Curbside Consult with Dr. Jayne 6/25/12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 6/18/12

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 6/11/12

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 6/4/12

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

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

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

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

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

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

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

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

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

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

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

Got docs? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/28/12

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/21/12

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/14/12

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/7/12

Have You Been Meaningfully Used?

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/30/12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/23/12

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/16/12

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/9/12

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/2/12

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

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

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

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

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

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

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

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

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

I wonder if he includes himself in that assessment?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 3/26/12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 3/19/12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult by Dr. Jayne 3/12/12

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult by Dr. Jayne 3/6/12

The League of Extraordinary Gentlewomen

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne