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.

Curbside Consult with Dr. Jayne 8/8/11

I had a long, lazy weekend, of which I spent a good part staying up too late catching up on the Netflix releases that have been mocking me from the top of my television. Kind of like those folks that tend to smoke only when they visit bars — when I stay up late, I have a bad habit of winding up at Taco Bell. As I sat in the drive-through lane pondering what it is that makes even the most health-conscious physician stray, I noticed a billboard for a local hospital advertising the ability to hold one’s place in line in the emergency department.

It was news to me that one of our competitor hospitals had partnered with InQuickER, whose slogan is “Skip the Waiting Room.” Essentially, for a $9.95 registration fee, patients can register for their emergency department visit and wait at home until their projected treatment times. Kind of like call-ahead seating at Red Lobster, although I assume you don’t get a cute crustacean-shaped beeper when you arrive.

As a technical person who also speaks fluent Administralian, it sounds good. It’s a relatively easy technical application – if restaurants can do it, there’s no reason it can’t be applied to other industries, including healthcare. As a physician leader, I can imagine that patients who aren’t frustrated from sitting for hours in a crowded waiting room are likely to give higher scores on patient satisfaction surveys and may be less likely to taunt the triage staff or harass caregivers.

On the other hand, as a clinician, it makes me cringe a bit. Although InQuickER admits it doesn’t actually schedule appointments but rather holds a patient’s place in line while they wait at home, it does offer a guarantee in which users who aren’t seen within 15 minutes of their projected treatment time are given their money back.

During the past decade, I’ve watched the physician/patient relationship slowly erode. There are a lot of factors impacting this both positive and negative.

Personally, I believe that educated patients are healthier patients. I believe in patient self-determination and that some physicians need to jettison the antiquated paternalistic tendencies they continue to carry. I want patients to be smart shoppers and to understand their healthcare choices. I don’t want them to necessarily do things because “the doctor told me to.”

On the other hand, I believe the overt consumerization of healthcare has some serious downfalls and minimizes the complexity and skill involved in caring for and treating patients.

Although InQuickER’s FAQ section clearly states that hospitals do use triage protocols and that its users do not receive preferential treatment, it’s easy for a patient who doesn’t read the fine print to make the logical leap that they’re going to receive special or quicker treatment. They advertise a 95% success rate for patients being seen within 15 minutes of their projected treatment time, and for physicians already under pressure to reduce cycle times and see greater numbers of patients more and more quickly, this is just going to add more stress to an already bubbling pressure cooker.

I cover the emergency department regularly and see a large proportion of patients who don’t need to be there, many with non-urgent conditions who haven’t tried any over-the-counter remedies or exercised a reasonable degree of Boy Scout-level first aid skill. In some cases, the thought of sitting in the waiting room with “all those sick people” is enough to keep them at home and out of the emergency department, and sometimes their issues spontaneously resolve without at $50 copay.

For a mere $9.99, the inconveniences of waiting are avoided, and I worry that this will bring more non-urgent cases into our already overcrowded system. On the other hand, for some cases, this could be heaven sent – for the migraine patient who has exhausted all home prescription medications and is bothered by light and sound, the ability to minimize time in the waiting room is solid gold.

As I crunched on my Volcano Taco, I surfed the hospital’s Web site. Injecting a bit of humor into the situation was this: the InQuickER site projected a 75-minute wait for me, while the hospital’s own handheld app advertised a 14-minute wait on their real-time waiting room ticker. With stats like that, of course, the odds that I’d be seen before or within 15 minutes of my projected treatment time were pretty good.

I can see both sides of this one, so for me, the jury’s still out. Nevertheless, I put the word out to colleagues at the hospital in question to ask how it’s really going, but I’d also like to hear from readers. Are any of your facilities using the system or that of a competitor? InQuickER is SaaS model — how are they to work with? How is support? Any issues? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 8/1/11

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 7/25/11

Last week, Inga mentioned that the results of the annual EHR User Satisfaction Survey have been published by the American Academy of Family Physicians. Unfortunately, AAFP has this content on a restricted members-only site, so I had to bribe my favorite cross-town family doc for a copy.

I don’t want the copyright police to come after my friend, so I won’t share the full article, but I’ll summarize some key thoughts here. It also gives me a chance to hone my “speech” because I’m sure I’ll have colleagues waving it in my face (just like they did the last time the survey was conducted) and wanting to talk about how “our” system did. Some key thoughts:

There were “far more” responses than previous surveys. However, I found the reasons for excluding some respondents pretty funny. They included:

• Not using an EHR
• Not naming the system they used
• Naming a practice management system rather than an HER
• Naming a “home-grown proprietary system or… something that we could not verify as an EHR”

There were 2,719 usable responses covering 205 systems. Only 30 systems had 13 or more respondents. Those that had over 100 respondents included:

• EpicCare Ambulatory – 392
• NextGen Ambulatory – 247
• eClinical Works – 244
• Centricity EMR – 209
• Allscripts Enterprise – 180
• Practice Partner – 123
• e-MDs – 120
• Allscripts Professional – 106

There was a broad distribution of practice sizes.

Detailed information on version and implemented features was not presented. Nearly half of respondents “apparently did not know their product’s version number.” My spidey senses always tingle when small practice users have issues with their EHR. I’ve worked with docs who are using versions that are up to three years outdated and are surprised at how well the “current” version works once it’s applied.

The version paradox isn’t unique to small practices, though. For example, how many different flavors of Epic are there depending on how it was implemented? One of my buddies complained that it was ridiculous that Epic doesn’t have e-prescribing. Turns out her organization hadn’t included it in the initial physician training for some unfathomable reason.

Duration of use of the system ranged from “weeks” to “20 years,” with the majority being up to three years and another chunk being in the three to 10 years category. I think time on the system might be a useful exclusion criteria for future surveys. From experience, even with the best implementation, it still takes some practices a minimum of six to eight weeks for users to settle in and for workflow to stabilize if not longer depending on the commitment of the users and the willingness (or resistance) to change.

Fourteen percent of respondents have switched systems at least once due to dissatisfaction with a previous EHR.

The authors recognize these limits, summarizing:

As we said to begin with, it’s probably best to consider the survey results as input you’d get from a large number of colleagues who volunteered informally to report on their EHR experience. That said, we believe that the results presented in this article and its online appendix can help any family medicine practice considering the purchase of an EHR system.

This is a really key point. The study was not randomized, but rather respondents self-reported. Bias could be toward either providers who have serious concerns about their system or those who are significantly satisfied. Although the numbers were much better this time around, it’s not a true cross-section of users and doesn’t account for variables that can truly make or break an end user’s experience. These include poor implementation, lack of commitment among providers and office staff, and failure to implement recommended best practices.

During the implementation of my first EHR, there was no “kickoff” to bring everyone in the practice to the same page. Nor was their a discussion of workflow changes or process redesign. The trainer showed up and started teaching the template builder without the users having any context to her lessons. Coupled with her training on a version that was different than what we had installed, it was an unqualified disaster.

On the client side, some providers feel entitled to behave badly. I’ve had providers refuse to show up for training, refuse to complete practice scenarios, and refuse to be part of the customization process, yet complain relentlessly that the EHR doesn’t meet their needs. Those of us that have been in this a while know that deploying an EHR on top of a dysfunctional practice will only make it more dysfunctional. Partners who have historically felt disadvantaged in the practice often use implementation as a time to lash out against their peers.

Users often go against what the vendor recommends. Sometimes this is justified, such as when there are defects in the software or specialty-specific or regional issues that the vendor isn’t addressing. But sometimes it’s not. I’m currently watching the equivalent of an EHR car crash as one of my closest colleagues is being forced onto a system that isn’t configured optimally. She’s part of a larger group and is a younger physician with little political power to counter the decisions being made higher up. As a user of the same system, I’m keenly aware that the choices they have made will lead to more work being placed on the physicians, less efficient charting, and potential patient safety and regulatory issues.

I’ve armed her with enough knowledge to try to steer them in the right direction, but so far she hasn’t been successful. Eventually they’ll learn, but at the price of user bitterness and potentially patient safety. I recommend that new users take advantage of all the training and information they can get their hands on, whether formal – training programs, client conferences, user symposia, webinars, and the like – or informally through Internet chat groups, informal user get-togethers, hospital colleagues, or blogs.

Many systems offer the ability to customize on a per-physician basis. Providers who are not fully educated on the risks and benefits of doing so can quickly customize themselves into a corner and out of the ability to achieve a decent workflow (not to mention loss of the ability to reach Meaningful Use). I strongly recommend users make an attempt to use the system as the vendor delivers it for at least a month before customizing (although if the system arrives with defects and bugs, often customization is needed to effectively deploy the system).

I encourage practices to consider using EHR implementation as a chance to look at all office policies and procedures, whether written or anecdotal. Automating bad workflow just allows bad workflow to happen more quickly on a greater scale. I encourage partners to think out of the box and consider whether it’s rational for each doc in the office to have his or her own process for handling phone messages and refills. Often there is one process that is more efficient that can be expanded to the entire office with a little effort, resulting ultimately in greater satisfaction for end users.

A survey such as this one can’t account for all these factors, so my advice to users (and those still shopping for an EHR or looking to replace what they have) is to take it with a grain of salt and do your research. Talk to current users and not just those references served up by the vendor sales team. Talk to your colleagues. Spend as much time hands-on with the application as you can, and carefully consider your choices during the build and implementation process.

And for those users who are dissatisfied with their systems or feel their needs aren’t being met, don’t just fillet your vendor in the next survey. Take a proactive stance. Review your contract and implementation documents and make sure you’ve taken advantage of all the training you were allowed, and if you need more, buy it. It amazes me that physicians who wouldn’t start performing a new surgical procedure if they didn’t feel fully trained are happy to jump into an EHR with only a few minutes of training.

Log defects with your vendor and keep records of any defect and enhancement submissions. Understand your support contract and how your vendor is required to respond to issues. Take advantage of any account management or client management services that your vendor offers. Even if you’ve been on a system for years, don’t be afraid to consider retraining, especially if you have to upgrade your software to qualify for Meaningful Use. It’s a great opportunity for a refresher, and CMIO types like myself can always use the Big Bad Wolf of MU to sneak in additional workflow coaching during “mandatory” training.

AAFP has conducted this survey three times before. The first had 408 responses, the next 422, and the 2009 survey had 2012 responses. It will be interesting to see what the results look like the next time it’s conducted and whether any conclusions can be drawn once Meaningful Use is in full swing.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 7/18/11

I’m finally back in my normal routine with the usual rounds of meetings, committees, working groups, conference calls, and Meaningful Use activities that make up the fun-filled CMIO lifestyle. Lots of reader response this week, and that has kept me going through it all. Every time I take vacation, I forget how much one gets punished the week after, so thanks to all of you for keeping me going. Your e-mails have been a true bright spot in an otherwise harried week.

Last week’s piece on physician rating web sites generated several comments. Most of them agreed that the sites don’t have a tremendous amount of worth compared to word of mouth or physician recommendations. Tammi sent her thoughts:

Too bad there isn’t a truly reliable source I would trust. Having been down the roads I have been down, my choice would still be to do my homework and ask around and ask the right folks. And then ask again. It is about more than the physician, too. Who supports them and what is their experience?

Entirely true. There may be a lead physician performing a procedure, or a primary care physician quarterbacking the care, but there’s a whole world of nurses, consulting providers, patient care technicians, case coordinators, therapists, and a host of others involved. Having seen it from both the physician and patient sides, it pays to do your homework.

In response to my comments on physicians and social media, Chris reminds us that it goes both ways:

A lawyer friend of mine passed this along the other day about a judge allowing Facebook posts as evidence in a personal injury case. I wonder how long until we see this same thing in a medically related case?

Based on some of the antics of my employees on Facebook, it’s apparent that people don’t care who is reading or what they are writing. And no, I’m not stalking them. Most of them actually friended me, so it’s not as if they don’t know that I might be reading. I worry for their livers and their brain cells, that’s all I’m saying.

Tremendous feedback on my quest for appropriate cocktail pairings to go with mandatory online training. I can officially confirm that Personal Protective Equipment is much more enjoyable with a drink and some nibbles. Judy encouraged me to not forget Compliance as a potential topic. My recommended pairing for either Compliance or Risk Management training:

Over the next few weeks, I’ll be working on some online modules that are required for specialty board recertification. For those, I have chosen some picks from Caduceus Cellars.  (For those music lovers who like Mr. H’s notes on what he’s listening to, you may be interested to know that Caduceus is project involving Maynard James Keenan, legendary front man for Tool and A Perfect Circle.)

Rock star HIStalkapalooza correspondent Evan Frankel mentions:

I have fallen back in favor of Portugal’s very unique and refreshing green wine ‘vinho verde’ with scholarly research. With an iced glass as its chalice, [it] really does induce people to sit outside, enjoy a sunset and get into really meaningful and enjoyable conversation about the future of healthcare in America.

Evan, do you wear your fabulous jacket when you drink it?

Matthew noted:

One cannot go wrong with Orin Swift’s excellent The Prisoner. Not only is this blend of mostly Zinfandel, Cabernet Sauvignon, and Syrah pleasing to the palate, the label itself perfectly sums up how one feels while attending mandatory training offerings.

Oh yes, I will be using this one. Perhaps some bottles as attendance prizes for Meaningful Use upgrade training? Or for myself, when I’m forced to attend said upgrade training, which although I wrote and approved, I have to attend to verify credit in the online system?

Speaking of verification of attendance, a letter to the editor in American Medical News caught my eye this week. Massachusetts surgeon Jeffrey Kaufman writes about his experience of being required to punch a time clock. Although I’ve not had to actually clock in and out, my employment agreement and pay stubs reflect an “hourly wage” for being a physician. I don’t remember the last time I worked a straight 40-hour week. When I asked about it, I was told that the personnel resource management system (aka software) can’t handle a salaried employee. I’ve been known to mentally divide my salary by actual hours worked. As a Chief Resident, I could have done better on the night shift at Taco Bell.

Last but not least, the perfect wine pairing for a discussion of Meaningful Use. I will definitely be looking for this one the next time I shop for the fruit of the vine. I’ll have to make a point to have some in house prior to the final decisions on Stage 2. Have any other cocktail suggestions? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 7/11/11

I talked a little last week about the perils of new resident physicians starting at teaching hospitals. Not only do new residents relocate in the summer, but a lot of families do as well to take advantage of the gap between school years. Knowing I’m a physician, a new neighbor surveyed me about choosing a primary care doc for the family. Unless you have a doc next door, most people consult relatives, co-workers, neighbors, and friends for recommendations. One hot button area that doesn’t get much coverage in Health IT circles though are online rating services such as HealthGrades, RateMDs.com,  Angie’s List,  and others.

Remembering my experience with the Medicare Physician Compare website, I decided to find out what I look like on some of the other sites as well as what it would be like to correct errors, should I find them. I started with HealthGrades, which listed me at the correct address at least, but I had no ratings. Although that doesn’t help new patients at all if they are looking for a physician, one thing it does say is that at least I haven’t made anyone sufficiently mad enough that they logged on and gave me a thumbs-down.

Kind of surprising since I make at least one patient a day angry by refusing to prescribe antibiotics when they’re not necessary or by refusing to order unneeded imaging tests. HealthGrades does have a physician portal where providers can update their information or post a response to ratings. I searched two of my friends, just for additional sample size. One who works for a large HMO had no ratings; another who is part of a small private practice had nine. No individual patient comments were posted.

RateMDs.com had me listed at a location where I haven’t practiced in half a decade. I didn’t have any patient ratings, nor did my HMO colleague. My private practice buddy had eight ratings this time, seven of which were extremely positive and one which could not have been lower. Individual patient comments were posted, and the site also had the ability for logged in users to respond to other users’ posts.

Not being a member of Angie’s List, I couldn’t see what we look like there. They do offer the ability for “businesses” to register and see their own profiles but I’m trying to have a bit of a vacation and was tired of fighting the molasses-like hotel internet so I took a pass on registering. Regardless, I’m not sure what I think about being rated as a degreed healthcare provider in the same vein as auto mechanics and tree trimmers. Patients are not SUVs or oak trees. A website that had the potential to be inflammatory was WrongDiagnosis.com, which seemed to just be a redirect to HealthGrades information as opposed to anything sensational.

I talked to my two colleagues to see what they thought about these sites. My HMO connection didn’t think much about it at all – she said it has never really come up with any of her patients and if they have issues with her care, it goes through an internal ombudsman process, which she theorizes is responsible for how quiet her profile was, as well as other docs in her organization that she pulled up. Virtually no one she works with had any ratings either. (We were having a good time searching people we know while we chatted, kind of reminded me of going through the Freshman Annual at college trying to figure out what info we could gather on classmates in the pre-Facebook era.)

On the other hand, maybe for my small-practice colleague, patients felt they didn’t have any other feedback mechanism than the websites. She revealed that she’s had issues with a particular patient in the past, who was terminated from the practice for disruptive behavior. The patient then went on multiple rating sites posting information about my colleague which was found by the state medical board to be unsubstantiated. She and her staff spent what she believes to be hundreds of hours having all the comments from that patient removed.

Determining whether a bad outcome was the result of mistakes by the healthcare team, issues with patient compliance, underlying comorbid conditions or other factors is extremely difficult. In the case of my colleague, from the ratio of glowing reviews to poor ones, it’s pretty obvious that either something dramatically different from all the other visits happened, or that the physician and patient didn’t click. From my limited sample, it’s not clear whether the rest of us are just boring physicians that no one cares to write about, or whether this technology hasn’t really taken off with patients.

If you have an experience with physician rating sites, whether as a provider or as a patient, I’d be interested to hear about it. Until then, I’m headed back to the beach with some Inga-inspired reading material:

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 7/4/11

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 6/27/11

My colleague Dr. Doug Farrago (self-proclaimed “King of Medicine,” who I interviewed back in March) has recently renamed the Placebo Journal Blog to the Authentic Medicine Blog in an attempt to connect readers back to the roots of medicine. The blog is targeted at identifying medico-political barriers in the way of providers actually treating patients.

I have to give him full credit for sharing a recent article from American Medical News that helps explain why it is that no matter how much money the Medicaid stimulus plan pays to providers who adopt certified EHR technology, it will never be enough to reimburse them adequately for what they do. Following the Accountable Care Organization trend, Arkansas is looking to bundle Medicaid pay. Arkansas Medicaid Director Eugene Gessow proposes groups of “partnerships” that would parallel ACOs but will avoid being labeled as such. Seeing how successful Medicare ACOs have been so far, I’m skeptical. And now we’re going to do it with patients that, unlike their 65-and-up counterparts, are in and out of the payer’s coverage?

This type of restructuring may push some providers over the edge. Many providers are reluctant to accept Medicaid due to the increased documentation and regulatory burden compared to other payers. Many of those with Medicaid populations comprising 30% of their panels (20% for pediatrics) saw the opportunity to receive Meaningful Use payments as a way to try to obtain funding they sorely need to continue that mission.

To put this in perspective, I receive $24 per visit for Medicaid for a visit that with private insurance pays out at $65 to $80. Do the math – it’s increasingly difficult to continue to see patients whose reimbursement is less than the cost of doing business, and these tend to be more medically needy patients with significant socioeconomic-related health issues. Mr. Gessow states, “We need to stop paying fees for the process of treatment and instead reward the successful results of that treatment.” In short: we’re going to take the most medically needy patients and make payment for their care outcomes dependent? It certainly sounds that way.

I understand what they’re trying to do. I, too want to see more funding for care teams, social workers, and ancillary staff so they can work with the patients more directly, allowing physicians and other licensed providers to do what we trained to do rather than figuring out transportation issues and prescription vouchers. Those are essential services for many patients, but it doesn’t take an MD to do it.

Arkansas plans to rely heavily on existing EHR and other health IT systems to meet their quality goals. As an “IT guy” watching the havoc caused in the EHR industry by Meaningful Use mandates, I can’t wait for all fifty states to jump on the bandwagon and come up with a patchwork of state-specific mandates that will disrupt development cycles and create make-work upgrades for medical practices and hospitals. Vendors can barely keep up with state requirements as it is. I’m still looking for a vendor who can correctly render every state prescription blank, has state-specific immunization consent forms, and who ships out of the box with state-specific EPSDT forms for Medicaid child well exams.

Trading my “IT guy” hat for my scrub cap, as a physician, I just don’t see it as a reality in a nation where free will and self determination are key social tenets. Ultimately, it doesn’t matter how fabulous your IT platform is, how endearing your health coaches are, or how persuasive your clinicians try to be. If the patient doesn’t want to do what’s recommended, you can’t make them. No amount of clinical decision support or orders tracking can fix that one (although it does help the process of cajoling, bargaining with, and ultimately harassing noncompliant patients).

I’ve been doing quite a lot of travel lately, and have seen some things that as a physician make my hair stand on end. I have no idea how to successfully counsel against behaviors that patients continue to choose regardless of how negatively they may affect their health. Recent favorites:

1. Motorcycle riders without helmets (regardless of the law).
2. Establishments that serve daiquiris through a drive-thru window as long as there is tape over the lid, rendering the container “closed.”
3. Parents at the airport absorbed in their iPhone and iPod universes who ignore their stroller-bound children (folks, have you ever heard of reading a book to your child? It’s recommended by a variety of evidence-based organizations and my state Medicaid program requires me to counsel you on it or I won’t get paid.)
4. My bikini-clad neighbors on the beach, discussing their wrinkle-preventing Botox injections while sunning themselves to a color that I believe Crayola calls “burnt umber” while smoking (some days I really wish I had trained in dermatology).
5. Parent holding an unrestrained infant in the front passenger seat of the car (yes, I know some of us grew up without car seats and lived to tell, but it’s dangerous and illegal in 2011.)
6. Patients who want to talk about whether Kim Kardashian’s alleged gluteal implants would actually show on a radiologic study  (no kidding, I had this question) rather than their diabetes.
7. Patients who can name the starting lineup of the local baseball team, but not their BMI or cholesterol numbers.
8. Folks who take the concept of the “all you can eat” buffet seriously.

So, good luck, Arkansas Medicaid providers. I wish you well. Good luck to the IT vendors as you scramble to meet whatever regulations they come up with and to the clients who pay for customization while waiting for the vendors to achieve an aggressive go-live timeline for mid-2012. And finally, good luck to the patients who are unwitting participants in an experiment that wouldn’t pass most Institutional Review Board approval processes.

The only silver lining here is for the hordes of consultants that will descend, trying to figure out ways to secure their piece of the “savings” that Medicaid anticipates.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 6/20/11

Well, it seems Dr. Jayne has a new not-so-secret crush. His name is Ricky Roma. Seriously, I almost swooned reading his response to my recent Curbside Consult. 

Why, you ask? Because 90% of the time, I sit on that wall right beside the fearless IT warriors at my hospital, defending security policies and standards as well as truth, justice, and the Enterprise Way.

I’m the one who has the fun of giving the smack-down to whiny end users (frequently Department Chief types or high-profile surgeons) who don’t understand why giving their passwords to their students and staff is a bad idea. I get to explain why each department can’t have their own customized software when we’ve got a large health system to run. I’m a huge fan of that speech in A Few Good Men and I’ve used a variation of it more than a few times.

One of the things I enjoy most about writing for HIStalk is for Dr. Jayne to be able to represent viewpoints that are not necessarily mine. I’ve been an “IT guy” long enough to know that we do play a somewhat parental role. Like those who celebrated Father’s Day yesterday, giving in to everything that’s asked of us isn’t a good idea.

Another aspect I enjoy is the ability to throw topics out and see what’s hot and what’s not. And this is clearly hot. I’d like to share some of the responses I received. Regarding my comment about an orthopedic colleague who had the wide-aspect laptop, one reader pointed out:

The hardware issue is really a software issue. Your point about software working on 4:3 vs. 16:9 screen displays is valid to a point. However, I find that my Web apps can adjust to my display, especially if the display is a phone. It seems to me that with the growth of HD capable monitors and gaming- and video-optimized laptops that software vendors would let go of their control of each pixel and allow folks to optimize their software for the aspect ratio of their system.

One of the coolest things I ever saw was a technical writer would could take his massive 16:9 monitor and pivot it from landscape to portrait orientation and his application (Word in this case) reoriented the display to take advantage of the orientation. He went from side-by-side book layout of two pages to one page over the other. Very, very cool.

HIT should demand that kind of separation of display from the underlying application. I know it can add to support costs, but is the goal here to reduce support costs or make medical practitioners more efficient and comfortable in their work.

I don’t disagree. More vendors need to make their user interface dynamic. However, when the vendor clearly states in the documentation that there is a specific aspect ratio and resolution required for the product but the IT staff purchases something different, it’s a hardware/people issue. Agreeing on that point, the reader added:

Having started in healthcare at a startup years ago then moved on to other fields, including mobile, and then back into healthcare and EMRs, I felt as if the industry had not changed in my absence. What I see is that there just has not been enough money in the market for anyone to actually maintain apps the way they should be, which is managing the infrastructure as well as just shoveling on more features.

In the ambulatory EMR market, I just see a race to add functionality without investment in redesign so you get these incredibly long series of tabs with very difficult discovery of how to do what you want to do next. In this world of Google, it is crazy that many searches are still bound to a particular field rather than being ‘softer’ and allowing for searches across multiple fields with a list sorted by relevance.

There is this huge disconnect for healthcare workers between the systems they use at work and those they use in their private pursuits.

This last statement is incredibly profound. It supports why so many physicians want to use the technologies available to them in other arenas when they are caring for patients.

Trust me, I understand security. I understand encryption. I understand HIPAA, OCR penalties, and the perils of letting users slap any old device on the network. I also understand load balancing, network and server performance metrics, and a host of other things that, when spoken about in mixed company, render other physicians clueless.

Having had not only my physician data breached (including SSN) but also my own PHI, I really do get it. What I have difficulty understanding though, is an IT department that runs Windows XP across the board and will allow Fujitsu tablets on the network but not HP devices.

Some savvy readers noticed that although many reader comments were of the “no Apple, no way” variety, other than citing the project at Albany Medical Center, I never suggested that IT departments should allow users to put personal devices on the network at their every whim, or that Apple products didn’t have potential security issues. In speaking of the variety of hardware in the market today, I used the word “nightmare” to describe the consequences of lack of standardization. I didn’t suggest that IT departments throw the baby out with the bathwater, but noted that those who are able to temper their requirements have an advantage over those who don’t.

Not every IT department is understaffed, underfunded, or abused. One correspondent cited a hospital where the IT department has more employees than any other business unit, as well as a level of funding that is many times that of the top clinical divisions combined. (word of advice – if you don’t want to “out” your employer, don’t message on Facebook because I can see who you work for. And BTW, I am not surprised!)

What’s extremely hard for CMIOs to do, even those of us who sit in solidarity with our IT brothers and sisters, is to explain to the physician who is working with the ergonomics team because of a visual disability that the IT department does not have any devices to offer her other than a fixed-location PC with a large monitor (even though they’re readily available from the vendor) because they’re not “standard.” As Shipes commented, maybe it’s an IT governance problem.

How should we respond to the colleague who has read about competitors using different technology, or the one who is on staff at a competitor hospital who allows iPads for patient care? HIStalk and other media are full of articles about healthcare organizations embracing the iPad. Clearly some organizations have figured out ways around the security issues, or are able to limit use to certain applications. Clinicians are looking for facts, not fear. As I was thinking that I’d like to hear from those groups how they do it, my inbox made its happy little ‘ding’ sound, and a fellow CMIO hit the nail on the head:

Security and productivity can’t be mutually exclusive, or healthcare is doomed. It is imperative that everyone in IT from the CIO and CMIO down to PC support realize we all share a common mission: (1) patient safety and satisfaction (often forgotten); (2) organizational productivity (no margin, no mission); and (3) physician satisfaction (we like happy docs). If this means devoting resources to figure out how we can provide secure access from physician devices, we should plan on that investment. I often hear from my colleagues that we care little about their practice, we have no consideration for patient care, and we have no interest in helping them with daily activities of being a physician. IT has become integral in the care of patients and needs to act that way.

We are in the process of provisioning the Epic Haiku (iPhone) and Canto (iPad) app to probably close to 1,000 physicians. We did an internal survey and discovered 90% of our physicians use smart mobile devices, greater than 75% the Apple platform. The Epic mobile app allows them to have deep access to the patient’s current chart and past history in real time, and with AT&T, they can be speaking with a nurse or colleague while reviewing the chart simultaneously. Please tell me how that sort of convenience isn’t worth the extra steps to ensure secure PHI. The app is set up as a remote viewer, no PHI is stored on the phone, and it requires three-factor authentication (user ID, password, and unique device ID). That’s much more secure than random papers floating around in hallways and cars.

As a CMIO, it’s my job to represent the physician perspective and help bridge the gaps between the needs of IT, the needs of clinicians, and the almighty budget. When I’m not drowning my end of day sorrows in a nice scotch, I’m hoping for the miracle that allows me to deliver the impossible with solutions that are simultaneously fast, safe, and physician friendly. In the meantime, though, I’m right next to you on that wall, Ricky Roma.

Curbside Consult with Dr. Jayne 6/13/11

A good friend of mine works for a large academic medical center that has restrictive IT policies. Fiercely loyal to certain vendors, the IT gatekeepers restrict hardware choices, from server infrastructure to smart phones. Apple products are largely banned, and the popularity of the iPhone has led many employees to carry multiple handheld devices. Corporate e-mail can only be received on personal phones if the employee knows the “right” people in IT who are willing to bend the rules to make the customer’s life easier.

Although I appreciate that it’s important to discourage employees from playing Angry Birds or from Facebooking on company time, they’ve taken control to extremes. His hospital IT department seems to be missing the point that their prime role is to support staff in the safe and efficient care of patients. Making it more difficult for clinicians to do their jobs isn’t in harmony with that mission, not to mention the cost of the hospital paying for owned handhelds and then reimbursing staff for personal devices.

When I saw a recent article called Doctors Driving IT Development with their Mobile Device Choices, I immediately thought of him. I instant messaged the link to him on both his hospital device and his iPhone to see which one was read first. Of course, it was the iPhone. Surveys estimate that over 80% of physicians are using smart phones, up 11% from 2010. The article states, “Instead of hospitals and vendors telling physicians to adapt to their preferred ways of using technology, physicians are gaining the power to sway hospitals and vendors to their preferred way of using it.”

Albany Medical Center is cited as allowing physician-owned devices on their network to meet physician demand. Administrators created a project to allow physicians to test drive an iPhone, iPad, and BlackBerry over a three-month period. The Apple products were clear leaders. I’ve personally used all three, and each has its strengths and weaknesses depending on the demands placed on them by users.

Everyone talks about usability these days, although in most contexts, it is application usability being discussed. I don’t hear as many discussions about hardware usability as I used to. That’s a tremendous “miss” in my opinion. I hear a lot more discussion of the color choices for carts used in computer on wheels implementations than I do about the computers that will ride on those carts. (And for the record, if I was asked — which I wasn’t — I would have picked colors that would have helped identify which users left their carts abandoned in the hallways for me to weave through on rounds — red for phlebotomy, pink for OB registrars, green for interns, etc.)

Some CIOs I know are quick to blame software vendors for poor usability, failing to realize that hardware often plays as much a role in how usable a clinical application is as does the operation of the application itself. Case in point: an orthopedic surgeon to whom I regularly refer patients cornered me in the doctors’ lounge complaining about his EHR (which happens to be the same one I use in practice). He wanted to know how I stand “all that scrolling you have to do all day long.”

I told him I haven’t had to scroll since taking Version X of the application in 2009 and asked if he was on an older version. No, he said he was on the same version I was. Even though he’s employed by a competitor, as the designated “computer expert,” I wanted to help him. (Plus, he’s a darned good surgeon and always sends me a nice bottle of wine at the holidays.) I asked him to send me a screen shot of his scrolling problem.

After a brief phone call to explain how to do a screen shot, I had his answer. His wide-aspect laptop didn’t allow his workflow to appear without scrolling. His application fell off the bottom of the screen and he had a huge amount of white space on the right. The scope of choice allowed by his IT department is this — Tablet PC (one option) vs. Laptop (one option) vs. Desktop (one option).

For the last two years, he had been blaming the software vendor, when really it was the hardware. I sent him a screen shot of my workflow — the patient’s chart fits neatly on the screen with no problem. Although I’m sure his laptop is great for streaming Netflix, it wasn’t a good choice for his EHR.

I understand that there are a great number of choices in the market today and hospitals can’t be expected to support each and every one. It’s not practical for contracting and procurement, it’s expensive, and it’s a support nightmare. On the other hand, IT departments have a duty to provide hardware that properly displays applications and meets user needs for durability, portability, and speed.

Hardware vendors are savvy and will continue to create new platforms and expand on those already in the marketplace. Users are savvy and will always want the latest and greatest in hopes that it will make their work easier. IT teams who can temper their own needs and wants in favor of those of caregivers and end users will continue to have greater successes than those who don’t.

E-mail Dr. Jayne.