’t return to full productivity as quickly as they’d like.

My final theory revolves around the glacial speed of decision-making within hospital-owned practices. Physicians have given up a degree of autonomy (often for good reason – they’re lured by the promise of practicing medicine without having the pressure of dealing with staff, OSHA, CLIA, credentialing, vendors, and other distractions). Decisions are made among multiple levels of mangers, regional administrators, and hospital presidents.

There are often meetings to discuss the meeting before the meeting, not to mention the obligatory meeting after the meeting. Committees (and subcommittees, action groups, and departmental fiefdoms) have to sign on prior to things actually being decided. The ability to move forward with EHR adoption in a nimble fashion is seriously compromised. Each time the cycle repeats, adoption declines.

For those of you in the ambulatory arena, what’s your theory? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/26/11

Last week I talked about the recent government proposal to allow patients direct access to their laboratory results. A certain Mild-Mannered Reporter responded to my call for information from the laboratory vendor side and his remarks are worth sharing:

As an IT manager in a commercial lab that services a state where test results may not be released directly to the patient without specific instructions from the ordering provider, we are just now beginning to think about how we will deal with this new requirement. Our entire Laboratory Information System (LIS) is designed to be provider / client oriented, so modifying our lab result delivery processes will not be a trivial effort.

As I read through the rules as written, a number of concerns pop into my head and refuse to leave:

• Many of our lab results are not patient-centric. As there is no universal patient ID and each of our ordering providers may identify a patient differently, we may have a difficult time locating all of Mary Smith’s results.
• How far back do we need to go? There are CAP retention requirements that we abide by, but not everything is kept online forever.
• We have no idea of what the demand will be. A hundred per day or two per month?
• How will we be required to deliver the results? Your comment about utilizing an electronic portal makes sense, but the current wording seems to indicate that it is up to the patient to define how he/she wishes it to be delivered:

Processing a request for a test report, either manually or electronically, would require completion of the following steps: (1) Receipt of the request from the patient; (2) authentication of the identification of the patient; (3) retrieval of test reports; (4) verification of how and where the patient wants the test report to be delivered and provision of the report by mail, fax, e-mail or other electronic means; and (5) documentation of test report issuance.” [Federal Register: September 14, 2011 (Volume 76, Number 178)] page 56722

Interesting in this wording that encryption is not mentioned when specifying e-mail. Looks like more opportunities for labs and others to accidentally violate HIPAA/HITECH by accidentally disclosing to the wrong party.

I suspect that he lion’s share of the costs will be creating new delivery systems, researching the results, and authenticating the patient. None of these costs can be passed on to the patient — only postage and media costs.

We have always run our business to serve the patients, our physician clients, and our insurance payors. It is a delicate balance to keep everyone happy, but if our clients want us to somehow manage a delay result release and the patients demand immediate access, we may be in the proverbial rock and a hard place predicament.

Now I know that there are a number of states that already require that patients have access to their lab results, so I know that this is all doable, but we need to do a lot of planning to meet this new requirement. For now, I think that we will wait for the final rule before making any major changes.

I should also add that for me, this is not really an issue. My primary care doc publishes the important lab values with his comments on a patient portal for me to see. It works just fine because we have a deal – I don’t try to practice medicine and he doesn’t come down to the lab and tell me how to run my shop.

I’ve always been a fan of The Simpsons, and hopefully some of you are familiar with Lisa’s mentor, jazz musician Bleeding Gums Murphy. (I’m a bit disturbed, though, that when I did a Bing search for ‘image bleeding gums murphy’ it also brought up a photo of former Surgeon General C. Everett Koop.)

Hopefully each one of us has had at least one person in his or her life to fulfill that mentor role. I was lucky enough to have my own Bleeding Gums Murphy for more than two decades. He passed away this weekend, and this is the first time I’ve experienced the relatively new cultural phenomenon of grieving via Facebook. A lot of people think of Facebook as a frivolous time-waster (sometimes I don’t disagree) and many cursed it mightily this week for changing too quickly for our liking. But there’s no doubt that social media have the power to bring people together.

We don’t always have the luxury of having our mentors physically close to us, but it’s been heartening over the last few days to know that when my BlackBerry dings there’s a really good chance it’s going to be someone posting a memory to his Wall. Another friend who studied with him said it best: “I will celebrate his life in memory and mourn only those who never met him.”

In the words of Carole King:

When the Jazzman’s testifyin’ a faithless man believes
He can sing you into paradise or bring you to your knees
It’s a gospel kind of feelin’, a touch of Georgia slide
A song of pure revival and a style that’s sanctified.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/19/11

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/12/11

Mr. H’s recent Time Capsule on hospitals wanting software to do the dirty work of changing physician behavior is as true today as it was five years ago. All too often, we see the fallout of this strategy – poor adoption, user dissatisfaction, and worse.

The editorial mostly discusses CPOE, which was the hot ticket item at the time. Back then, there wasn’t a lot of attention to the ambulatory space, although Meaningful Use has certainly brought that to the forefront for many organizations.

Changing physician behavior on the ambulatory side, whether in an integrated delivery system or in a private practice, brings different challenges than on the inpatient side. Hospital have well-defined governance rules and entities to deal with problems when they arise. (note that I said ‘when’ – this is not an ‘if’ situation. There will be problem providers.)

Typically, you have a medical executive committee of some kind, made up of department chairs, service line directors, administrators, etc. Each specialty department typically has a chair who can address behavior issues with providers. Providers (both compliant and difficult) are used to these enforcement structures as they pertain to delinquent medical records, unsigned verbal orders, and the like.

Providers are used to JCAHO-dictated processes and procedures, care plans, and lots of administrative involvement and oversight. They are typically subject to medical staff bylaws of some kind and can lose their hospital privileges for misbehavior.

The ambulatory space in many organizations, however, is like the Wild West. Physicians are used to a high degree of autonomy. Even in hospital-owned provider organizations, leadership is often unwilling to be the ‘stick’ needed to change behavior. The average primary care physician generates roughly $1.5 million in downstream revenue and organizations are afraid of disruptions to referral and test ordering patterns. Unless there are legal or regulatory issues at stake (and sometimes even in those cases), physician non-compliance is often overlooked.

Implementing an ambulatory EHR is seen by some as a relatively easy way to address these behaviors. Rather than deal with true process and workflow issues, the thought is to just mandate the behaviors through system configuration. The software becomes the third-party “bad guy” to force change.

This rarely ever goes well. Users placed in these situations (both provider and other) immediately demonize the software, the implementation team, the selection team, and the vendor. This negative response isn’t very helpful or productive for anyone.

I’ve been involved in implementations where physicians were told that something is required by JCAHO or Meaningful Use when it frankly had nothing to do with either. It was just used as an excuse to try to make physicians behave one way or another. That puts implementation staffers in the middle of this fight. I’ve seen savvy physicians who know their facts completely derail training and implementation efforts as they argue with training staff who may or may not know they’re part of a manipulation effort, but either way, are not decision-makers.

Independently owned or smaller practices are also subject to manipulation efforts, but usually from within (unless there’s a Stark-related subsidy involved – that adds an additional level of potential control.) Typically, a subset of partners or a lead partner will try to leverage the EHR to change colleague behavior or practice patterns rather than addressing them head on.

We all know the old adage that putting automation on a dysfunctional process will only serve to make it more dysfunctional at a faster rate. Practices who try to implement EHR without cleaning up internal issues first place themselves at significant risk. Much like a driver’s license exam, there ought to be a test before practices are allowed to implement. I know some vendors who do readiness assessments and will reschedule practices who don’t have their acts together, but most seem to allow them to forge ahead regardless of the risk.

Some key advice for ambulatory organizations ready to implement EHR:

• Decide on what level of customization will be allowed. Will it be at the practice, specialty, or provider level? If you’re really willing to support provider-level customization regardless of outcomes, cost, or impact, then you don’t have much to worry about as far as changing physician behavior.
• For practice- or specialty-level decision-making, start the change management process prior to implementation. Standardize order sets and get agreement in the paper world. Make sure new protocols and initiatives actually work in your culture before adding an EHR to the mix.
• Revisit state and federal laws and regulations. Ensure compliance before implementation so that providers clearly understand the origin of the mandate.
• Revisit standing orders and care protocols. Make sure they are up to date. Build them accurately into the EHR and work with your vendor to ensure effectiveness.
• Analyze staff roles and responsibilities. Optimize performance and clarify expectations. If staff isn’t up to par, start remediation now. Help staff understand that EHR will change their jobs regardless of their role, and if they can’t live with that, they need to adjust or start looking elsewhere.

These items seem deceptively simple, but in fact are the hardest things a practice needs to do to be successful and are often the ones that are ignored. Implementing an EHR is not going to accomplish this for you. There are no magical lines of code to deliver a keyboard-induced shock to their sneaky little fingers. Non-compliant physicians will simple use the EHR as an excuse for their behavior rather than change.

Organizations with large numbers of “outliers” may need a formal change management initiative in addition to EHR implementation efforts. The benefit is well worth the cost.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 9/5/11

Today is Labor Day, which according to the United States Department of Labor, is dedicated to the social and economic achievements of American workers. I decided to spend a bit of time crunching numbers from the Bureau of Labor Statistics. The BLS predicted that healthcare would generate 3.2 million new wage and salary jobs between 2008 and 2018.

The Bureau also predicted that computer systems design and related services would be one of the fastest growing industries in the economy. Management, scientific, and technical consulting services were forecast to be the fastest growing, with an 83% increase.

Of course, a recession has a way of throwing a wrench into things, but I’d be interested to see how far off the mark these numbers are when it’s all said and done. ARRA and HITECH legislation have had and will continue to have a significant impact on employment in the healthcare IT segment.

The industry continues to move at high speed, not only on the development side, but in implementation as well. For the latter, I worry that too many organizations are moving at a pace that is foolhardy. Every day I hear another horror story from a colleague.

There was the one about the hospital that didn’t have their support structure figured out just four six weeks before their scheduled go-live on clinical documentation. Numerous project members tried to call a “time out” to arrange appropriate resources, but leadership forged ahead anyway in order to be able to go-live before a competitor. Physicians had no super users or trainers on the floors to help them, just a call center number.

Then there was a facility that didn’t have all the end-user hardware in place for a CPOE go-live, but went live anyway. Physicians were frustrated and actively developed ways to circumvent workflow, including hiding from nurses and phoning verbal orders from the doctor’s lounge. Juvenile, but understandable.

My personal favorite is from a small primary care practice. A few weeks prior to go-live, a competing practice hired away several key staffers. The practice used a temp agency to quickly fill the positions and stayed with their original go-live data. The temporary staffers had only a few hours of training and the practice didn’t block patient schedules to allow time for documentation. Tempers flared and staff refused to return to the assignment, making matters worse. Rather than pausing to regroup, the providers elected to continue to try to implement.

I don’t understand why anyone thinks that continuing to steamroll ahead when these situations come up is a good idea. Sure, some people continue to drive their cars with the “check engine” light on, but this is the equivalent of driving not only with a dashboard light illuminated, but also with a flat tire and smoke coming from under the hood. I can’t imagine that these same physicians would start a surgery with missing instruments or with a scrub tech who has never done the scheduled procedure.

It is folly to try to implement with an untrained staff, a recognized lack of hardware, or without an appropriately scaled support structure. It doesn’t matter how much time, money, or effort has been invested in the planning – it’s simply a recipe for disaster. If you are on one of these runaway freight trains, you know what I’m talking about.

October is approaching and many eligible providers and hospitals are going to try to achieve Meaningful Use attestation in the last 90 days of the year. I imagine I’ll continue to hear lots of stories from the field, as organizations that are simply not ready move forward, no matter the cost or chaos.

Have a war story to share? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 8/29/11

Hurricane Irene is this week’s big news, and I can’t help but think if Inga was on the East Coast this is what she would be wearing. All kidding aside, I’m glad to see friends and colleagues start checking in on Facebook and other social outlets to let people know they are OK.

Unfortunately, it’s not over yet. Air travel will likely be a mess most of this week.  Several friends can’t get flights until at least Thursday.

Once the winds are gone, flooding is the next problem. For those of you in affected areas, I hope your disaster recovery and business continuity plans are working without a hitch. For those of you who haven’t shared in the bounty of natural disasters we’ve seen in the US this year, it’s a good opportunity to review those plans and consider a drill.

Numerous East Coast hospitals evacuated patients. Others canceled elective procedures to reduce census numbers and make room to receive evacuees and potential casualties. Some suspended visiting hours or made arrangements for staff to stay in the facility after their shifts were over to prevent them from having to go out into dangerous conditions (not to mention that it might be handy to keep them in-house should relief staffers not make it in).

One colleague reported using her electronic medical record’s patient portal site to push messages to pregnant patients, instructing them what to do if they should go into labor during the storm. Another mentioned a communication from the Department of Defense’s TRICARE program saying that patients in affected areas may be eligible for a waiver of the Primary Care Manager referral requirement as well as emergency “refill too soon” procedures to ensure patients have needed medications.

Providers who personally experienced the impact of Hurricane Katrina in 2005 shared their experiences and recommendations over the last several years and it appears that many organizations took these to heart. I’m not seeing too many reports of hospitals that were severely affected, and I hope most if not all continue to remain unscathed throughout any flooding. It’s not looking good in Montpelier, VT where officials are considering flooding the capital to save a dam.

I’ve personally experienced some significant flooding and am a veteran of sandbagging. I’m always disturbed by the photos of people outside in the storms or defying evacuation orders. I hope folks in New Paltz, NY return to their senses. Due to the large number of people gathered to watch flooding, officials had to ban alcohol sales and order people off the streets.

If you’re among those impacted by Irene, the thoughts and prayers of the HIStalk team are with you. Stay safe.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 8/22/11

As most of us know, it doesn’t matter how much time you spend doing e-mail. It’s impossible to stay ahead. Sometimes I e-mail myself articles that I would like to mention. Before I have a chance to get my thoughts on paper, they scroll up, up, and away as the inbox gets larger and larger.

(Speaking of, have you ever tried to change the way you work your e-mail, say from top to bottom when you’re used to working bottom to top? I recently had this experience, and for whatever reason, it was extremely difficult. Talk about assaults on muscle memory! It’s finally back the way I like it, but it was a painful experiment that although designed to yield efficiency, just made me crazy.)

As I did some e-mail cleanup during a bit of unexpected free time (thank you, cancelled conference call!) I found an e-mail that reminded me to look at a journal article: Longer Lengths of Stay and Higher Risk of Mortality among Inpatients of Physicians with More Years in Practice.  The study looks at patients hospitalized during a two year period (2002-2004, coinciding with the residency training calendar on a July-June basis) on the teaching service.

For those of you not in hospitals that have residency programs, the teaching service is staffed by interns and residents under the supervision of an attending physician. Depending on the structure of the teams, supervision of the trainees varies, but ultimately it’s the attending physician who’s on the line should something go wrong.

There is speculation that patients who are hospitalized in July do worse because of transitions in the trainee pool (I talked about this “July Effect” last month), so I was glad to see this study controlled for the variable of having residents and students involved in care. All of the patients were treated at Montefiore Medical Center in the Bronx. They also controlled for any chance that having a more lengthy physician-patient relationship would influence the outcome by restricting patients to those who had never received care from the attending physician.

The authors looked at four groups of attending physicians: those in practice 1-5, 6-10, 11-20, and >20 years. Although the number of physicians was only 59, they looked at over 6,000 patient admissions. Patient groups were similar in demographics and clinical characteristics.

The study found that physicians in practice more than 20 years had greater mean length of stay numbers and greater mortality rates (both in-hospital and 30-day) than physicians with less than five years in practice. This impacted the sickest patients greater than those with less-complex conditions.

They also found that when the teaching service was less busy, patients stayed the same amount of time regardless of physician age. However when there were more patients to care for, length of stay increased in the longer-practicing group.

The authors conclude, “Inpatient care by physicians with more years in practice is associated with higher risk of mortality. Quality-of-care interventions should be developed to maintain inpatient skills for physicians.”

Well, isn’t that special! Talk about a solution that doesn’t necessarily address root cause.

Quite a few organizations commented on the study, with some citing earlier data showing that more seasoned physicians are less likely to adhere to published guidelines. This strengthens the argument that physicians should have to recertify periodically to prove that they are staying abreast of current standards of care. 

I agree with that. My specialty requires everyone to recertify, but other specialties have allowed older physicians to be “grandfathered” into perpetual certification.

Certification aside, though, I’d like to propose two other areas that need analysis. The first is the fact that the more seasoned physicians have gone through a tremendous amount of change in medicine over the last two decades. There have been drastic changes in the non-clinical work physicians are responsible for (insurance issues, E&M coding, pay for performance, loss of autonomy, economic pressures, etc.) and one of the natural responses to change is to entrench in the past.

The second involves looking at the systems that have proliferated based on the changes above, both operational and technical. There has been a proliferation of operational platforms impacting how clinicians are forced to navigate – everything from the Disney Institute to Six Sigma. Simultaneously, there’s been tremendous pressure to move to electronic systems that range widely in their ease of use, stability, and quality.

I’d like to see similar data where they survey the physicians about their comfort level with not only hospital policies and procedures (including proliferation of care coordinators, discharge specialists, length of stay coordinators, coding coaches, etc.) impacting their care, but also on their comfort level with the systems they use and how well they use them.

Because of the presence of interns and residents, I have a sneaking suspicion that some of the more experienced attendings may not have leveraged technology and the team approach (sometimes perceived as interference) as much as they could have. Old work habits are hard to break, and when you’re used to the lower-ranking physicians doing everything and just co-signing at the end, it’s easy to miss things.

Coupled with a mistrust for technology, it’s even more complex. I suspect newer attendings for whom these systems have always been present would be more likely to be hands-on with the technology rather than passive.

Regardless of the reasons, it’s something that deserves a second look.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 8/15/11

In the realm of medical devices, this is one of the coolest things I’ve seen in a long time. University of Illinois engineering professor John A. Rogers and team have designed a sensor that’s about as obtrusive as a temporary tattoo. Not only can it pick up biometric data, but when placed on the throat, it can sense differences in spoken words such as “stop” and “go,” as well as directional commands. Hot news for patients with muscular or neurological conditions, it appears in last week’s Science.

Pardon me while I embrace my inner physics geek, but the sensor adheres using the van der Waals force, which is what geckos use to climb glass. Sounds funny, but it’s a big deal for patients who are allergic to medical adhesives. Tuck that away for your next Trivia Night.

I came across too many juicy tidbits this week to hold them for EP Talk, so this week’s Curbside Consult is more newsy than usual. Some recent all-nighters and an insane volume of Meaningful-Use related work also may have caused my attention span to be so short I’m not sure I’m capable of crafting an entirely cohesive page-long feature at the moment.

And did I mention the not-so-subtle influence of Las Vegas, home of total sensory overload? (BTW, it’s chock full of Siemens people. I thought about crashing, but maybe some readers can send me reviews and commentary from the Innovations ’11 Customer Education Symposium.)

Now that some vendors have finally tweaked their systems to allow appropriate documentation, the World Health Organization declares the H1N1 “swine flu” pandemic over. It doesn’t mean that the virus has gone away, just that it no longer meets pandemic standards. As an IT person, this was a great litmus test for the ability of vendors to be nimble. Quite a few were able to load systems with the ability to document, treat, and track quickly; several were less fortunate. This isn’t the first time we’ve seen emerging diseases (remember SARS?) and certainly won’t be the last, but hopefully next time it will be easier for the end users.

The Patient Right to Know Act will bring back a controversial Illinois database housing information on physicians, including malpractice settlements and judgment information. The database and its associated Web-based tool went offline following an Illinois Supreme Court decision regarding a medical malpractice reform law. The database will contain information on over 46,000 physicians and should be online in a few months.

Speaking of state news, Kentucky and Ohio are banding together to share prescription data. KASPER, the Kentucky All Schedule Prescription Electronic Reporting system, will connect with the Ohio Automated Rx Reporting System, also known as OARRS. (Not to be confused with the band O.A.R., which if Mr. H hasn’t listened to them yet, he should check them out — their new album was released last week.) Focusing back on the topic, it sounds like a great idea, but I’m very interested in how it actually works for the doc who’s trying to figure out whether the patient is drug seeking. If anyone has details or first-hand knowledge, please share.

Athens Regional Medical Center in Georgia has seen a 15% rise in online scheduling since implementing a scannable Quick Response code in advertising materials. The code is different depending on where it is placed, allowing tracking for the most effective referral sources.

Speaking of smart phones, I’m liking Mobiledia right now. Sometimes I need a break from healthcare, and their recent piece on Chinese plans for an app to update People’s Liberation Army troops on the latest happenings was just what I needed. Watch out though – the site is fascinating but will take you Wonderland-style right down the rabbit hole. I quickly bypassed the blurb about the recent bust of counterfeit Apple stores straight to the one about the Chinese teenager who sold his kidney for an iPad 2. (I don’t think I’ve ever put three hyperlinks in the same paragraph, so you can tell how addicting it is.)

I just discovered this is the tail end (no pun intended) of the World Mermaid Convention, so I’m going to check that out. If it’s a bust, there’s the Official Star Trek convention as well. Viva Las Vegas!

E-mail Dr. Jayne.