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EPtalk by Dr. Jayne 11/8/18

November 8, 2018 Dr. Jayne 1 Comment

There was some chatter in the physician lounge this week about a study published in JAMA Network Open looking at the accuracy of EHR medication lists vs. the substances actually found in patients’ blood. Researchers looked at 1,350 patients and found that while a majority of medications were detected in the blood as listed in the EHR, there were many more medications detected that were not reflected in the EHR. Such incomplete documentation prevents systems from performing drug-allergy and drug-drug checking, placing patients at risk.

As much as some clinicians don’t like it, I prefer when patients bring in all their medications and supplements, even if it takes extra time going through a brown bag, shoebox, or tote. That way we can keep the EHR updated and also physically impound medications that patients shouldn’t be taking, if warranted.

There was also a fair amount of conversation around Tuesday’s elections, and the various positions held by candidates regarding healthcare. Kaiser Health News published a great piece looking at the various terms being thrown around during the election, including single-payer, universal healthcare, and Medicare for all. Gubernatorial candidates in California, Massachusetts, and Florida were pushing for state-run single-payer systems, where others were calling for less specific “universal coverage” or “public option” provisions. Like those mentioned in the article, the physicians around my lunch table didn’t fully understand the different models or what they might mean not only to their practices, but to their families.

There was zero chatter around the announcement by CMS that access to Quality and Resource User Reports and PQRS Feedback Reports will be sunset at the end of December. Since 2016 was the last performance period for those programs and 2018 was the final payment adjustment year, there isn’t much of a need for the reports to remain online. Physicians or their authorized representatives can download them until December 31, but it’s unclear how many providers reviewed the data in the first place or whether they tried to use it to drive practice-level improvements. Reports will be available eon the CMS portal for those of you looking for a little bedtime reading.

As I was getting ready to leave, one of my colleagues asked me what I thought of Atul Gawande’s recent New Yorker essay on “Why Doctors Hate Their Computers.” He takes readers through Partners HealthCare’s journey from homegrown EHR to Epic, and all of the physicians around the table were familiar with that 16 hours of training he leads with. (In our case, it was 17, and let me tell you everyone was counting.)

Having run more than a handful of EHR implementation projects, I loved Gawande’s description of his trainer, “younger than any of us, maybe a few years out of college, with an early-Justin Bieber wave cut” whose technique incorporated “the driver’s ed approach: You don’t want to be here; I don’t want to be here; let’s just make the best of it.”

Gawande walks us through his own thoughts about the rise of computers, including the once-coveted Commodore 64, which brings back memories for some of us who have been on the cutting edge. Having been the second person I knew with a modem (the first being the guy from whom my brother bought the used card from), I felt a little bit of his pride and optimism as he readied himself for training. The last three years have quashed that optimism, however, and he has “come to feel that a system that promised to increase my mastery over my work has, instead, increased work’s mastery over me.”

I appreciated his discussion of “the Revenge of the Ancillaries,” where design choices were considered by constituents from various parts of the organization. He makes a point that was telling: “The design choices were more political than technical: administrative staff and doctors had different views about what should be included. The doctors were used to having all the votes… Now the staff had a say (and sometimes the doctors didn’t even show.)”

I’ve seen that happen during several build decision projects, and it sounds like there may not have been adequate checks and balances in the governance process. For example, requiring stakeholder signoff in addition to participation in the working groups. Requiring user acceptance testing of critical workflows would also have caught some of the issues he cited, such as hard stops and required fields, prior to the go-live. He also highlights issues with the maintenance of patient problem lists that are exacerbated by governance issues, with duplications and lack of specificity in entries. Cut and paste is also an issue, one that could be addressed by governance and consensus among users about the best way to use the EHR.

Gawande does discuss the phenomenon of governance, noting that, “As a program adapts and serves more people and more functions, it naturally requires tighter regulation. Software systems govern how we interact as groups, and that makes them unavoidably bureaucratic in nature. There will always be those who want to maintain the system and those who want to push the system’s boundaries.”

I’m in agreement, but it’s still a challenge to figure out why organizations don’t spend the time needed up front to define some of these goals. What is the vision for the new system? How does it support the mission? What are the expected outcomes? How do we define success? Instead it’s often a race against a timeline, which may or may not reflect organizational tolerance for a particular speed of change. The best implementation I ever worked on had a motto of “go slow to go fast.” We may have spent more months in the design and build phase than other organizations, but when we went live, we hit the ground running and there were very few changes needed to the system in the first few months.

Mr. H has already commented on the Gawande piece, and one reader shared their thoughts on the physician mentioned who admittedly ignores messages in her inbox and deletes them without reading them. I hope there aren’t any patients reading The New Yorker who might have a concern about their care in her practice, because if she is ever called into court about a missed diagnosis, things aren’t going to end well for her. I can’t imagine publicly admitting that I don’t review results and I doubt that the medical staff administration is going to think too kindly of it.

Reading the piece from the perspective of a clinical informaticist, there’s a lot to unpack, and also a lot of opportunity to potentially improve things for the impacted physicians. I’m not sure what I think about it from a patient perspective or a non-IT perspective, since it oversimplifies and under-explains some of the complexities that have brought us to where we are. That’s what I told my colleague, and I ended with a reminder that the one of the EHR subcommittees still has some openings, so if he wants to be part of the solution, there’s a venue available.

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I don’t frequently call out companies for wacky marketing, but this one is baffling. The subject line of the email advertises a profitability webinar with “cybersecurity strategies you can use,” but the email itself discusses patient experience and how to “cultivate a loyal base.” Oh yeah, and there’s the part where they sent the invitation out less than 24 hours in advance for a webinar that is in the middle of the work day. For mass marketing emails, I’d recommend peer review at a minimum before sending them out. Get it together, folks.

[UPDATE] Greenway Health was quick to read Dr. Jayne’s comment and apologize that their email preview line displayed incorrect wording (the subject line itself was correct). They also note that this was the third in a three-email series, so those who wanted to sign up had ample time well before this email. They also say their surveys and best practices indicate that 2:00 p.m. ET works best for providers.

Do cold emails entice you to join webinars in the middle of the day? How many do you register for that you end up not attending? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 11/5/18

November 5, 2018 Dr. Jayne 3 Comments

A reader recently asked for Mr. H’s prediction on what to expect from Medicare’s “Patients Over Paperwork” initiative. Mr. H asked me to chime in, along with readers, with my thoughts on the proposed changes to E&M codes, office visit documentation, and other paperwork.

He noted that, “It’s hard to separate meaningful HHS/CMS announcements from the political rhetoric spouted by its campaigner-appointees, so I’ve quit trying.” I agree that it’s a quite a challenge to figure out what is going on with CMS lately, since there seem to be many announcements talking about how great things are going to be, but with little change for the people actually doing the boots-on-the-ground work.

I’ve been shocked by the level of rhetoric in CMS announcements under the new administration. Everything seems to have been cranked up a notch and things that need not be political are being politicized. Healthcare finance and payment for providers is complicated and divisive enough and doesn’t need red vs. blue overtones applied on top of it all.

As to the initial question, I think that some of the details in finalizing the 2019 Physician Fee Schedule (PFS) and Quality Payment Program (QPP) rules show that the current CMS/HHS leadership might have bitten off more than they can chew. Physicians were initially excited about a potential move to overhaul Evaluation and Management (E&M) coding, creating fewer “blended” codes that were purported to more accurately reflect the work being done by physicians during office visit encounters. Although there was some positive excitement, the majority of the 15,000 comments that CMS received were negative, according to multiple reports (for those of us who didn’t read all of them). On November 1, CMS responded to that dichotomous excitement by delaying changes to those visit codes until 2021.

It’s important to remember that even though CMS ostensibly only makes the coding rules applicable to Medicare patient visits, because of how things work, they’re pretty much applicable to everyone, including commercial insurance payers and Medicaid. Self-pay patients are impacted somewhat, depending on how practices handle those patients.

The overall sentiment cited in the announcement of the delay was concern by physicians that the planned blending would reduce payments to physicians caring for Medicare patients with complex health conditions and/or multiple chronic conditions. CMS will now plan to consolidate the codes from eight to three instead of the originally-proposed two, preserving the “level 5” code used for the most complex (and most time-consuming) office visits. Another two years are needed to work out the details, apparently. CMS Administrator Seema Verma is quoted as saying, “We know this is going to have a tremendous impact on many physicians in America. We want to get it right.”

I take issue with that comment. If you knew it was going to have such a huge impact, why did you think it was OK to go ahead and put it in the most recent proposed rule? Wouldn’t it have been better to put together some working groups or task forces, etc. including actual working physicians rather than cobbling together something internally and then having to take it back? To an in the trenches physician, this back and forth makes one feel like CMS doesn’t understand us and that it has become reactionary rather than proactively addressing the issues that all of us face. If the wheel was less squeaky, would this have moved along?

The American Medical Association and the Medical Group Management Association are in support of the delay, noting in various press releases and on-the-record comments that the plan was flawed. MGMA SVP of Governmental Affairs Anders Gilberg stated, “Blending payments rates in 2021 won’t necessarily reduce burden, especially with CMS’ newly required add-on codes.” More than 150 various medical societies signed on to a letter opposing the new structure prior to the announcement of the delay.

CMS claims that proposed changes will simplify the way physicians bill for visits, and along with other modifications, are expected to save clinicians $87 million in administrative costs in 2019, ultimately yielding a net savings if $843 million over the coming decade and 21 million hours by 2021.

You know what would also save money and reduce physician angst, possibly slowing the retirement and exodus of much-needed clinicians? Stop harassing physicians with coding audits. Practices constantly receive requests from their Medicare intermediaries asking for documentation to justify the various codes. The practices I work with have gotten responding to these down to a fine science, trying to waste as little of their time as possible. Most of them have a 95 percent or greater success rate in justifying their codes.

I agree that means that five percent of the time they are overcoding or undercoding, but does catching that justify the millions of hours spent dealing with the audits? How about targeting the most egregious offenders and letting the rest of the physician base spend their staff resources managing patients rather than printing and mailing/faxing records to auditors? Burden isn’t just a financial problem – it’s a psychological one and is closely associated with clinician burnout.

Notwithstanding the delay in the E&M codes, CMS is moving forward with other elements of the Rule (and other proposed rules) that are supposed to reduce burden or save money. Physicians can focus on documentation of the interval history since the previous visit, rather than re-documenting previously documented information just for the sake of documentation. Physicians will not have to re-document the chief complaint and history of present illness already documented by their staff or by the patient himself/herself, just because the rules require it. Wholesale acquisition costs for Medicare Part B drugs are supposed to be lowered with the savings passed on to consumers. The so-called “Meaningful Measures” plan should simplify quality reporting for various federal programs that often do not align. Telehealth services and remote monitoring under home health should save money.

As I try to put my thoughts together on this complex topic, my blood pressure is definitely rising. I struggle with the conundrums that we’re facing in healthcare today, at least in the way that I have boiled them down so that I can attempt to understand them:

  • We don’t want universal healthcare, but we want universal control over how physicians and facilities bill and how they are paid.
  • We want to set up complex rules to control payments, but then we get upset when organizations figure out how to game the system (RIP, provider-based billing).
  • We don’t want higher-quality physicians to be able to charge more for their services on the front end, but want to spend loads of administrative money trying to incent them (or penalize others) on the back end.
  • We don’t want to require payers and employers to cover a universally agreed-upon subset of preventive services and money-saving interventions such as birth control, but we want to reduce disease burden and lower the rate of poverty.
  • We want the most high tech services in the world regardless of whether they’re indicated, but we don’t want limits on those services based on ability to pay or overall financial burden to society.

There are many other elements I could cite, but I’d like to preserve some good spirits for the rest of the day and a charity project I’m about to go work on. I wonder, though, as policy-makers debate the solutions they propose for all of this, if they really think about both sides of the various equations or whether we’ve gotten to such a position of polarization that they can only see their own perspective.

What do you think about the Patients Over Paperwork initiative? Leave a comment or email me.

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EPtalk by Dr. Jayne 11/1/18

November 1, 2018 Dr. Jayne No Comments

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November is Home Care & Hospice Month, so let’s give a shout-out to members of the healthcare informatics community who work in those environments. From my time at Big Health System, it seems like hospital projects get all the recognition and the lion’s share of the budget, while ancillaries like home health and hospice are struggling to even get support.

There are a number of challenges faced by these disciplines that make their work tricky – connectivity issues, mobile documentation, chart fragmentation, lack of coordination among prescribers and referring physicians, and more. Plus, there are the challenges inherent with going into people’s homes and dealing with unpredictable (and sometimes dangerous) situations.

Our occupational health clinic works with a home care group and I’ve heard stories about home care teams that go the extra mile bringing food and personal care items to patients who are struggling to stay out of the hospital. Hats off to these vital members of the healthcare team and the informatics personnel who support them.

Whether it’s related to the month of recognition or not, CMS released a rule finalizing changes to the Home Health Prospective Payment System. Claiming it will “strengthen and modernize Medicare,” it made changes to coverage for remote patient monitoring, added home infusion therapy benefits, and updated payments for home health with a new case-mix system. Burden is also supposed to be reduced through fewer reporting measures for certifying physicians. The changes begin in calendar year 2020.

Building on the legacy of EMRAM, HIMSS Analytics releases a new Infrastructure Adoption Model called INFRAM. Along with AMAM and CCMM, the models are designed to measure organizational efforts to improve processes and outcomes through technology implementation and adoption. INFRAM is designed to assess technical infrastructure within health systems, benchmarking prior to go live on EMR (as HIMSS still calls them) systems. Subdomains assessed as part of the model include security, collaboration, wireless capabilities, data center, and transport.

The American Medical Association is providing $15 million in grants over five years to fund innovations in residency training. The Reimagining Residency Initiative aims to transform residency training to better prepare graduates for the healthcare system of the future. Depending on the specialty, graduating residents are often unprepared to operate in the “non-system” that we have going in the US – they may not have been trained on value-based care, coding in such a way that one can actually be paid, and working collaboratively with other physicians and members of the healthcare team.

AMA did this previously in a $12 million program with medical schools, leading to development of a “Health Systems Science” textbook and curriculum to teach physicians to work with emerging technology and how to participate in patient safety, quality improvement, and team care projects. The Request for Proposal will be distributed on January 3, 2019 with letters of intent due February 1. Medical schools, health systems, and medical specialty societies are invited to participate along with graduate medical education sponsors. Awards will be announced in June 2019.

NCQA announces availability of various datasets to help us with our analytics endeavors. The Quality Compass 2018 dataset includes HEDIS and CAHPS data, aiding benchmarking. The current set includes data for commercial, Medicare, and Medicaid submissions. Separate data is also available for CAHPS 5 OH Adult survey results for commercial and Medicaid payers. Also, there is a CAHPS Booklet includes benchmark data for Adult and Child CAHPS surveys. Last, the Health Insurance Plan Ratings 2018-2019 results include scores similar to the Medicare Five-Star Quality Rating System.

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The American Medical Informatics Association announces its Inaugural Class of Fellows for the newly established FAMIA Applied Informatics Recognition Program. The program is designed “to recognize AMIA members who apply informatics skills and knowledge within their professional setting, who have demonstrated professional achievement and leadership, and who have contributed to the betterment of the organization.” The recognition is open to physicians, nurses, pharmacists, and others within clinical informatics. Formal recognition will occur at the AMIA 2019 Clinical Informatics Conference in Atlanta, April 30-May 2, 2019. Some of my favorite people are on the list – congratulations to all!

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As I’ve worked with youth in various community organizations over the last decade, I’ve seen the expansion of smartphones, with both positive and negative impacts on youth knowledge, exploration, and relationships. Time magazine reviews recent research on the impact of technology on young people’s mental health, noting increased rates of diagnosis for depression and anxiety in those using screen-based devices for more than seven hours per day. The data is from a 2016 study looking at more than 40,000 children ages 2 to 17.

When doing a sanity check on the data, I originally balked at the seven-hour figure as an outlier, but the study notes that around 20 percent of youth aged 14 to 17 spend this amount of time on screens each day. Youth in this use category were also more easily distracted, had emotional lability, and had difficulty finishing tasks compared to those who spent only an hour a day on screens. Adolescents were more likely to have issues than younger children.

Every time I’m in an airport and see toddlers and young children glued to a phone or tablet while their parents are also glued to a phone, I want to scream. Maybe I’m turning into the local curmudgeon, but childhood is a time for wonder and explanation. I want to tell them to take their children over to the window and look together at what is going on around the airplane. Watch the baggage handlers and look for your bags. See how the plane gets refueled. Talk about the jobs people do and how everyone plays a part in getting you to your vacation or grandma’s house or wherever.

Those behaviors in young childhood influence how individuals will use phones and devices as teens, and we know from numerous pieces of research that social media use is linked to low well being in teens and adolescents. There’s nothing funnier than watching a group of teens stand in a circle and “group chat” instead of actually chatting face-to-face with each other. Funny, but sad. I’m glad that one of the organizations I work with is a no-phone zone for the most part, forcing young people to interact with each other and also with the adults supporting their adventures.

Weird news of the day: Having one’s appendix removed has been linked to a nearly 20 percent lower risk of developing Parkinson’s disease. Researchers noted that the appendix holds alpha-synuclein, which is thought to influence Parkinson’s development. One working hypothesis is that the appendix participates in immune surveillance “contributes to Parkinson’s through inflammation and microbiome alterations.” It’s not compelling enough to run out and have surgery, but I’ll be interested to see where the data takes us.

What is your organization doing to celebrate Home Care & Hospice Month? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 10/29/18

October 29, 2018 Dr. Jayne 1 Comment

I happened to be in New York this week during the pipe bomb scare, close enough to the CNN offices to receive an emergency alert on my phone advising me to “shelter in place.” The presenter in the continuing education seminar I was attending must have seen everyone checking their phones even though they were supposed to be silenced, so she stopped the presentation to find out what was drawing everyone’s interest.

People were texting friends and family members to let them know that they were OK or were looking for news on what was happening in the neighboring building. It was clear that with everything going on there wasn’t going to be much learning happening, so the conference organizers wisely instituted an unplanned break.

Although most of us were from out of town, several physicians at the table in front of me were residents of the city who had been in practice there during the World Trade Center attacks in 2001. They began talking about what it was like that day, being put on alert by their hospitals that they should prepare for a mass casualty event. They talked about the preparations to receive hundreds of patients, including possible air transports to hospitals outside the city, as the events began to unfold. They also talked about the horrible experience of waiting for patients who never arrived and how that affected them as clinicians. It was clear that even after so many years, they are still profoundly impacted by the events of that day.

The conversation moved into one around disaster preparedness and what is different for them now compared to what was in place then. As we talked, they were checking in with their hospitals to let them know their location and status should there be an actual bomb detonation. By that point, we were informed that our building was on a modified lockdown procedure, with guests and employees being encouraged not to leave and no one allowed to come in. I assume they would have allowed physicians to leave in the event they were needed emergently, but I’m glad the incident was resolved relatively quick and we never had to find out how the lockdown really worked in the lobby.

There was a side conversation about the fears that clinicians and others that work in hospitals carry with them. People are afraid of how they might react to a disaster or mass casualty situation, whether they would be able to stay the course and care for patients or whether they would want to focus on making sure family and other loved ones are safe. A few mentioned episodes of violence they had experienced in their own hospital workplaces, including assaults on patients and staff and even an active shooter event. Nearly everyone mentioned a higher frequency of drills and discussions of potential dangers, with several in the conversation noting that the ongoing drills and reviews are likely contributing to the anxiety.

The fear of violence has influenced technology purchasing decisions. Hospitals are installing advanced security systems and some require visitors to present identification so they can be credentialed to enter the facility. Visitors are wearing stickers with their names, pictures, and sometimes their destination, such as a room number or office suite. It’s different from back in my Candy Striper days when we looked up the patient’s name on a printout, told the visitor the room number, and pointed them towards the elevators without a second glance. I don’t think there are too many facilities that would leave a lone 13-year-old girl manning the front desk any more.

We talk a lot about EHRs, revenue cycle platforms, clinical and financial analytics, telehealth platforms, and the numerous systems that support our hospitals and practices. Although I’ve seen the booths for security vendors at HIMSS, I’ve not had the chance until recently to reflect on those additional systems that CIOs might be called on to select and support in order to ensure business continuity for the facility. One vendor’s website notes their commitment to using big data to analyze incidents and predict patterns in order to better protect patients and staff. That’s a tall order to consider for those of us who are more used to contemplating PHI breaches than we are to thinking about breaches of the physical perimeter.

Although we have a panic button under the front desk of each of our clinic locations, I’ve been fortunate in not being at work in a situation where the staff had to use it. The staff has activated it on accident and based on the anxiety level while they worked to get it resolved, I can’t imagine what they would feel like in a live-use scenario.

In past clinical positions, I’ve worked at facilities where I had to park my car in a chain link enclosure inside the parking garage. I have staffed emergency departments where metal detectors and armed guards were just part of the daily scenery. We performed “fit for confinement” examinations on prisoners being transported by law enforcement, so on any given shift, there might be a patient handcuffed to the gurney. In those situations the potential risk was visible and fairly obvious and we grew to accept it as part of the job, but we didn’t think much about some of the other dangers that might come our way.

I would be interested to hear from readers on the state of security in their facilities and whether their organizations are using technology to help mitigate threats to patient and staff safety. In the times we live in, there is more to think about then tornadoes, fires, floods, and hurricanes.

What keeps you up at night about safety or potential disasters that might impact your organization? Leave a comment or email me.

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EPtalk by Dr. Jayne 10/25/18

October 25, 2018 Dr. Jayne 2 Comments

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ONC has posted the agenda for its annual meeting to be held November 29-30 in Washington, DC. Day One begins with a welcome from Jared Kushner, director of the White House Office of Innovation, followed by a heynote from HHS Secretary Alex Azar. Breakout sessions will cover international health IT efforts, disaster response, HIEs, APIs, FHIR, and an “Ask the ONC Clinical Team” session. Day Two includes a fireside chat with National Coordinator Don Rucker, MD along with Senators Lamar Alexander and Tammy Baldwin.

Value-based care is the chief buzzword for many healthcare organizations and the Comprehensive Primary Care Plus (CPC+) initiative was touted as a way to end the chicken-or-egg struggle faced by ambulatory organizations as they try to figure out how to pay for better care coordination that will lead to incentives that can help them pay for better care coordination and more comprehensive care. The American Academy of Family Physicians has called on CMS to modify the window between when practices have access to their Performance-Based Incentive Payment reports and when they have to repay incentives plus interest.

The reports were to be available around September 26 with interest starting to accrue on October 18. There’s a 19-month gap between performance and reporting, but the CMS piper expects to be paid within a month. The Medicare Shared Savings Program gives Accountable Care Organizations 90 days to repay shared losses. If the current timeline holds, it’s yet another barrier to practice participation in what is supposed to be a driver towards value-based care.

It’s clear that the focus on quality and value isn’t changing any time soon. CMS is hosting a National Provider Call on October 30 to talk about Physician Compare and the upcoming release of publicly available Quality Payment Program data for 2017. A 30-day preview period will allow providers to review their information before it is posted for all to see. The session will include time for question and answer, so if you’re not sure how to navigate the release of information or what to do if you feel it’s not accurate, I’d recommend attending.

Telemedicine is growing and I’ve considered dipping my toe in the waters as an opportunity to deliver patient care without spending 12- to 14-hour shifts in the trenches. Consumer Reports is bringing a recent Annals of Internal Medicine study to the masses regarding increased antibiotic prescriptions issued during telemedicine encounters. The study suggests that there is an association between the length of the visit and the likelihood of an antibiotic prescription. It looked at 13,000 telemedicine visits performed for patients with respiratory complaints. More than 65 percent of phone encounters resulted in an antibiotic prescription. Unfortunately, the research team didn’t have access to the actual encounter documentation so there was not a solid way to determine whether the antibiotic prescriptions were appropriate.

The article offers good information on being an informed telemedicine patient, and notes that “patients often view a telemedicine encounter as more of a consumer transaction than a healthcare visit … here’s an expectation that they get to call a doctor, pay for the visit, and get a prescription.” The author encourages patients to write down their symptoms first including when they started, which is good information for any patient seeking care.

Physician practice management publications such as Medical Economics are encouraging providers to bill telemedicine codes for their own patients. Close to 30 states have so-called telemedicine parity laws, which require commercial payers to reimburse telemedicine services at the same level as face-to-face visits. There are some nuances to coding, though, and physicians are wise to investigate their payer contracts as well as the requirements for proper coding of phone visits.

Many of the scribes in my practice are applying to medical school or physician assistant programs. Those that know I’ve spent time as an administrator often ask about that career path and opportunities in healthcare should they not be admitted to the program of their choice. Money isn’t everything, but I’m happy to share the trend in hospital executive salaries with them. The study looked at CEO and CFO compensation at 22 non-profit medical centers in the US using the “US News & World Report” hospital honor roll list from 2016-17 along with four notable health systems. The authors looked at the growth of clinical worker wages compared to nonclinical workers and management workers.

The rise in value-based care demands administrators with strong financial and quality management backgrounds, which may be driving increased executive salaries. Operational leaders are also in demand as health systems retool their strategic plans. Still, the authors conclude that “there does not appear to be a proportionate increase in healthcare utilization. These findings suggest a growing, substantial burden of non-clinical tasks in healthcare. Methods to reduce non-clinical work in healthcare may result in important cost savings.” I don’t know of too many physicians who would disagree with that sentiment.

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Interesting news for patients who rely on fitness trackers as a tool to assist with their fitness goals. The British Journal of Sports Medicine reports that many trackers aren’t good at measuring energy expenditure. The authors reviewed data from 60 studies looking at 40 trackers worn on the arm or wrist. Devices tended to underestimate energy expenditure, but those that also measured heart rate were more accurate. As an experiment, I used my Garmin watch on the treadmill in “indoor” mode and found that it, too underestimates the mileage my treadmill says I’m logging. The Garmin is accurate in GPS mode when I take it outside for a workout, so it’s still my wearable of choice.

There was quite a bit of buzz in the physician lounge this morning about the FDA approval of Xofluza, which is the first new anti-influenza agent in roughly 20 years. It’s a single dose and can be used to treat patients age 12 and older as long as they’re diagnosed within the first 48 hours of illness, similar to current medications. The wholesale price has been set at $150, but the retail price hasn’t been listed. Genentech makes it and will be offering a coupon for patients with commercial insurance that allows them to purchase it for $30. Now we’ll have to see how quickly EHR teams can get the drug updated for easy prescribing.

How quickly can you get a new drug into your providers’ virtual prescription pad? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 10/22/18

October 22, 2018 Dr. Jayne 1 Comment

Clinician burnout is at epidemic levels, so I always keep my eye out for scientific papers looking at the issue. A recent paper titled “Implementing Optimal Team-Based Care to Reduce Clinician Burnout” talks about team-based care as a model that “strives to meet patient needs and preferences by actively engaging patients as full participants in their care, while encouraging all health care professionals to function to the full extent of their education, certification, and experience.”

The idea of working at the top of one’s education and licensure is one that I continue to struggle with as I work with physicians who feel that EHRs have turned them into data entry clerks. Although I work with some high-functioning offices, there are far too many where people are doing work that could be done by individuals with less training or experience and at a lower cost. Getting the team composition just right is a challenge, and in the corporate practices I work with, there are barriers such as headcount caps to content with.

I recently worked with a practice that was dealing with a “brick in, brick out” philosophy from their health system HR department. When a highly-paid and long-tenured RN retired, the practice wanted to split her salary and hire three lower-level resources to handle some high-volume office tasks. The hospital-focused HR team would have no part of that strategy, even though it was budget neutral and would benefit the practice, citing various policies and a temporary hiring freeze as barriers. The practice could hire a less-expensive resource to fill her shoes, but then it would lose that salary difference out of their budget for the following fiscal year, hobbling them in a different way.

The practice’s leaders elected to replace the nurse with a similarly-priced resource, which didn’t solve their problem, but preserved their overall budget in hopes that they might be able to make a change in the future if they could get the HR team onboard. It was sad to watch a practice be forced to make bad business decision that reduces their ability to deliver the patient care that needs to be delivered because the corporate structure couldn’t get out of their way.

The paper addresses digital barriers to team-based care, noting that “although EHRs have important advantages in terms of improving continuous access to legible clinical information, they are not optimally designed to support clinical care.” The authors encourage organizations to look at ways to expand the utility of EHRs, including:

  • Examining excessive signature requirements or mandates that physicians must perform certain documentation elements.
  • Accelerating information exchange.
  • Including systems other than EHRs in the discussion of interoperability, including patient health records, registries, etc.
  • Facilitating a learning health system including the use of predictive analytics and artificial intelligence.

They go further to call for CMS to modernize “outdated” documentation guidelines that were created to support billing in the era of paper records. They also suggest that ONC and CMS “could make prescribed medication selection, alternatives, and pricing transparency available to clinical teams at the point of care as a regulatory EHR requirement.”

I’m sure vendors wouldn’t be too thrilled about additional requirements, but as a clinician, I would be thrilled to have that kind of functionality in my EHR. Right now, the only price transparency I have for medications is for the prescriptions we dispense in-house, which are either $10, $20, or $30 at the time of checkout. We don’t make a lot of money on them and we don’t run them through insurance but offer them as a convenience to patients who don’t want to have to stop by the pharmacy on the way home.

The article also looks at workforce barriers, including issues “from the training and mind-set of health care team members to team organization and leadership.” Employee turnover is a challenge for many of the ambulatory organizations I counsel, and usually it’s driven by several factors: inadequate interview and hiring processes, inadequate training, lack of on-the-job mentorship and support, and work/life balance challenges.

Poor interview and hiring processes can lead to mismatched expectations and poor fit with workplace culture. Poor training can lead not only to patient care issues, but to fear and trepidation for employees who feel they’re being asked to perform beyond their comfort zone. When I worked for Big Hospital System, new medical assistants received zero standardized training beyond HIPAA and other compliance trainings. Any clinical training was at the purview of the office manager, who didn’t report to the physicians in the office but rather to a regional administrator. The result was a staff that didn’t always know what they should know to be successful, which led to physician distrust and reluctance to allow them to handle even basic clinical tasks such as taking a blood pressure.

At my current practice, clinical support staff are put through a rigorous training program including clinical terminology, procedures, organizational culture, patient communication, and more. They are then scheduled a certain number of “training shifts” with a clinical leader, where they must complete their procedure logs and document their clinical tasks. These training shifts are added on to a practice’s regular staffing. Although they are training on the job, they’re not expected to immediately fill a standard scheduled position – they are there to learn.

We lose some folks along the way with this rigorous training. Mostly people who realize that our staff really do work at the top of their licenses and who aren’t on board with working as independently as we allow our staff or doing the procedures we expect our staff to perform on a daily basis. I’d rather lose them in training, though, rather than a month or two in.

Once training is complete, each employee is assigned to a “core team” of employees for the purposes of communication, mentoring, and ongoing training. This core team may or may not include people they work with regularly, which gives them the opportunity to have a sounding board about situations which may have happened in the clinic or with other employees. It also provides accountability for ongoing training and mentorship opportunities.

Lack of work/life balance certainly contributes to burnout, not only among physicians, but among all clinicians. I’ve worked with practices where employees can only request a certain number of days off each month regardless of how much vacation they have in their bank. I spoke to one nurse recently who was working during a family wedding because his son also had religious confirmation that month and he was only allowed to “protect” one weekend.

Although I realize the need to balance schedule coverage, this doesn’t build loyalty or allow team members to meet their personal needs. This employee made no secret of the fact that he’s interviewing for a position in telemedicine, where he can work more flexible schedules. Employers need to be in tune with the needs of the current workforce, especially in fields where there are shortages and competition among employers to be the workplace of choice.

The paper closes by noting that our “current payment system is not designed to offset the costs associated with forming, training, and sustaining clinical teams.” Because these tasks are often considered soft skills, organizations often give them less attention than hard-data items like patient volume, patient satisfaction scores, and clinical quality metrics. The money spent on building high-functioning teams is well worth it, but comes at a cost that might derive from a chicken-or-egg finance equation. Programs like the Comprehensive Primary Care Plus initiative are designed to provide this money up front, but only time will tell if that approach is as successful as we hope.

What is your organization doing to foster team-based care? What are they doing to unwittingly sabotage it? Leave a comment or email me.

Email Dr. Jayne.

EPtalk with Dr. Jayne 10/18/18

October 18, 2018 Dr. Jayne No Comments

A reader recently asked how/where I keep my own personal medical records. I may have written about it in the past, but my strategy is always evolving, so I’ll share my answer. From my college and medical school days, I have a few paper documents, mostly pathology reports printed from our hospital’s HIM system, and an original vaccination record from our student health clinic. The vaccinations I also keep as a PDF, which becomes useful when I have to turn in my annual health form to volunteer at a youth summer camp. I always chuckle when I have to transfer that data, because I received my last two non-influenza vaccinations (Hepatitis A and Tdap) only because my staff mistakenly drew up doses that were going to have to go to waste, so I had them “waste” the vaccine into my left deltoid.

Beyond that, I have a thumb drive with my entire OB/GYN medical record, provided to me by my physician when she closed her practice. I’m pretty sure it’s not encrypted, and I’ve summarized the important parts into a Word document. I used to have an account on a commercial patient health record courtesy of my employer, but it was clunky and cumbersome, and frankly just creating my own word document was more useful. My genetic counseling records are all on paper, given to me at the end of my visit by my counselor. Her office does not store records electronically or communicate via patient portal. It’s very old-school. When my local health system began their conversion to Epic last year, I did download all my records from their portal, storing them as PDFs on my OneDrive. That way, I can access them from anywhere should I need them. I also store copies of my living will and healthcare power of attorney on the OneDrive, because I’ve seen too many bad things happen and I trot those documents out as needed.

It’s not an elegant solution, but as a physician I have a pretty good handle on my health status and can quickly put my fingers on the data I need even, if it’s not very well organized or categorized. I’m relatively young and healthy, so I don’t have a lot of records to track. I love the idea of patients having their own curated records that they can share, but that concept still scares a lot of physicians silly. I’ve seen some really good solutions on the market, but there hasn’t really been a lot of traction with patients, even with Apple on the scene. I do have an iBlueButton account with Humetrix, although I haven’t used it in a while. Hopefully I’ll stay healthy with no additional data to add.

Speaking of staying healthy, many of us in clinical informatics pride ourselves on delivering evidence-based care using robust clinical decision support tools. Still, the last mile in making evidence-based care a reality is often the conversation between the clinician, his or her staff, and the patient. During this year’s influenza vaccination season, we’re seeing patients who are resistant to the vaccine because of the perception that it was ineffective last year. This is borne out in a recent survey by Stericycle, which notes that a third of US respondents don’t plan to get a flu shot this year. Last year, influenza killed more than 80,000 people, but the data doesn’t appear to sway these folks. My staff has practiced and role-played various talk-tracks for patients, so we’ll have to see if we can continue to convince our patients that it’s the right thing to do. For certain, we’ll be getting an EHR-delivered score card at the end, so every vaccination counts.

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I recently learned about the Neighborhood Navigator tool, released by the EveryONE Project in partnership with the American Academy of Family Physicians. The tool uses more than 100 languages and integrates with Google Maps to help patients find directions and connect with social services for needs such as food, housing, transportation, employment, legal services, and more. There is a set of training videos for physicians to help them understand the tool and how to best refer patients.

My colleagues in the physician lounge often lament the changes in healthcare brought on by the growing presence of the Internet and the rise of social media in everyday life. Data from recent surveys reveals some interesting statistics: 54 percent of millennials (and 42 percent of all adults) have either “friended” their provider on social media or would like to do so; 65 percent of millennials (and 43 percent of all adults) find social media appropriate to use to contact their provider about a health issue; and 32 percent of those surveyed have taken a health-related action as a result of information they read on social media.

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I stumbled across the “Shots by AAFP/STFM” app in the Google Play store. It includes full CDC vaccine schedules and footnotes, as well as dosing information, contraindications, and catch-up schedule information for all available vaccines. Content is written by immunization experts at the Society of Teachers of Family Medicine. You can also enter a patient’s age and various parameters to get a recommendation on what vaccinations are needed. I use multiple resources in trying to figure out vaccine schedules for people, so I’m looking forward to giving this a try to see if it will be my new one-stop-shop. It’s also available on iTunes.

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My slow day in the clinic allowed for a lot of Web surfing in between studying for boards, and I also stumbled upon ePrognosis from University of California, San Francisco. The site’s goal is “to be a repository of published geriatric prognostic indices where clinicians can go to obtain evidence-based information on patients’ prognosis.” I ran the profiles of my favorite community-living nonagenarians, and it looks like the odds of them continuing to do well are very good indeed.

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Working at an urgent care that also provides occupational medicine services, we see a number of patients who come in for drug screens. Many employers require these to be observed drug screens, so that there is no question of an employee substituting someone else’s urine sample. I chuckled when I saw this feature on a Florida convenience store that has had to put up a sign telling users not to microwave urine samples. Even our drug screens that are not observed include taking the temperature of the sample to make sure it’s within a valid physiological range, so if someone were going to try to microwave it, they’d have to get it just right. Still, it makes one think twice about using a public microwave.

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Curbside Consult with Dr. Jayne 10/15/18

October 15, 2018 Dr. Jayne No Comments

As an urgent care physician, I enjoy the satisfaction of being able to make a bad day better for many of my patients. Although I live in a major metropolitan area, there is a relative shortage of primary care physicians (at least ones taking new patients). For those patients who have primary physicians, there’s a shortage of same-day and after-hours appointments that mesh with patients’ busy schedules and their desire for convenience.

I’m happy we can meet our patients’ needs, but I’m often conflicted about the fact that delivering what is essentially primary care in an urgent care setting often contributes to the fragmentation of care. That’s in addition to the cost contribution, because a visit with us typically costs more than a visit to a primary care physician due to negotiated contract rates with payers and higher co-pays for patients.

The fragmentation could potentially be reduced through better technology, particularly better interoperability. Our EHR allegedly has all the interoperability bells and whistles, but local hospitals and their owned physician groups aren’t too keen on sharing data with competitors despite our desire to deliver better patient care. Our state HIE’s provider-centric pricing model makes it cost prohibitive for us to connect, given that the majority of our providers are part time. Even if it were more economical, our HIE is largely read-only, which doesn’t do a lot for the efficiency or accuracy of being able to bring patient data to life in the chart.

A good chunk of our patient volume happens before 9 a.m. and after 5 p.m., which is a testament to the fact that patients want to receive care at a time that is convenient for them, even if it might be more expensive. They also like being able to get care same day and not have to wait for 3-5 days for an appointment for straightforward medical problems. Many of our patients are hourly workers who don’t have paid sick time, and even those who have sick days may be challenged to find two or three hours to visit their primary physician during the work day.

I often think of the reasons behind why people choose to get their care when and where they do, so this Kaiser Health News article caught my attention.

The article covers the idea that millennials are at the forefront of wanting convenience when selecting their care and tend to choose urgent care, telemedicine, and retail clinic options. A poll of 1,200 adults found that younger patients were less likely to have a primary physician, ranging from 45 percent of patients ages 18 to 29 and declining to 12 percent for those age 65 and older. We see that play out in practice, whether it’s strictly due to the convenience angle or whether it’s due to a lack of available primary care capacity.

However, I’m seeing more patients in the Baby Boomer demographic who may have a primary physician, but choose to come to urgent care because they’re busy in their retirement and don’t want their schedules upset by needing to seek medical care.

I have several friends who are dabbling in telemedicine as an adjunct to their regular primary care practices. They report that patients have discussed their desire to handle medical issues at the time and place of their choosing, whether they actually get to interact with the physician face to face or not. Patients are used to transacting the business of their lives online, whether it’s banking or retail, and since healthcare has become a commodity, it’s no different.

One colleague notes that while the patients are glad she’s offering the service, many of them would be just as happy seeing any other physician and not specifically her. We’ve moved into a generation where patients no longer have a primary care physician for life. They may have one for three or four years and then have to change because their employer selected a different network, or they may change due to relocation and the more fluid lives that people tend to live now.

There are concerns that moving away from that continuity where physicians know their patients not only drives up costs, but also leads to inappropriate antibiotic use or misdiagnosis. We see patients who come in specifically because “my primary wouldn’t call me out a Z-pack” and spend a lot of time educating them about viral illnesses. At least we can send them home with medications to help with their symptoms, which makes them feel like they’ve done something to get better even if it’s not an antibiotic. There’s a powerful psychology in that.

We also see patients who have been to their primary care physician and also a subspecialist, but feel like their problem isn’t being addressed so they come to us “for another opinion.” It’s difficult to explain that we’re not experts and if they’ve been to a subspecialist at one of the local academic medical centers and there’s not an answer, that we’re unlikely to find one at the urgent care with our limited testing and radiology capabilities.

I’m particularly interested in the concept of delivering regular primary care via telemedicine, rather than just care for urgent and acute issues. Virtual visits have the power to revolutionize what we do, adding convenience for both patients and providers. In order to be successful, though, we have to get payers and policies aligned to pay for them so that physicians will be more likely to offer them. We also have to get technology aligned, including robust patient portals, the ability for patients to upload their own health data and documents, and better understanding from mid-career physicians that telemedicine isn’t going to suck away their evening and weekend hours.

I think about all the hours that my practice spent trying to track down patients and get them to come in for appointments back when I was in the primary care trenches. I would bet that at least half just disliked the process of going to the doctor and would have been game to do a virtual visit.

I’m excited about projects that pair community health workers with physicians to deliver a combination of in-home contacts with virtual physician visits, particularly in rural areas. A friend of mine recently received a grant in that regard, and I can’t wait to hear how it plays out in real life. I know she is having some challenges figuring out how to actually deliver the services, whether to try to integrate something with her EHR or to use a third-party telemedicine solution. It sounds like the options among vendors vary dramatically, so she is going to keep me posted on her progress.

Are you a physician who regularly incorporates virtual visits into care, or a healthcare IT person who supports one? I’d love to hear from you. Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/11/18

October 11, 2018 Dr. Jayne 2 Comments

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I was excited to hear that Atul Gawande, MD has been booked as the opening keynote speaker for HIMSS19. Many of us were initially enthusiastic about the efforts by Amazon, Berkshire Hathaway, and JP Morgan Chase to revolutionize healthcare delivery. That enthusiasm was somewhat tempered by the clarification that they’re really focused on solving the issue for themselves as employers, although it may eventually be extrapolated to the world at large. Regardless, Dr. Gawande has significant street cred in the healthcare trenches, and as a practicing physician, I’d much rather hear from him than from some of the other recent HIMSS headliners.

I was also excited to hear some information coming out of the American Academy of Family Physicians annual meeting this week. The American Board of Family Medicine used the meeting to announce a pilot program starting in January that will “assess the value and feasibility of a longitudinal assessment option to the 10-year secure examination.” Completing educational opportunities on an ongoing basis rather than cramming for an exam every 10 years is much closer to what we do every day in practice and was the preferred choice for recent exam-takers who were surveyed by the University of Florida in conjunction with ABFM’s assessment of the role of the exam. The questions will be administered quarterly and providers can use resources to find the answers, which better demonstrates our ability to manage knowledge rather than memorize.

I’m doubly excited since I have to recertify in 2019, although I already spent nearly $1,000 on a self-study board review course. The proposal still has to be approved by the American Board of Medical Specialties Committee on Continuing Certification in November. There aren’t any details on how large the pilot will be or whether everyone who wants to participate can actually take part, so I might still have to take the exam. I’ll be crossing my fingers, though.

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The use of ride-sharing services as an alternative to ambulances for transportation to the hospital is getting some coverage in mainstream media. Data from 2011 shows that the US spent $14 billion on ambulance services, more than a third of which was paid for by Medicare. Inappropriate use is estimated at approximately 30 percent.

Although it sounds like a good idea from a cost perspective, I’ve found that in practice, patients don’t do the best job of determining whether an ambulance is necessary or not. We’ve had patients in the midst of active heart attacks at our urgent care who want to argue with us about an ambulance transport because of the cost. I’d hate to see someone in that situation summoning an Uber to their home because they’re worried about the money.

In order for this lower-cost transportation to be appropriate, patients are going to need education on whether it’s the right option for them. Maybe the ride sharing services need to add some screening questions to the app to not only help patients, but also to protect drivers from unwittingly picking someone up who needs serious medical attention. So far, what I have heard about Uber Health is that it will allow providers to order transportation, but doesn’t necessarily address the issue of patients trying to get rides on their own. I’m still up for some screening questions in the apps themselves.

Last week, the US Senate sent for presidential signature a bipartisan package fighting the opioid epidemic. The bill passed the Senate by a vote of 98 to 1, showing that political adversaries can and actually will cooperate when the circumstances are right. The only opposition was from Senator Mike Lee of Utah. The 600-plus page bill includes relaxation on Medicaid payments for inpatient treatment, increased surveillance on opioids being imported by mail, and allows certain midlevel providers to prescribe buprenorphine treatment. It doesn’t appear to have been signed yet, but I’m keeping my eye out.

The opioid bill is timed nicely with the release of the Surgeon General’s report on “Facing Addiction in America.” Assisting in management of opioid use (not only prescription, but illicit versions) is an area where EHR technology can be expanded for better support of clinicians. It’s not just about making it easy to link the EHR to the state prescription drug monitoring program (assuming the state has one, which one state does not) but in getting those links into the right part in the prescribing workflows and making the connections fast enough that they don’t impede provider workflow. It’s also about providing clinical decision support including morphine equivalents for drugs patients are already taking as well as those providers are considering for a new prescription. These should be relatively simple things to code, but don’t seem to be given much bandwidth on the development calendars of vendors.

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It’s National Health IT Week, but I didn’t see a celebration in the physician lounge. Most of my local physician colleagues still see healthcare IT as a threat, not necessarily because of what it offers at face value, but because it’s a proxy for the perceived decline of medical practice as they used to know it. National Coordinator for Health Information Technology Don Rucker, MD blogged on the HIMSS site about how automation in healthcare is transforming medicine. Rucker talks a fair amount about the 21st Century Cures Act and its prohibition on information blocking.

Despite being signed into law in December 2016, it hasn’t done anything to improve information blocking in my region, which is largely due to competing health systems that refuse to share data even though they could do it fairly easily if they wanted to, especially now that all of them are on the same vendor platform. As an urgent care physician, I can’t even get their physician-owned practices to give me a medication list over the phone (despite the fact that it’s permissible under HIPAA for treatment, payment, and operations), let alone gain access to their clinical data repositories to find out what testing has already been done for patients before they arrive in my exam room.

Speaking of automation (or lack thereof), I’m still battling a billing issue with the hospital where I had emergency surgery over a year and a half ago. They sent me a bill last month for which I had no explanation of benefits document, which is unusual since I save every scrap of documentation around my healthcare. I hadn’t yet had time to call my insurance and see what the story was, but in the mean time, the hospital sent me to collections less than 30 days from the date of the statement.

I hopped on the phone to the payer, who had no record of a claim for that date of service, then had to call back to the hospital’s outsourced collections company, which provided me a supposed claim number. I called back to the payer to learn that the provided claim number didn’t even fit the standard format. They dug a bit deeper and found a charge for the same amount, but on a different date of service. It turns out it was paid, no one knows why I didn’t receive an explanation of benefits, and no one can explain why I was billed more than 18 months after the fact or why I was sent to collections less than 30 days after the bill was mailed. I paid my co-insurance online after sorting it all out, so hopefully this adventure is at an end.

What’s the longest running medical bill saga you’ve ever seen or experienced? What are you doing to celebrate National Health IT Week? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/8/18

October 8, 2018 Dr. Jayne 1 Comment

Although the majority of my work is in the CMIO space, I occasionally do some work for vendors. Depending on the vendor and the situation, it could be anything from participating in a focus group to helping design and execute on usability studies.

I’ve worked with vendors who truly get it and are just looking for supplemental input or outside validation for their strategies, but occasionally I work with a vendor that has some significant gaps. This week included successful interactions and one that left me perplexed, so I’ve decided to put together some thoughts for vendors on what to do (or not do) when seeking input from physicians.

First, vendors need to know what they hope to accomplish by interacting with physicians. Do you want an actual practicing physician, and if so, in what specialty or what setting of practice? If not, do you just want someone who “thinks like a physician” and can take you through typical diagnostic or management options? Do you want to work with physicians who understand both the clinical and informatics spheres, so they can provide input on the end user experience but also strategies for solving the problems they may help you identify? Do you want someone who can help with clinical guidelines only and needs no understanding of software and technology?

Working with physicians can be costly since many expect compensation for their time equal to what they would have earned seeing patients during the time they spent with you. It’s important to not only make sure you have the right type of physician, but also that you are prepared to spend your time with him or her wisely.

I worked with a company early in the week that knew exactly what they wanted. They provided a brief synopsis of the project and the assumptions they wanted to test with a physician. They provided that information with enough lead time that I could review it thoughtfully prior to our call. They made sure to let me know that they wanted to interact over video, which let me know that I shouldn’t be in my pajamas or look like I just came off the treadmill, which is occasionally my habit depending on how many calls and meetings I have in a given day.

When I joined the call, it was clear that all internal resources had joined with enough time to be set up and oriented and they were ready to introduce themselves and describe their roles on the project. They also asked me to say a few words about myself and my background, which allowed for adequate level-setting all the way around.

We worked through a product prototype first at a high level, with me giving initial impressions and the team documenting any questions I raised or elements that I didn’t understand. That allowed us to get through the entire workflow without being derailed by details or issues with the mock-ups. Then, we took a second pass through the prototype and addressed the areas where I had questions or didn’t understand where the workflow was going.

I think it was helpful to them that I understood that we were working with some enhanced wireframe designs and not actually software on some of the screens, so that I could phrase my questions around whether what I was seeing was just an artifact of the mock-up or whether it was actually a design element. We then took a third pass through the workflow, with the team allowing me to identify areas where I thought the flow could be enhanced or where functionality could be added to better meet the original design intent.

It was clear that the team was experienced in respecting the time of their audience and also that they had prepped for the call, knowing approximately how much time to allot for the different phases of review. It didn’t feel rushed, we didn’t end with a lot of time left over, and there weren’t too many items that needed additional follow up. They clearly took good notes during the call because they were able to come back to different comments I had given and read them back to me almost verbatim, asking for clarification or expansion on what I was thinking. The whole experience was challenging and fun, and I hope they’ll be interested in my feedback as the project progresses.

The vendor I worked with later in the week provided a polar opposite experience. It was a bit of a different situation to begin with, since the vendor is trying to introduce a new spin on existing workflow and technology rather than moving forward with an innovative product. In my opinion, that makes it challenging since anyone looking at their offering is judging it against their current technology whether consciously or not.

They were asking me to evaluate a new way to do work that I’ve been doing electronically for nearly two decades across half a dozen platforms with numerous upgrades on each. Although one could take the strategy that it would be good to have an experienced clinician who can provide feedback on what other vendors are offering or have tried in the past, the developer kept interrupting the conversation and going on and on about not allowing “the experience” to be hampered by “the technology of today.”

I didn’t realize there were going to be developers on the call. That’s always a tricky one since sometimes when you provide feedback, they can take it personally, and especially since they weren’t introduced when the call began. Having silent parties on a feedback call that suddenly jump in and start a conflict with your research subject usually isn’t an effective strategy.

The product owner tried to calm him down, but it wasn’t working. I tried to explain that unfortunately the workflow they’re trying to address is hampered by a litany of external requirements that they hadn’t addressed, such as governmental and payer regulations. It doesn’t matter what your UI looks like if it is going to force the end user to behave in a way that is going to cause trouble in the case of an audit.

Part of the exercise was for me to work through an alpha version without direction or training to evaluate how intuitive the workflow was. At one point, someone who probably thought he was on mute but wasn’t actually said, “She’s doing it wrong. Why is she clicking there?” When I replied, “I clicked there because every other screen has the ‘save and close’ button in the bottom right corner and that’s where my hand naturally flowed,” there was just a stunned silence. At that point, another member of the team took over the call and we moved forward in the workflow, but I had a hard time thinking of the product vs. whether someone was getting schooled out in the hallway.

The session ended about 30 minutes early. I wasn’t sure whether they were out of material or whether they were just flummoxed. Frankly I was glad for it to be over, because it was stressing me out and my treadmill was calling. I’m happy to help, but there’s a level of dread that they might ask me to work with them again. We’ll have to see how the next sprint cycle unfolds for them. I hope if they’re working with other physicians (they had better be, because when you’ve heard one physician’s opinion, you’ve heard one physician’s opinion) that it’s a more successful experience.

Do you have any advice for software vendors who are seeking physician input? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/4/18

October 4, 2018 Dr. Jayne No Comments

ECRI Institute releases its 2019 list of the Top Ten Technology Health Hazards. The list is created each year by assessing various factors around each potential hazard, including severity, frequency, preventability, and breadth of the hazard. Insidiousness is also considered – whether the problem is difficult to recognize and whether it could lead to downstream errors before the problem is identified.

This year’s list contains some hazards that are clearly healthcare IT issues. but also some problems that healthcare has been grappling with for a long time:

  1. Hackers can exploit remote access to systems, disrupting healthcare operations
  2. “Clean” mattresses can ooze body fluids onto patients
  3. Retained sponges persist as a surgical complication despite manual counts
  4. Improperly set ventilator alarms put patients at risk for hypoxic brain injury or death
  5. Mishandling flexible endoscopes after disinfection can lead to patient infections
  6. Confusing dose rate with flow rate can lead to infusion pump medication errors
  7. Improper customization of physiologic monitor alarm settings may result in missed alarms
  8. Injury risk from overhead patient lift systems
  9. Cleaning fluid seeping into electrical components can lead to equipment damage and fires
  10. Flawed battery charging systems and practices can affect device operation.

Most of us are familiar with the need to address cybersecurity concerns, as we see ongoing cases of not only breaches, but ransomware attacks. However, I’m still surprised by the number of organizations that don’t keep their systems current with recommended patches and updates, or that are even on versions of software that are no longer supported by their vendors.

Other items such as alarm settings may be addressed by policy and procedure, which can be harder to institute than technological safeguards unless the organization is truly invested in a culture of safety.

Items 2 and 5 are simply gross and it seems they should be straightforward. Unfortunately, the situation is complicated by some manufactures not providing detailed cleaning recommendations or institutions using harsher cleaners than recommended, which damages the surfaces of equipment and allows absorption or sequestration of contaminants.

Retained surgical sponges are an issue that hospitals and surgery centers have tried to address through technology, including special thread in sponges that shows up on x-rays. Other technologies augment the manual counting process and can be effective if they are used correctly. These vary from special counting racks to radio frequency locator systems.

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The Centers for Disease Control’s National Center for Health Statistics recently updated its guidelines regarding hurricanes. These go into effect October 1. The hurricane piece is located on pages 19-20 of the 120-page document, which I’m sure all physicians, coders, and billers will be lining up to read. It mostly addresses the ICD-10 codes for external causes – although they have been in place for years, the guidelines direct physicians how they should be used. The guidelines also address the use of Z codes, which can explain why patients presented for care, including homelessness, inadequate housing, poverty, and lack of availability or inaccessibility of health care facilities.

Speaking of CMS, a recent blog by administrator Seema Verma addressed the topic of “Better Data Will Serve as the Foundation in Modernizing the Medicaid Program.” Essentially, CMS is seeking to demonstrate how the ever-growing Medicaid budget is driving better health outcomes. CMS is also looking for ways to “improve program integrity, performance, and financial management in Medicaid and CHIP.” CMS has identified core sets of quality measures that will be used to monitor outcomes, although reporting is voluntary at this time. It admits that reporting is burdensome and has tried to mitigate the burden through the Meaningful Measures initiative, noting future intent to “leverage existing and more automated data reporting systems to generate these Medicaid measures on behalf of states, thereby reducing reporting burden while also improving data consistency, comparability, and comprehensiveness.”

That’s a buzzword bingo winner right there. Theoretically, isn’t CMS already receiving the data through individual provider reporting as part of Meaningful Use? Wouldn’t that allow CMS to aggregate the data rather than having states submit it? I’m not in the details on Medicaid MU very much any more, but maybe someone who is can shed a little light on this for me. All I know is that as a practicing clinician, fewer of my peers are accepting Medicaid patients and those who are have generally stopped booking new patient visits, leaving a continuing gap in care delivery and pushing patients to the emergency department.

Flu season is officially upon us, with positive cases being reported even though the 2018-19 season is not yet being named on the CDC website. We’re seeing plenty of cases in my practice, along with a particularly nasty influenza-like illness that walks like the flu and talks like the flu but comes out negative in testing.

Our urgent care volumes during last year’s flu season were largely driven by patients who either couldn’t get in to see their primary care physicians or who didn’t want to go to the emergency department due to potential wait times, overcrowding, and perceived lack of service. We’ve hired several new providers and a small army of paramedics and scribes to help us get through the upcoming season. If you haven’t received your vaccine yet, now is the time.

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We already knew it in our hearts, but I was saddened to see the Journal of the American Medical Association call out the “Southern diet” as deadly. Its main mechanism is thought to be elevated blood pressure. The study looked at nearly 7,000 people who were part of a larger long-term study of diet and lifestyle. It tracked weight, blood pressure, cholesterol levels, alcohol use, income, and exercise habits along with symptoms of stress and depression. The study notes, “The largest statistical mediator of the difference in hypertension incidence between black and white participants was the Southern dietary pattern, accounting for 51.6 percent of the excess risk among black men and 29.2 percent of the excess risk among black women.” Hispanic and Latino individuals were excluded from the study.

I looked in the full-text article as well as in the references for the link to the “Southern diet score” they used but didn’t find it. I’m curious how my own diet stacks up – I do love a good fish fry with cheesy potatoes and apple cobbler.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/1/18

October 1, 2018 Dr. Jayne 2 Comments

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I occasionally do a little bit of work for a local personal injury attorney. It’s not the big-time expert opinion work you hear about physicians doing on the side, but more of a translation service. Basically, I take hundreds to thousands of pages of printouts from EHRs and try to reconstruct a coherent timeline of what happened and who documented which data, so that the legal team can understand the facts of a case and determine whether they have something they want to take forward. At least the printouts are virtual, and I’m sifting through PDFs rather than dealing with boxes of documents delivered to my door.

I worked on a case over the weekend from a local hospital where I have never been on staff. The most striking part of the assignment was the poor quality of the records.

The case involved a “routine” outpatient surgical procedure that ended in the patient’s death. The entire episode of care lasted barely more than 24 hours, but there were six different PDFs sent, ranging from 20 pages to 370. Although all the notes and entries were electronically signed by the pertinent physicians, it was quickly apparent that the physicians hadn’t really read the notes before authenticating them. Either that, or they read them and just have a passing familiarity with the idea of matching the pronoun to the gender of the patient or ensuring that the note actually makes sense. Especially since this episode of care contained a profound medical misadventure, one would think that the attending physician (who was going to receive attribution for the case) would have made sure the key portions of the record made sense.

The hospital had numbered the PDFs from one to six, and I quickly realized that the numbering was not at all related to what one would expect in a typical chart. Each file contained a mixture of timelines and care locations (pre-operative area, operating room, intensive care) and was so confusing that I actually thought about printing the whole thing out so I could sort it into chronological order. The admission history and physical was in the middle of the third file, and the discharge summary (also known as the death note) was in the middle of the second. It probably would have been better if the discharge summary was at the end of the last file, because after reading it, I was so aggravated that I had to take a break.

Although the document was clearly identified as a death note, it also contained “Home Instructions for the Patient” and a list of “Medications You Should Continue at Home.” I imagined myself as the widow of this patient reading that and how insensitive it must have seemed to her. She had requested the records personally and provided them to the attorney after she was unable to get answers to her questions from the hospital’s risk management team.

I imagined how confused she must have been by the six files, how disjointed they were, and why she felt she needed to ask the hospital for clarification because the records didn’t make sense. I also put on my EHR hat and thought about how easy it would be to have a separate template for the death note that didn’t have those components that only apply if a patient is actually leaving the hospital.

When I finally made it to the physician notes, I noted how poorly the history of present illness (HPI) was written even though it was either dictated or typed as free text. The patient had been transferred from the operating suite to the intensive care unit after being emergently intubated and placed on a ventilator, which the HPI described as “the patient was difficult to breathe.” The patient was referred to twice as “her” and the rest of the time as “him,” the latter of which was appropriate. Another physician note said that the patient had been “electively intubated for the outpatient procedure” which was incorrect, which somewhat makes one question the accuracy of the documentation in general.

The nursing notes were also interesting, with a nurse documenting that a fall risk assessment was performed and “the patient verbalized understanding” despite the patient being paralyzed, sedated, and on a ventilator, with a documented Glasgow Coma Scale of 3 which basically means the patient was nonverbal and unresponsive to verbal or painful stimuli. One can perhaps blame that one on a macro or shortcut being used, but as a healthcare provider I was embarrassed to see it. The patient also had a “weapons assessment” performed upon arriving to the intensive care unit, although I’m not sure how he could have become armed after being assessed similarly in the pre-anesthesia care unit and having been unconscious most of the time. I understand the value of checklists, but it was just one more thing clogging up the notes that didn’t make sense.

I was heartened to see that the hospital was using a virtual sepsis protocol and remote ICU services from a tertiary care center. My enthusiasm was curbed, however, when I reached the laboratory data section, which displayed the data in an extremely hard-to-read grid (above). I can’t imagine that there was much clinical input on or approval of that document before putting it into the system, and if there was, would love to have a conversation with whoever approved it to go into production. I’m sure users are reading the data on a screen with a scalable display in real time, but it’s still important to be able to have a printout that makes sense.

The attorney who sent me the case felt that there was not likely a valid claim, but had asked me to review to help provide answers to the family. Even in that context, I always review to see if there was an element of negligence or substandard care. I wasn’t pleased to see that the consent for surgery document didn’t have the patient’s name filled out or the surgeon’s name completed in the respective blank spaces. It did have a patient sticker and MRN on it, but not using the blanks as designed just makes it feel like either someone was in a hurry or someone didn’t care, neither of which are great when there has been a poor outcome.

The bright spots of the entire chart were the chaplain’s notes. They were free-text narrative, and although I couldn’t tell whether they were dictated or typed, they were cohesive and actually told the story of what had happened to the patient far better than the physician progress notes (each of which was 8-10 pages long because they contained copy-and-paste content from previous notes). The chaplain’s notes also contained detailed summaries of what was discussed with the family and their responses to the information provided. Those chaplain’s notes were probably the most solid piece of documentation in the chart and they illustrated that the clinical team acted within the standard of care after the initial event.

In the healthcare IT world, we think of projects and timelines and budgets and deliverables, but often we struggle to find the time to think about patients and their families and how those individuals would view our efforts. This family probably doesn’t think very much of the quality of records at this institution and I know the attorney doesn’t either.

As a CMIO, a patient, and a family member of patients, I’m appalled by what I saw. We can do better, and our patients deserve it.

I’d like to throw out a challenge to readers. Take a look at the documentation your systems are producing. Find a death note or a discharge summary with an outcome of “deceased” and see what’s in it. Make sure that you are producing documentation that you would want a patient’s widow or child to see. If you’re a vendor, take a look at your document production code and see if you’re contributing to the problem or helping to solve it. I challenge you to find the development budget to make these issues right if you’re the cause.

Do your users read and correct their notes, or just sign them? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/27/18

September 27, 2018 Dr. Jayne No Comments

The request period for CMS to provide a MIPS Targeted Review is open for less than three weeks. Eligible Providers who participated in the Merit-based Incentive Payment System in 2017 can review their final scores and performance feedback on the QPP website. These scores will determine whether providers receive a positive, negative, or neutral payment adjustment for Medicare-covered services in 2019.

A Targeted Review can be requested if MIPS-eligible clinicians or groups believe that an error has occurred in the payment adjustment calculations. Examples where this applies include data quality issues, eligibility issues (such as being below the low-volume threshold but being assigned a penalty) or not being treated appropriately if qualifying for reweighted scores due to extreme and uncontrollable circumstances. Based on the chatter in the physician lounge, it seems that hardly anyone is reviewing these, so they’ll just be surprised when they find out if they’re getting an incentive or penalty. If you think you should have a review, requests can be made until 8 p.m. ET on October 15.

A group of 29 participants in the CMS Next Generation Accountable Care Organization program is uniting to work with CMS to ensure continuation of the Next Generation ACO program. This is in response to some pushback against the program, which allows organizations to take on greater financial risk in return for expanded flexibility for care coordination and other services. Some organizations feel the promised savings hasn’t appeared as quickly as expected. Participants in the coalition include Dartmouth-Hitchcock Medical Center, Henry Ford Health System, Mission Health, Carillion Clinic, and Trinity Health.

The group members plan to “focus on developing elements of future payment policy, network design, and beneficiary engagement.” They also plan to share best practices and show how risk-bearing arrangements can accelerate transformation in care delivery. Next Generation ACOs were responsible for more than $61 million in savings in 2016, when there were only 18 organizations participating. That number is now up to 51 organizations, which are focusing on chronic care and disease management as well as expansion of primary care services.

Speaking of healthcare savings, a new report from The National Council for Behavioral Health’s Medical Director Institute shows that simply getting patients to take their medications as prescribed could lead to substantial cost savings and improved clinical management. It’s long been quoted that nearly half of people who are prescribed medications don’t take them as instructed. The problem is complex and involves many factors: understanding the need for medication, being able to acquire it (cost or transportation issues), understanding how to take it, and actually taking it at the right time and under the correct circumstances each day.

The institute projects a potential $2 billion yearly savings from reduced hospital costs alone, assuming that a number of its recommendations are adopted over the next five to seven years. Some of the recommendations seem straightforward, such as “better communication between physicians and patients” and improved risk assessments to determine who might not take their medications. However, under our current fractured and stressed system, even something like communication is a challenge, with little time available to actually sit with patients and ensure they understand why they need medication, how to take it, and what to expect.

Of course, technology can help with some of these, such as embedding risk assessments into the EHR or serving them up via a patient portal, but the latter assumes patients have Internet connectivity and a certain degree of health literacy. Data sharing can be used to identify non-adherence – I love the medication history in my EHR that lets me see when patients refill their medications, which can be a proxy for not taking it as directed if the dates aren’t as expected. Other solutions require more cooperation from other parts of the healthcare system, such as expanding use of long-acting injectables as compared to daily oral medications and increasing patient access to pharmacy services.

The institute cites data that one in six Americans take psychiatric drugs and notes the risks to patients not taking medications as directed. I saw this in my practice the other day with a patient who came in for fatigue and lethargy, and it was most likely a medical misadventure with incorrectly administered psychotropic medications. It took me a good 30 minutes to get to the root of the matter, which caused a backup in the clinic and skewed my productivity numbers for the day. Sitting with the family was the right thing to do, but not all clinicians are going to do it (and I doubt my emergency department-trained midlevel providers would have). The patient hasn’t had a psychiatrist for six months due to insurance issues and I ultimately wasn’t able to “fix” the problem, but at least was able to point his family in the right direction.

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Most of the news coverage coming out of Washington, DC this week is swirling around the Supreme Court nomination, but I was glad to see that Congress is still at work trying to complete legislation dealing with opioids. A deal reached on Monday includes a measure to allow use of Medicaid funds for inpatient treatment of addiction. The so-called “IMD provision” (Institution for Mental Disease) lifts a ban on using those funds for treatment. The initial ban was put in place because of a concern that scarce funds would be paid to higher-priced inpatient facilities. It’s not like addiction goes away because someone is hospitalized, and since there generally aren’t enough beds to go around already, I don’t think the availability of funds is going to significantly impact utilization. It’s hard to charge for a bed that doesn’t exist. There are also waivers already granted for 15 states with waivers pending for 11 more, but that doesn’t cover everyone which explains why Congress is stepping in.

It’s hard to tell exactly what’s going on in the measure, though, because the final legislative text is not yet publicly available. According to my sources, the Senate bill lifts the ban, and the House version provides for treatment of all addiction, not just restricting it to treatment of opioids and cocaine. There is still some contention around HIPAA and confidentiality rules, with healthcare providers pushing to align the confidentiality rules with HIPAA so that clinicians could share information. It looks like the current law will stay in place, keeping additional protections for records of substance abuse treatment.

The House also blocked changes to the Medicare Part D “donut hole” that were requested by pharma. No one wants to be looking like they’re allowing pharma to benefit while allowing the proposed changes to ride the coat tails of bills targeted at the opioid epidemic. I’m sure we’ll see pharma trying to tack this onto something else as the legislative season continues.

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I’ve been struggling this week due to a catastrophic outage at my hosting vendor, whose disaster recovery plan completely unraveled. Apparently it started with a server administrator who was supposed to perform a “file system trim” but mistakenly executed a “block discard” instead. Needless to say, the storage platform immediately dropped all data and crashed everyone. In a serious of unfortunate events preceding that calamity, someone had disabled the snapshot functionality, so there was nothing to use to quickly restore data. Instead, they tried to access the off-site backup server in another state, finding an I/O capacity issue that limited restoration efforts.

I don’t mind my websites being down, but it also took out my email for several days. Although I was able to reach out to key clients and pass along an alternate address, I suspect a number of people think I’m just ignoring them and have no idea what I’ve missed. The outage was long enough that most mail servers would stop trying to redeliver.

Having been on the other side of outages, my heart goes out to the admin who created the problem as well as the company’s leadership who is finding out that “trust but verify” is a lot more important than they thought. As I followed their updates (which were extremely transparent) and the customer forum, I was amazed by the number of fellow customers that had no backup of their sites and no disaster recovery plan of their own. There was talk of how much money they were losing, but no discussion of business continuity insurance or even of disaster planning. There was a lot of screaming in all caps and little realization that flooding the support center with tickets asking them to “FIX THIS MESS NOW!!!!!!” probably wasn’t helpful, especially since they were posting real-time updates to all clients.

It’s a good reminder to make sure that your data is backed up in multiple places (and not just by your vendor, but by you personally) and that also your vendor is testing their backup system and restoration process frequently. Stuff happens, and having a plan makes it a lot less painful, that’s for sure.

When is the last time you tested your disaster recovery plan? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/24/18

September 24, 2018 Dr. Jayne 1 Comment

Being in the consulting world, I am exposed to a large variety of practices, partnerships, health systems, integrated delivery systems, and more. It’s always challenging when clients and prospects want me to “find someone that looks just like us” before they agree to start working on a project.

I let them know that it’s not just a question of finding someone in my client base that has similar characteristics, but sometimes even finding someone in the healthcare realm that looks like them is challenging to impossible. Explaining this can be difficult, especially after clients have interacted with vendor sales reps who have done their best to convince them that as long as they talk to someone in the same specialty, or as long as they talk to a group of the same size, that they can expect to have comparable experiences.

I see this with both small and large clients, even with large health systems that think that just because XYZ health system on the other side of the country did a certain project a certain way, that they will have similar outcomes. There are so many variables that play into a project’s success, that it often becomes one of those “your mileage may vary” situations.

I ran across this recently with an organization that was looking to understand what size of a team they needed to support their ambulatory EHR needs after migration to a new system. They seemed rather upset that I couldn’t just tell them how many people to hire, without performing some level of discovery around the level of support they planned to provide, what their proposed governance structure would look like, what the organization’s support budget was, and what skill set they expected the team to have.

It’s a complex equation, and I always try to attack the idea of governance – both clinical and application – as the first step in figuring out what makes a group tick and what their needs might be. Organizations that understand the value of governance are like gold to me. They understand that decision-making is important, as is understanding who owns the application and who is responsible for making decisions related to implementation, maintenance, support, and upgrades.

When an organization decides to have tight governance, it can result in not only cost savings due to decreased variation, but also in measurable quality when providers understand that it’s important for people to deliver care in a standardized way. Many organizations do a good job with this during the design and build phases of an implementation, but once the system goes live it’s tempting to fall into bad habits.

Organizations may make customizations to appease a single provider or a small group of providers, which not only consumes resources in the present time, but also in the future, as those customizations have to be constantly evaluated against upgraded software versions. Some organizations I’ve worked with don’t even track their customizations, so they can’t possibly evaluate them. Each upgrade becomes a bit of a surprise as they try to figure out what the “out of the box” software looks like vs. what they have installed in their environments.

My first Lean Sigma project years ago was to work on an EHR upgrade, and I admit that the project itself failed – we ended up not taking the upgrade – but we learned a tremendous amount about the methodology needed to successfully evaluate a new release and get it through the upgrade process. We created an evaluation paradigm that I still use today, across multiple vendors and even outside of EHR applications.

Sometimes the decision to modify the application rests with a clinical committee, but other times it’s the nebulous “IT” that reviews requests and makes the changes. This is unfortunate because technology projects require care and feeding not only by the technical team, but by clinical and operational owners. However, it’s easier to blame “IT” rather than addressing inadequate or absent governance. Other groups may keep their governance structures after go-live, but they become weak over time due to shifting priorities, members’ attention being focused elsewhere, or outright neglect.

It’s great when things are ticking along just fine, but bringing your governance group together quarterly even if there aren’t major decisions to be made isn’t a bad idea. There may be issues that are brought to light or maybe the group just confirms that things are going well, but it’s one of those things that if you don’t ask, you might be missing problems that you didn’t even know existed. If you can’t even get people in the room, that might be a red flag for apathy or end users checking out rather than engaging.

Governance can be tightly linked to management, although it’s best if neither exists in a vacuum. Strong management helps ensure that decisions that are made are carried out in an effective and cost-efficient manner. Effective management is what transforms an organization to being reactive towards the squeaky wheel into one that can proactively look for issues and identify solutions before things turn into problems. It’s often difficult though to have strong management with physician groups, especially when there are numerous competing personalities and where organizational politics becomes a factor.

I’ve seen so many groups take a page out of “Lord of the Flies” rather than be willing to address difficult colleagues or tackle ineffective team members. When I work with them, I present techniques for communication and consensus-building and sometimes it seems like this is the first time they heard that there are “treatments” that can help get them through the rough spots just like there are remedies for medical conditions.

Both governance and management can be tightly linked to culture. I frequently encounter organizations that can’t articulate their culture, and I guarantee that if the leadership can’t even define the concept, they’re not doing a great job of carrying it to the rest of the organization. If leadership is preaching the need for strong governance and effective management,and then doesn’t deliver on those expectations at the highest levels, it becomes not only demoralizing, but often costly for the organization which ends up floundering. The importance of these relatively “soft” disciplines shouldn’t be underestimated.

It’s with all of these factors mind that I approach each organization I work with. One has to understand who they are, where they have been, where they are going, and where they want to be before you can make recommendations to help them. When you’ve seen one organization, you’ve seen one organization, regardless of how similar they may be in size, scope, specialization, etc. It’s tough to determine whether your experiences might be like someone else’s without asking some difficult questions.

I challenge organizations who are in the market as buyers to consider this concept when you are presented with a reference site or a case study that someone is trying to use to convince you to buy, or when you’re trying to determine your implementation or support model. You might find yourself asking some difficult questions of your own organization. Uncomfortable as it might feel, it’s a good thing.

How does your organization approach concepts like governance? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/20/18

September 20, 2018 Dr. Jayne No Comments

This week is Prescription Opioid and Heroin Epidemic Awareness Week. There are several ONC resources available to help clinicians lean what technology is available to them, including prescription drug monitoring programs and electronic prescribing of controlled substances. My practice still hasn’t taken the leap to the latter since we dispense the majority of our controlled substances from our in-house pharmacy, although it’s now mandatory in some states.

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AMIA has issued a Call for Participation for its 2019 Clinical Informatics Conference in Atlanta. The CIC meeting has a greater focus on applied clinical informatics, clinical decision support, and health policy compared to the annual fall AMIA meeting. Atlanta is a fun town and I’ve heard the clinically-focused meetings are great, but I’ll miss it due to it conflicting with my annual stint teaching in an outdoor classroom program.

I had some great reader feedback on my recent piece about cultural competency. Readers seem to appreciate the articles that aren’t necessarily pure healthcare IT but touch on issues that many of us face in the workplace.

One reader shared their own experiences with cultural competency training that’s likely to be minimally effective. It’s being delivered as a single mandatory three-hour session and we all know how much information people really absorb after the first hour or so. The reader notes, “Everyone I’ve talked to has been longing for the olden days before text pagers, when you could go to a meeting, set off your own beeper by surreptitiously turning it off and back on again and then acting surprised before rushing out to respond to the ‘emergency,’ never to return to the dreaded mandatory activity.”

The training is also being delivered lecture-style to large groups, which is a shame because group discussion could really bring this topic to life. If care teams or groups of workers attended together, discussion could help them learn more about each other and how to work together effectively as a team as well as with their patients. The reader goes on to describe an institutional push to curb profanity, noting the need to start “whipping out thesauruses looking for allowable substitutes – maybe they should just put Ivory Soap dispensers in the hall to allow cleansing of tongues and improved hand washing in one swoop.” I suggested they consider the Elizabethan Curse Generator, which automates insults in Shakespearian English. Take that, thou distempered fat-kidneyed wagtail!

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I was glad that Jenn mentioned the annual Physicians Foundation report on the state of physician practice. The decline of independent practice continues, with barely a third of the 9,000 physicians surveyed using that term to describe themselves. Although Jenn covered some of the highlights, including that 80 percent of physicians feel they have experienced burnout, I found some additional statistics that were thought-provoking:

  • US physicians handle over 1 billion patient encounters each year across all settings of care
  • 12 percent of physicians are planning to find a non-clinical position
  • 61 percent favor either a single-payer health system or a single-payer system with a private insurance option; 27 percent favor a market-driven system; and only 4 percent think we should maintain the current system
  • 22 percent of physicians either do not see Medicare patients or limit the number they see
  • 32 percent of physicians either do not see Medicaid patients or limit the number they see
  • 47 percent of physicians are compensated based on quality/value, but only 18 percent believe that these payments will improve care or reduce costs
  • On average, each office-based physician supports about 17 jobs and pays a total of $1.4 million in wages and benefits.
  • 49 percent of physicians would not recommend medicine as a career to their children or other young people
  • 27 percent of physicians would not choose to be a physician if they had their career to do over
  • More than 68 percent of physicians do not believe that Maintenance of Certification processes accurately assess their clinical abilities
  • Physicians work an average of 51 hours per week

The report includes a listing of questions and responses aggregated by various demographic factors including age, employment status, gender, and specialty. It also includes direct comments from respondents, which start on page 50 if you’re interested.

One of the mechanisms that physicians use to combat burnout and reduce the amount of time spent interacting with the EHR is the medical scribe. JAMA Internal Medicine ran an article  this week titled “Association of Medical Scribes in Primary Care With Physician Workflow and Patient Experience.” The question posed was whether using scribes decreases documentation burden, improves productivity, improves patient communication, and enhances job satisfaction among primary care physicians. Not surprisingly, the study (although limited at 18 primary care physicians) showed that using scribes was linked to reductions in documentation time and improvements in productivity and job satisfaction.

I’ve been in a practice that uses scribes for the last three years, although I don’t always have a scribe during every shift. We deploy them based on volume of patients seen at our various locations, so if you are scheduled for a lower-volume location you may be on your own. When it gets busy and five or six patients walk in at the same time, you definitely wish you had a scribe. Although I’m fast with the EHR and have tons of personalized templates, macros, and order sets, it’s still not as fast or as accurate as working with a scribe who can document while you’re doing the exam and speaking with the patient.

Unfortunately, many of our scribes are pre-meds or post-baccalaureate students trying to gain admission to medical school or a physician assistant program. This means that once the admissions letters come out, we have to hire a fresh crop of scribes and attempt to turn them into Olympic athletes before influenza season hits.

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The new Medicare cards continue to roll out, with more than 35 million mailed to date. Medicare is processing claims and eligibility requests using the new Medicare Beneficiary Identifier and it seems to be going smoothly for the regions where the new cards have arrived. Cards should be mailed to all Medicare participants by April 2019. I polled a couple of colleagues on the revenue cycle side and haven’t heard of any major hiccups, but would be interested to hear from readers who are knee deep in it (especially any readers who are Medicare beneficiaries themselves.)

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/17/18

September 17, 2018 Dr. Jayne 1 Comment

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To maintain my board certification, I have to do a variety of coursework “modules” on an ongoing basis. Sometimes they’re more academic, such as learning the latest and greatest clinical guidelines, and sometimes they’re more practical, such as a practice improvement project around handwashing by providers and staff. For those of us who aren’t in traditional practice, the choices are sometimes slim since we don’t have continuity patient panels that we can research with or look at trends in quality. One of the offerings that I completed for my upcoming board certification renewal was a module on cultural competency.

In healthcare, cultural competency means caring for patients in a way respects their health beliefs and cultural practices. Sometimes it can directly impact medical treatment, such as not making recommendations for animal-derived products when that would be contrary to a patient’s beliefs or preferences. In other situations, it might be more subtle, such as having an understanding of the communication preferences of different cultures and how decisions are made within extended family structures. It can also be having an understanding of medical treatments performed by different groups, including everything from cupping to intercessory prayer. It might also be respecting a patient’s desire to entirely reject treatment regardless of the potential for success.

Understanding different cultural beliefs of your patients can certainly help build trust and rapport with them, as well as helping to identify treatments that they will accept and complete. Letting patients know that you’re interested in learning about their values and beliefs helps them feel empowered and part of the care team. It’s great that healthcare providers are thinking about cultural competency, but learning more about it got me thinking about cultural competency in that context of the general workplace.

I recently worked with a company that placed a priority on this, creating various forums for employees to interact based on their family situations, ethnic groups, or interests outside of work. It was great to watch people who might not normally interact get together around a common characteristic and get to know each other.

I’ve also worked with companies that don’t have even a basic understanding of cultural sensitivity. In our increasingly polarized society, some people push back against the idea of political correctness, but rather than thinking about it that way, one might want to consider that it’s just a basic human kindness to respect the beliefs of others. I’ve been at a company that was hosting a development team from India (along with the host team’s existing multicultural employees) where the catered lunch that was ordered consisted entirely of barbecued beef and other items that had meat in them, including the baked beans and the potato salad. I cringed when I saw several people with plates of only corn bread and coleslaw.

I’ve been in meetings where the presenters used hunting metaphors such as, “You can’t shoot the moose from the lodge” and other gems, not noticing that it wasn’t playing well to the non-sportsman audience. Of course, the audience can exhibit cultural sensitivity and understand that the presenter is reflecting his own cultural practices as well rather than just acting horrified. Cultural sensitivity is a two-way street.

That’s the challenge in coaching people to develop a workplace demeanor that allows them to respect their own beliefs and traditions without stepping on those of their colleagues and employees. There’s certainly a continuum of behavior, ranging from insensitive to boorish with many different shades in between.

It’s important to understand the potential for difficulty here, because when someone in a leadership position doesn’t understand that balance, it can be perceived as creating a hostile workplace. Even when it’s unintentional or through sheer ignorance, a pattern of disrespectful behavior can become a serious workplace issue. Some companies have responded to this by formally implementing diversity training programs employee education, but it needs to go beyond that. Sometimes those programs are highly focused around specific groups rather than focusing on the more general concept of acting in a way that would make people comfortable regardless of their cultural background or beliefs.

Assuming that people from a specific background don’t eat or not eat specific foods can be an issue. I’ve worked with dozens of people whose practices are very different from their historical roots. Sometimes it’s easier to think about these challenges in a broader way – for example, thinking of dietary needs as not only a cultural issue, but also a medical one. Asking a more open-ended question around whether people have any dietary restrictions or requirements is more inclusive than asking whether people need a specific type of meal. I’ve been to plenty of corporate-type lunches where the question is never asked. That’s an easy pitfall to avoid and keeps the meeting planner from trying to figure out what different parameters they need to accommodate.

From a healthcare provider perspective, it’s great to learn about different traditions and practices so that you’re not surprised by the descriptions of treatments that patients may be doing at home, or that so you can have an understanding of how those therapies might complement or conflict with what you might recommend. However, a larger part of cultural competency is just learning how to talk with people about they prefer to be treated and being considerate of fellow human beings. It’s about not making assumptions and not trying to cast your own beliefs and values on the people with whom you interact.

There is a tremendous amount we can learn from each other and it just takes being open to learning about other people’s beliefs and needs and understanding how they may differ from your own. It’s about going back to the basics of hospitality and helping ensure that people feel comfortable regardless of where they come from or where you are going.

How does your organization approach cultural competency? Leave a message or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/13/18

September 13, 2018 Dr. Jayne No Comments

As we move into hurricane season, the American Academy of Family Physicians has released disaster preparedness resources for both practice and personal needs. I’m always amazed by the practices I visit that don’t have an EHR downtime strategy or business continuity plan. Even if they have plans, it’s rare that they have done drills or really discussed what would happen in a serious emergency. I’m not a serious doomsday prepper, but I do have some survival basics in my car including water, food, a first aid kit, and a survival blanket. There are plenty of organizations that end up having staff sleep at the hospital or medical office buildings in the event of major disasters, so it’s not a bad idea to keep some extra clothing and essentials like a toothbrush in your “go bag” because you never know where an emergency is going to happen.

Backup solution vendor Webair is offering complimentary offsite backups and disaster recovery services for business affected by Hurricane Florence. Clients can select backup replication sites on the West Coast or outside the continental US. I took a look at their offerings and was happy to see that they include up to 72 hours per month for disaster recovery testing. Far too few sites test their backups or disaster recovery strategy, so this is a plus.

HHS has declared a public health emergency in the Carolinas in preparation for Hurricane Florence. The public health emergency eases some restrictions for Medicare and Medicaid providers, and likely will lead to accommodations for various reporting requirements for 2018. I know all of us hope that the storm will not be as bad as predicted and are sending our prayers to the East Coast.

CMS is convening a Technical Expert Panel to look at the Merit-based Incentive Payment System, specifically the Improvement Activities (IA). This panel will give feedback and provide “direction and thoughtful input on the improvement activities during development and maintenance.” They’re looking for a dozen clinicians with expertise in the Improvement Areas, consumer/patient/family caregiving, healthcare disparities, performance measurement, and quality improvement. Nominations close at 5pm PT on September 22.

A wise man once told me to always spend a little time looking for my next career move, so I keep my eye out for interesting postings or opportunities. On Tuesday, I received a notice from ONC that they were looking for a medical professional in the Clinical Division. I have no desire to relocate to Washington, DC but was curious about the posting. Clicking the link embedded in the email took me to Indeed.com, where the header said the posting was no longer available on Indeed. It’s going to be difficult to recruit someone if you don’t keep the posting live, and the email from ONC made it sound like it would be open through September 19. It did cross-link me to a Medical Officer posting, which was interesting in that it was targeted to someone who is already employed by a governmental or academic institution that is willing to contract them out for a period of two years. Despite the requirement that the candidates be MD or DO physicians, the salary range is $114k to $164k, and there is no eligibility for federal benefits. I wonder if they will have candidates beating down the doors for this one given the cost of living in the DC area and the earnings potential for physicians in clinical practice.

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It’s that time of year to start talking about flu season preparedness. This week brought a blip in reported flu cases, and I hope it’s not a predictor of an early or more severe flu season. Vaccinations arrived at my clinical office on Tuesday, and everyone rolled up their sleeves and got it done. After seeing the number of seriously ill patients we saw last season, no one wants to experience that personally. Please consider a flu vaccination to protect patients, your family, and the community.

LOINC is holding its annual Fall Conference next month in Salt Lake City. Workshop topics include Document Ontology, the use of the RELMA mapping assistant, Clinician Perspective, and FHIR. I’ve been doing LOINC mapping for clients for nearly a decade and appreciate the logic and deliberate construction of the framework. Sometimes the specificity of some of the tests seems complicated to those who haven’t worked in the depths, but when you’re looking for granularity with lab data it’s important to be as accurate as possible.

The Pew Charitable Trusts, the AMA, and MedStar Health have released a new report detailing recommendations for improving EHR usability and safety throughout the software life cycle. It also identifies what can be considered rigorous strategy testing and how to create testing scenarios based on currently-understood EHR safety issues. The report also addresses the culture of safety along with EHR user training as ways to improve patient safety. Other topics covered include EHR design and development, EHR implementation, configuration and customization by end users, and EHR upgrades.

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This is National Suicide Prevention Week and gives us the opportunity to reflect on the lives lost each year due to suicide. I think often of my medical school classmate, the high-school student I taught, and a family member we lost to suicide. Our local high school’s Harvard-bound valedictorian went missing after graduation and committed suicide. It really is everywhere, and it can be prevented. TMF Quality Innovation Network is hosting a webinar titled “Suicide Prevention Tips for Physicians, Clinical Staff and Their Patients,” to be held September 18 at noon CT. It features Christine Moutier, MD, CMO of the American Foundation for Suicide Prevention, along with Leah Patterson, a survivor. They will offer practical tips for clinicians to address suicide risk for patients, peers, and themselves.

Email Dr. Jayne.

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