Curbside Consult with Dr. Jayne 8/1/11

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Curbside Consult with Dr. Jayne 7/25/11

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

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

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

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

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

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

There was a broad distribution of practice sizes.

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 I’ve worked with docs who are using versions that are up to three years outdated and are surprised at how well the “current” version works once it’s applied.

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

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

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

The authors recognize these limits, summarizing:

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

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

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

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 7/18/11

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

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

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

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

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

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

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

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

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

Rock star HIStalkapalooza correspondent Evan Frankel mentions:

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

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

Matthew noted:

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

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

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

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

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Curbside Consult with Dr. Jayne 7/11/11

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 7/4/11

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Curbside Consult with Dr. Jayne 6/27/11

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

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

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 6/20/11

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Curbside Consult with Dr. Jayne 6/13/11

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 6/6/11

Lots of things going on this week, but one that caught my eye was decidedly low tech. The United States Department of Agriculture replaced the time-worn Food Pyramid with My Plate. Fruits and vegetables cover half the plate, with a circular dairy icon that looks a bit like a bird’s eye view of a glass of milk. Desserts don’t show up; neither do fats or oils.

I do think it’s a much more simple visual than the 2005 update to the food pyramid, which took a good idea and made it incredibly confusing and hard to teach to patients. (There have been multiple iterations of the food pyramid since its debut in 1992). The Washington Post notes that the new design “fails to direct consumers away from slathering their vegetables in butter or lard.”

What, you may ask, does this have to do with health IT? Potentially a lot. Look for targeting of obesity and other conditions that can be significantly impacted by lifestyle decisions to continue to be a major factor in healthcare reform, payment initiatives, and during the 2012 Presidential campaign. For the readers at the 20,000-foot level, that may not make a big difference.

But for the IT grunts in the trenches, look for more requests for reports in this area and for dynamic alerts and clinical decision support around these conditions. As more physician groups and health systems dip their toes into the Accountable Care Organization waters, look for “cherry picking” of desirable patients and “lemon dropping” of undesirable patients to increase. American Medical News reported last week on Florida physicians who are refusing to treat patients who weigh more than 200 pounds or whose body mass index indicates obesity.

Last month I talked a little about my support of the syndromic surveillance portion of Meaningful Use. On May 25, the Centers for Disease Control released a pre-solicitation notice that states, “there is a need for practice and technical standards that support syndromic surveillance using primary and inpatient care health data.” They are looking for someone to “identify messaging standards and information exchange architectures.”

The actual solicitation (RFP) will be posted on June 26, 2011 and will be open for thirty days. I suppose the cart went a little before the horse since providers are already going to have to test this to attest to Meaningful Use in 2011 or 2012.

Most of you are already aware that CMS has proposed additional “hardship exemptions” for providers hoping to avoid the 1% Medicare pay cut in 2012. One of these is for providers who may be in the process of adopting certified EHR technology that has delayed their implementation of e-prescribing. They recognized that these delays may have been due to the fact that the list of ONC Certified HIT Products didn’t start appearing until September 2010, whereas the eRx proposal went on public display in June 2010.

It’s always nice when the Feds admit that the right hand didn’t know what the left hand was doing, but it doesn’t give me confidence. Having trouble sleeping? You can read the proposal yourself here.

People who know me know I’m a shameless Netflix addict for a variety of reasons. Although I have several critically acclaimed films lined up for viewing, there is a part of me that likes mindless action flicks. This week’s pick was Unstoppable with Denzel Washington. Although most of the time I can see the plot on action films coming from a mile away, this one had some surprises and made a good diversion from the pile of technical reading I brought home with me this weekend. Have a movie recommendation, favorite ICD-9 code, or juicy CMIO rumor? E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/31/11

Dr. Jayne Interviews KC Frank, EVP, Document Imaging Systems Corp.

KC Frank is executive vice president of Document Imaging Systems Corp. (DISC) of St. Louis, MO.

Give me some background about yourself and DISC.

DISC has been in business since 1958. Originally founded as a microfilm company, DISC has evolved into a document management solution provider focused on improving our client’s business processes. In 2007, DISC was acquired by The Flesh Company, a 98-year-old print solutions provider. I joined DISC as vice president in 2003 and have helped develop new solution offerings, strategic relationships in healthcare, and growth strategies. I am a long-time member of MGMA, AIIM, AIIM, ARMA, and TAWPI and recently received an AIIM Distinguished Service Award for accomplishments in the Information Management industry.

One of your marketing campaigns, which has been mentioned on HIStalk, is “No hybrid EMRs.” What do you mean by this?

A hybrid EMR is one where providers rely on both an electronic and paper chart post-EMR implementation. I have heard countless stories of physicians walking into encounter rooms with both a paper chart and a tablet PC. Managing patient care in a dual environment is both incredibly inefficient and frustrating. Without a solid strategy to eliminate the paper charts, the hybrid EMR will be a reality for physician groups as they migrate to EMR.

Many practices I talk to think they can scan their documents cheaper or better themselves. What’s your experience?

If organizations truly understood the process of conversion before starting, they would probably all outsource. About 50% of the clients we work with have tried to scan on their own first. Most organizations underestimate the time, difficulties and costs associated with converting their paper charts. It’s been proven many times over that a scanning process managed and executed by inexperienced staff results in double and sometimes triple the cost of outsourcing to an expert service provider.

It’s common sense. Businesses get better each time they execute a process. DISC has converted over a billion documents in our history. Physician groups may have never scanned a single chart when they start planning their implementation. Service providers like DISC are converting documents using technology designed for large batches of scanning, including scanners that cost in the hundreds of thousands of dollars. With better technology and processes built on experience, it’s difficult to imagine a healthcare organization that could scan cheaper and better.

How is working with outpatient medical practices different from working with a hospital, or say an academic medical center?

There are subtle differences such as project design, chart setup, document types, chart access needs, and workflows. Ultimately, with strong project management by the client and service provider, the differences are negligible.

Do you just work with local clients? What’s the farthest client or most exotic locale you’ve visited to convert charts?

We typically provide services on a regional basis. Since we are certified by both Allscripts and NextGen to provide services in the central region of the United States, the majority of our clients reside in an 18-state central region of the US. We’ve provided services as far west as California and as far east as North Carolina. Do they practice medicine in Hawaii? We’re still waiting for that call.

Thinking of some of your more difficult customers, what are some pieces of advice for practices preparing to convert from paper charts to an EHR?

First, decide on a conversion strategy. Will you outsource or attempt an in-house conversion? Will you scan all charts prior to go-live or scan by the schedule after go-live? Will you scan the entire chart or just a portion of the chart? All key strategic questions. Many times organizations lean on providers like DISC to help understand the pros and cons of each of the strategies.

Pick a strong project manager. Many times the HIM or medical records director is the right choice. Make sure the person you choose cares about the success of the project. Do not hire temp staff to manage the project.

If you choose to outsource, choose a partner that has experience with medical record conversion and the EMR you are migrating to. A service provider that doesn’t have experience with your EMR system may not be able to get the documents filed appropriately in that system.

If you plan to scan yourself, do time tests to determine how long it’ll take to scan a chart. This is critical. If an organization plans to scan by the schedule, meets with 200 patients per day, and can scan a chart in 20 minutes, it’s simple math to determine that it’ll take about 66 hours per day (8 FTEs) to keep up on that project. Don’t be caught off guard.

DISC does more than just scan old paper charts. What other solutions do practices need to manage the mountains of paper they’re used to moving? Will you go out of business when all the old charts are scanned?

If we relied solely on scanning historical charts, we would be out of business in five to seven years. Fortunately, we have developed other solutions in both document and content management to evolve with our clients. Although paper is slowly being eliminated from business processes, the volume of electronic documents and content continues to increase.

Today, we are offering solutions such as Daily Go-Forward Scanning, Revenue Cycle Document and Content Management, Accounts Payable Automation, Electronic ROI, and Business Intelligence. We also offer a variety of solutions in other vertical markets, including finance, manufacturing, education, and government. We plan on being around another 50 years.

Does it make a difference whether a scanning vendor partners with an EHR vendor?

Absolutely. Having intimate knowledge of the system the healthcare organization is implementing allows the scanning vendor to automatically load the electronic charts directly into the patient chart within the EMR. Without the auto load, healthcare organizations may be left with electronic charts stored and retrieved in a third-party system or internal network drive. This, of course, is not optimal since providers have to work within two systems to find charts instead of just the EMR.

Both Allscripts and NextGen realized the importance of this integration and put certified programs together to support their clients. DISC is a part of both of those programs.

You’re located in the Midwest, an area hit hard recently by floods and tornadoes. Any great “saves” with your clients during these disasters?

We actually did have a client this year ask us to scan hundreds of boxes of records stored in the first level of their building due to flood concerns. Unfortunately, natural disasters have a history of reducing the historical content of a business to rubble; specifically all the important documentation which resides in a paper format. Fortunately, companies like DISC can digitize that critical information so disaster recovery of those documents is as simple as reloading a backup.

Any final thoughts?

Another common strategic discussion we have with clients is whether or not they should scan the entire chart or just a portion. We have seen successful projects on both ends. Understand that the benefits many organizations expect when going to an EMR, such as eliminating chart filing labor costs and reusing paper chart storage space for revenue-generating opportunities, will not be realized until the entire chart can be removed from the chart room. This decision is typically made with one of two goals in mind – to satisfy clinical needs (partial scan) or to satisfy business needs (full scan).

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/23/11

I was looking for the perfect quote to start this week’s Curbside Consult and thought I had it nailed. Like many avid readers, I tend to remember bits and pieces of great literature, but not everything. Just enough to do passably well at cocktail parties and trivia nights, but not well enough to lead a book club.

So, when I hit the Internet to validate the quote I was going to use, I was blown away by the parts I had conveniently forgotten.

It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way…

This is the opening of A Tale of Two Cities by Charles Dickens. I was going to use the best of times / worst of times metaphor to talk about two recent physician visits, one of which was electronic and one was paper. I’ll let you guess at which one was which because the poignancy of the rest of the quote and how applicable it is to healthcare in general strikes me too much to want to talk about anything else.

First published in 1859, the story is set in the tumultuous time of the French Revolution. The opening line serves largely to portray the contrasts inherent in that time — poverty vs. affluence, ignorance vs. enlightenment, good vs. evil, and so on. When you think about it, sometimes it seems that things haven’t changed as much in the last two hundred as we might have hoped. It feels like we’re on the cusp of a different kind of revolution, and not necessarily for the better.

Undoubtedly, this is the best of times for many people. People are living longer, largely due to improvements in health technology. Mechanical replacements for diseased body parts, amazing new drugs, implantable defibrillators — you name it.

We are, however, in a system with a great deal of inequality about how this technology is employed, resulting in a great cost to society and for many a great personal cost as well. Medical bankruptcies are again on the rise, accounting for more than sixty percent of all personal bankruptcy filings. The worst of times, indeed, when people have to choose between purchasing food and filling their prescriptions.

Meaningful Use should be the poster child for the age of wisdom and the age of foolishness. It seemed so promising: “free” federal money for providers to do what they should have been doing all along, implementing systems to improve patient care and strengthen patient safety. Many providers were already doing these things, and it seemed so easy to reward them.

The way it’s unfolding, though, is just sad. The disparity between the Medicaid and Medicare incentive programs is laughable. At times, the whole business feels like a crapshoot. If this were an investigative study, it would never have made it past the Institutional Review Board.

Many of us on the healthcare IT side of things are living in the spring of hope. We’re well on our way to having the right software installed with the right workflows and the right numerators and denominators kicking out at the end.

For some of us though, this will lead right into the winter of despair. Meaningful Use is the ultimate pass/fail class. Miss the mark by half a percent on one measure and you’re out. This doesn’t seem in keeping with the spirit of trying to improve healthcare and health outcomes.

What if we treated patients like this? “I’m sorry Mr. Jones. I know you’ve done a tremendous amount of hard work to get your diabetes under control, including exercising and losing weight. However, your hemoglobin A1c level only came down from 9.0 to 6.2. The goal was 6.0, so you lose. Here’s a scarlet ‘L’ to wear on your shirt. I’m raising your health insurance premiums by 40%.”

Many of my peers have done the math and know that even with the penalties that are coming, they can “do nothing,” see one or two more patients a day, and come out far ahead of their colleagues who are on the MU hamster wheel. Could the unintended consequence of ARRA and healthcare reform be the downfall of Medicare and decreased health outcomes for our growing senior population? Will it be the final blow to an already ailing primary care workforce? Will it be little more than a windfall for technology interests and consultants?

Only time will tell. But I leave you to ponder on the closing lines of the book.

It is a far, far better thing that I do, than I have ever done; it is a far, far better rest that I go to than I have ever known.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/16/11

When I started as a solo practice physician, if someone had told me that someday I would be able to have actual conversations about the business side of the house, I would have told them they were crazy. As a naïve postgraduate, I actually believed that most of practice would be about caring for patients. Tincture of time and a few rides on the revenue cycle roller coaster quickly proved otherwise. (No one likes going bankrupt, which is a real danger for small practices these days).

Knowing other providers have also had this experience, it shouldn’t have been surprising to me that business-related articles on HIStalk have generated quite a bit of feedback. In a recent EPtalk, I talked a bit about the need for office-based physicians to work on maximizing their use of practice management systems as a prelude to maximizing their use of electronic health records.

One reader asks:

When determining the first pass clean claims rate, do you count as ‘unclean’ a claim that (1) doesn’t make it through the EDI/clearinghouse scrubber (rejected), or (2) makes it through the clearinghouse/scrubber but is then denied by insurance (e.g., wrong coding, more medical information needed, etc)? I have seen a clean claims rate calculation as being just those rejected by the scrubbers, but I have also seen it where it includes every claim that wasn’t paid with only one touch.

I have to rely on my anonymous celebrity claims expert Bianca Billinghouse, who responds:

First pass is defined as a clean claim when it makes it through the practice management system’s claims scrubber as well as the clearinghouse. If it doesn’t make it through the clearinghouse, this is what we term a rejection. The office staff typically didn’t run their claim edits and it was caught by the clearinghouse. These count against the practice. If it makes it all the way through to insurance and results in a denial, depending on the reason, then it falls into controllable or not controllable denial. We see this often with eligibility, even though we are attempting to do this upon check-in.

I also got a fair amount of feedback on last week’s Curbside Consult about evaluation of practice management systems and their readiness for 5010. Several readers suggested other organizations as sources for evaluating practice management systems, such as KLAS or AC Group.

Another wrote with an interesting perspective on 5010 compliance, which I thought I’d share:

The new 5010 standard, in the short run, is the same old data repackaged a slightly different way from the 4010 standard. The truth is that if you send your claims via a clearinghouse in the short run, you don’t need to do anything. The clearinghouse and the insurance companies need to be able to exchange data in the 5010 format by January of 2012, and many companies are doing testing now through the end of the year. The reason that a provider doesn’t need to stress about this is the actual new data from the provider — i.e. ICD-10 codes — don’t go into effect until 2013.

Software companies, as you can imagine, use any change as a way to sell an upgrade or new release, and most of my clients are told you must do this or that. Whenever you are told you must do something by a software company, nine times out of ten you probably don’t. If you’re an office that sends all your own claims yourself direct to all the insurance companies, you may need an upgrade by January 2012. If you use a clearinghouse or a billing service, you probably have another year until your software needs to accommodate ICD10 codes. If you’re looking at a $2,000 upgrade vs. paying a clearinghouse $50 per month to take care of things for you, that is your choice.

Considering that my primary ambulatory system is with a vendor that doesn’t charge for upgrades (they’re included in maintenance), I have no skin in the game on upgrading vs. not upgrading as a cost-saving maneuver. Interestingly though, the same day I received that e-mail, I also received my snail mail copy of American Medical News with the headline, “Not electronic-claim compliant? Then expect no payments in 2012.”

The article mentions that 5010 requires submission of nine-digit ZIP codes on claims, which I suppose a clearinghouse with the postal database can “plug” as the claims pass through. It also includes the ability to “distinguish between principal diagnosis, admitting diagnosis, external cause of injury, and patient reason for visit codes” which I can’t imagine a clearinghouse being able to manipulate unless I’m not understanding what that means. (Damn it Jim, I’m a doctor, not a biller!)

However, 5010 is also a precursor to ICD-10. I worry that physicians who think they can delay the upgrades for 5010 adoption will unwittingly delay progress towards adoption of the new coding standard, which is already anticipated to be an extremely difficult transition for physicians.

Of course, another conversation with Bianca was in order:

He’s obviously using the clearinghouse spin, touting that they will take care of everything. Ultimately, it’s still the provider’s responsibility to comply with the mandates. I wouldn’t feel comfortable relying solely on my clearinghouse to map/plug the required loops/segments. He’s right that clearinghouses help in the process, but what will the clearing house do when its clients don’t get their claims paid because the primary payer wants 5010 and the secondary wants 4010 or even paper?

The American Medical News article goes as far as recommending that practices increase cash reserves and consider lines of credit to buffer potential rejections after the switch, which certainly doesn’t do anything to reduce physician anxiety. Personally, I’m extremely thankful that Bianca is looking out for my colleagues and me (no one ever gives the billing / claims / collections folks the credit they deserve). But I still I think I might have to temper my anxiety over ICD-10 with a nice Riesling.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/9/11

My large healthcare system, like many, is in the business of doing everything possible to make friends with independent physician practices. The average primary care physician drives several million dollars in ancillary revenues each year, so we can’t afford not to.

Our system offers discounted access to our EHR product for affiliated physicians. Although we have quite a few takers, many are still skeptical. After all, they’re independent for a reason. If they really wanted to buddy up, they would have been purchased long ago.

In a continuing effort to woo these last few holdouts, I was tasked with checking out some of the resources available to independent physicians seeking an EHR or practice management systems. Since Inga mentioned the new MGMA/AMA effort to create an online directory of practice management systems that are compliant with the 5010 standard, I decided to check it out.

I must have spent too much time with adolescent relatives over Mother’s Day, because my response to the directory is “lame, lame, lame.”

The directory lists only 20 vendors. Some of them aren’t even software companies – one lists its product as “Consulting and Implementation of several PM/EMR”s” [typo on parentheses left in on purpose.] As an AMA and MGMA member, I was embarrassed by this document. Version numbers included “n/a” and “current”, which I found hysterical.

Really? If this data would have been gathered by my intern, I would have sent him back to his cube in shame. They have a link on the page that if you don’t see your vendor, you should e-mail and they will ask the vendor to participate. Does neither the AMA nor the MGMA have the ability to identify the top 100 vendors and survey them to create a useful guide?

Now mind you, none of the vendors I use are on the current directory, so I can’t verify the accuracy of the listings. But in checking out a couple of the individual detailed profiles, I learned the following:

• Cerner PowerWorks PM has 250 customers and doesn’t support Microsoft .NET, does not use a “modern and widely supported relational database for the underlying data structure,” and the database is not ODBC compliant. Kind of a surprise.
• Ingenix CareTracker has one box checked that the “modern and widely supported relational database” is standard. Another is checked that says “does not provide.”
• MCA Systems CodeHERO product was about to get a “best product name” prize until I noticed it “does not provide” the following: appointment scheduling, resource scheduling, claims generation on the CMS 1500 or UB 04, or ability to maintain payer lists including fee schedules. How exactly is this a practice management system?
• Allscripts, GE, eClinical Works, NextGen, Sage, McKesson, and Athena are all missing in action on this list.

If I were a vendor not listed, I’d e-mail them at busdevelop@mgma.com and tell them to get with the program. If I were a listed vendor, I’d certainly double check my data and find out who in my organization submitted it, if it’s not accurate.

So what’s the point of all this? First, I always like to let Inga know I’m reading her material. HIStalk girlfriends have to stick together, you know? Second, whether I work for a monolithic organization or not, I’m still a small-practice physician by training and I care what happens to my friends in the trenches. Third, large organizations like MGMA and AMA who want to actually help said physicians in the trenches need to do better.

Do you have a better source of info for physicians who are shopping for a new PM system or want to verify that theirs will handle 5010? I still have to impress a hospital president with a fancy PowerPoint presentation. E-mail me.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 5/2/11

This has been a bit of a crazy week for me, with entirely too many hours at the hospital. I had a pounding headache after a particularly chaotic shift. After taking the proverbial two aspirin and trying to unwind with some quality Internet surfing, I came across a blurb about the noise levels in hospitals. Could this be the culprit?

Digging deeper into the Chicago Tribune, the article cited “alarm fatigue,” a significant safety issue for hospitals. If you haven’t experienced this personally and you live in the IT or medical device worlds, you’ve probably heard clinicians complaining about what the article describes as “incessantly beeping devices.” I definitely met this face to face while rounding on the cardiac floor, where every patient has a heart monitor.

The Trib mentions the Food and Drug Administration’s responsibility for regulating medical devices, and the scope of its reach is broad. Ever wonder what all they regulate? It’s much more than X-ray machines and prosthetic knees. A list of the various regulated devices is here. I had no idea they regulated some of the things they apparently regulate. Maybe I can use some of them for trivia at my next cocktail party.

Based on their extensive reach, I’m actually pretty surprised they haven’t yet gotten into the electronic health records arena. Many people are calling for FDA regulation. The Tribune article brings up some important points, however. FDA, in its regulation of devices, hasn’t been able to find the “sweet spot” between specifying the appropriate alarms to adequately support clinical care while reducing the fatigue caused by overly sensitive parameters.

The piece cites a noise researcher from McMaster University as saying, “People don’t pay attention to alarms; they exist as much for legal liability reasons as much as for actually doing anything for patients.” If we have this situation with devices that have been regulated for years, what does that say about the ability of the FDA to improve the performance of electronic documentation systems?

As cited in the article, ERCI Institute has a top ten list of technology hazards. For 2011, alarm-related adverse events is number two, right between radiation overdose (!) and cross-contamination from flexible endoscopes (yuck). Data loss and “other health IT complications” is number five. This is a pretty serious list: surgical fires and misconnected intravenous lines also made the cut.

The Chicago Tribune isn’t the only major outlet to report on this issue. The Boston Globe ran a piece in February. Their investigation revealed 942 alarms per day on a 15-bed unit at Johns Hopkins Hospital — a rate of one critical alarm every 90 seconds. In studies, up to 85% of alarms have been shown to be false alarms. The FDA is apparently stretched thin already, failing to follow up on case reviews with manufacturers in some cases.

Organizations other than the FDA have gotten into the alarm fray. Joint Commission made alarm recommendations part of its National Patient Safety Goals in 2004, but dropped them in 2005. Some safety experts have lobbied to block hospital staff from turning off critical alarms, a move that was rejected by an industry working group due to caregiver objections and the need to “permit the clinical staff to solve the problem in peace and quiet.”

As a clinician, I experience alarm fatigue every day. Cardiac monitors start beeping when patients turn or cough. IV machines beep when infusions are completed (even if the next infusion isn’t due to start for another 23 hours). My hospital’s EHR warns me that the diabetes drug I’m about to prescribe should be used with caution because it might lower blood sugar. Kind of sad, since that’s the main reason I’m prescribing diabetes medications in the first place — to lower blood sugar levels!

I’d love to see some standards put in place. Standards created by rational clinicians based on data and science, not based on the risk of lawsuits or on anecdotal experiences. The FDA doesn’t seem to have a track record in this area and they don’t seem to have the horsepower to take on regulation of another industry. As a physician, if they had additional funding, I’d like to see them tackle the dietary supplement industry first. How many patients are harmed by taking entirely unregulated substances marketed by greedy manufacturers who can say whatever they want because their product is classified as a food rather than as a drug?

Other federal agencies charged with regulating or advising in these areas haven’t fared much better. The United States Preventive Services Task Force is charged with recommending preventive health care services based on evidence-driven criteria. However, their recommendations have been blasted (and undermined) by various disease-centric organizations and professional groups and even the payment policies of CMS. It’s hard to explain to a patient why a test isn’t justified based on mountains of clinical evidence when they can counter with, “Then why does Medicare cover it?”

Let’s say we’re going to tackle alarm fatigue. Who can do it, how should they do it, and where are we going to get the money to pay for it? I’m interested to hear your ideas.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/25/11

In the last several weeks, tornadoes and other severe storms have ripped through various parts of the country. Based on a frantic phone call I received from a medical school colleague, this seems to be a good opportunity for a physician-friendly discussion of disaster preparedness for healthcare information technology. For those of you who are serious IT professionals, this may be boring, but on the other hand it may be a good conversation starter to e-mail (or even print if you have to) for the physicians in your lives.

Downtime and Disaster Recovery 101

The most important part of successfully dealing with an outage of your electronic health record is to have a plan. Most practices need both short-term and long-term plans, whether you’re in a well-known hurricane zone or tornado alley or not. Lots of things can happen: floods, fires, and earthquakes. No one is exempt and everyone needs a plan.

Downtime usually refers to a time when the system is unavailable, whether planned or unplanned. Downtimes can happen for a variety of reasons. Unplanned downtimes may include a local power outage, loss of Internet connectivity, or other nonspecific system issues that keep physicians from fully using the EHR. They may be limited — perhaps it’s just an outage of e-prescribing or faxing — or may affect the system across the board.

Limited downtime events often have simple workarounds. For example, if e-prescribing or faxing is down, one can always print prescriptions or documents, call medication orders to the pharmacy, or worst-case scenario (ugh) use a paper prescription pad and a pen. Loss of Internet connectivity can be overcome by using a cellular / wireless Internet card, provided the practice has planned ahead and such cards are available for use. If the local wireless network in the practice is out of commission, users may be able to plug in, assuming there are ports available.

For unplanned downtimes, unless they have in-house IT support 24×7, practices should ensure key personnel have checklists for troubleshooting issues and phone lists for Internet service providers, vendor help desks, etc. Make sure multiple people in the practice know how and where the information is stored — don’t count on a single employee to be the point of knowledge. Murphy’s Law dictates that if something goes wrong, it will go wrong when that employee is unavailable.

Planned downtimes are usually limited downtimes. This may include hardware upgrades, software upgrades, weekly or monthly maintenance, etc. When planning a downtime, physicians need to discuss their willingness to work without full access to the EHR. Many physicians may be willing to print summaries for patients who may be scheduled during an upgrade and ‘wing it’ for others. For some, being without data is unacceptable, and the office must be closed.

Careful planning can keep physicians from having to make this decision. Many vendors offer solutions where a copy of the database can be saved to a local computer and accessed in a read-only manner during an upgrade. There are several third-party solutions to this problem, and if you are interested in this for your practice, allow some time (often a few months) to make sure this is in place before a planned downtime.

Disaster recovery usually refers to a situation where something very, very bad has happened. This can include physical destruction of the practice, its servers, and its equipment due to a natural disaster. If the IT infrastructure is physically destroyed, it may be weeks before the practice can be up and running. Disasters can also occur due to poor planning, as my friend learned.

Practices need a plan to create backup copies of the data in the event of a disaster. If you use a Web-based or hosted EHR, often your vendor takes care of backups for you. However, you need to understand the interval at which backups are done. Daily, weekly, monthly? To determine how frequently you need to do a backup, ask yourself: how much data are you willing to lose? For a busy practice, backups should be done daily and practices should consider other strategies to continuously back up data throughout the day (but that’s beyond Disaster Recovery 101, so I’ll save the discussion of transaction log shipping vs. database mirroring for another day).

Backups should not be stored in the office. Think it through: if your office catches on fire and the backup copy is at the office, that’s not a great idea. Backups need to be stored securely under appropriate climate conditions — be mindful of temperature, humidity, etc. There is one important thing about backups that doesn’t cross most physician minds: the need to test the backup to make sure it works. Your IT professionals can do this by taking the backup copy of the database and restoring it to a test system, then checking it to make sure data is current and comprehensive.

Unfortunately, the solo physician who called me this morning learned this the hard way. When the power went out and the battery backup failed, the database was impacted. Her vendor recommended that they restore the database from the most recent backup. When this was attempted, the backup contained less than half the data they expected it to. Not a great situation. Although she was fortunate that the EF-4 tornado didn’t touch her building, it’s going to be a challenge to recover from the loss of so much data.

So physicians, heed this cautionary tale. Take a moment to discuss your downtime and disaster recovery strategies with your IT support staff, whether you work in a solo practice or for a large health system. Don’t be afraid of stepping on the IT team’s toes — many are proud of the downtime strategies they’ve created and will be happy to talk about them. If there is no written plan, make it a point to create and document the processes you need to practice should the system be unavailable. Make sure key staff have copies of the plan, and practice it. Use regular maintenance windows as an opportunity to practice what you would do if an unplanned outage occurred.

Preparing for system outages should be a regular part of the life of the practice, no different than fire drills, tornado drills, or the like. The odds of something bad happening may be slim, but if you’re in disaster’s crosshairs, you’ll be glad you took the time to prepare for the worst and to protect your patients and your practice.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/18/11

I try not to waste too much time on the Internet, but keeping an eye out for interesting stories on health and technology is an occupational hazard. How could I not read a piece with the headline Playboy Mansion Illness Traced to Hot Tub Bacteria when it crossed my screen? Apparently our old friend Legionella (the bacteria that causes Legionnaires’ disease) was found in a hot tub at the Playboy Mansion after scores of visitors were sickened.

As if a story about hot tubbing with Hef isn’t tawdry enough, epidemiologists were no doubt engrossed when the case was presented last week at the Centers for Disease Control’s annual conference in Atlanta. So what does this have to do with health and technology? Well, it seems that epidemiologists used social media to contact the 400+ people who were at a fundraising event where they came into contact with the bacteria.

In other news, the Associated Press reports that Odd Work Schedules Pose Risk to Health. From my experiences as an intern and resident, I could have written that one — it’s not good for the caregivers or their patients. According to Dr. Charles Czeisler, chief of sleep medicine at Brigham and Women’s Hospital in Boston, 30-50% of night shift workers admit to falling asleep at least once a week while working.

Although the article highlights findings related to recent issues with air traffic controllers snoozing on the job, the facts play to all of us in healthcare and IT, also. Czeisler states that taking work home on BlackBerrys and computers as well as the 24×7 availability of work and entertainment options contributes to sleep issues.

Somehow I missed this in my recent studies for my medical board recertification exam, but night shift workers are more likely to have chronic intestinal and heart diseases. Apparently, the World Health Organization has also identified shift work as a probable carcinogen. Not good news for those of us in the business of 24×7 technology and patient care activities, or the patients either. Having been sleep deprived for nearly five years during my training, I understand the near misses (and sometimes real misses) that can happen in the middle of the night when the thought process starts to get fuzzy.

These types of situations are great for employing technology as an additional safety net for our patients. Long hours aren’t going away (nor are distractions, overloaded schedules, nursing staff burdened with regulatory nonsense that detracts from patient care, or any of the other dozens of things that impact clinical decision-making). But well-placed clinical tools (like the Thomson Reuters tools mentioned by Dr. Gregg on HIStalk Practice)  can really make a difference.

Personally, I’d much rather have my anesthesiologist calculating drugs and dosages in a well-crafted electronic record than doing equations on the leg of his scrub pants (which, thank goodness, I haven’t seen in a long time). However, the systems have to be well designed, easy to use, and accurate if they’re going to make a difference. Users have to commit to attending training, using the system properly, and not short-cutting steps. IT teams have to keep the systems available (not to mention happy and healthy) continuously. Otherwise, make sure you have your scrubs on — and your favorite ballpoint pen.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/11/11

There’s been lots of buzz this week about the Care Connectivity Consortium. This initiative by Geisinger Health System, Kaiser Permanente, Mayo Clinic, Intermountain Healthcare, and Group Health Cooperative has been noted everywhere from The New York Times to Yahoo and MSN.

I can’t wait to see how this collaboration unfolds. Those of us who have spent the last several years knee-deep in Health Information Exchange know how difficult it can be to actually make this happen.

I’m interested in seeing details on the pre-work: consent, governance, and ownership. It’s challenging enough to get a productive HIE live that meets the legal hurdles of a single state, let alone meeting those of a disparate group covering Pennsylvania, California, Minnesota, Utah, and Washington (which just represent the headquarters states, not all the states where care is delivered, which will also have to be addressed).

The warm and fuzzy scenario presented in The New York Times piece: “A person walks into a clinic in Phoenix, say, and, with permission, her records from her hometown physician’s office in San Francisco are efficiently summoned with a mouse-click.” If only it were that easy!

Having been involved with attempts to jumpstart a regional HIE, I know that wading through the legalese for the patient consent and trying to fit it on a single page reminded me of the scene in the cult classic The Princess Bride, where the bad guy has a machine that sucks years of your life away.

The consent language for many data exchange projects can be nearly unintelligible for the lay person. I suspect the forms will become “just another form” that patients shuffle through and sign if they want to receive care, whether they understand it or not.

(Kind of like the paperwork in the Emergency Department – do they think patients actually read that? I don’t think so. They sign it because they are sick, hurting, and in need of care. When you just want to see your doctor, you don’t care about the HIPAA Notice of Privacy Practices, Patient Financial Responsibility statement, or anything else other than being treated.)

I’d like to see the details of how they’re going to do this. I’m sure it will be more than the proverbial single click – like documenting the patient’s consent or opt-in status, validating patient identifiers, etc. And once you have the patient identified, how useful will it be? I hope the Consortium goes “all in” with this and uses fully discrete data that can be exchanged and consumed by receiving physicians’ EHRs, not just another view vault application that’s the electronic equivalent of asking physicians to review paper documents from multiple institutions.

I applaud the groups’ ability to work out shared goals among the CEOs before it became too public. Kaiser’s CEO George Halvorson is quoted as saying, “The CEOs had to make sure the CIOs didn’t think this was crazy or impossible.” Probably a good idea, as this may have been a non-starter if too many people were at the table before the basics were agreed upon or if the CIOs opposed it.

But now that the basic agreement is done, what about the CMIOs and the actually physicians and caregivers who will have to use the system on a daily basis? I hope their input will be considered starting immediately, if this has not already happened.

How real-time will it really be? How are they going to handle corrections and errors? What about monitoring and maintenance of potential duplicate patients? Sensitive information, such as drug use, HIV status, sexual history, and the like? Patients who change their opt-in/opt-out status to avoid sharing certain information?

The devil will definitely be in the details. The answers to these questions, coupled with ease of use, will determine the success of this initiative (assuming the technical piece can be carried out in a timely and fiscally responsible way).

The New York Times pointed out that the groups also have insurance products. Collaboration could be seen as an attempt to compete with the lines of UnitedHealth, Aetna, and Wellpoint. Halvorson is quoted as saying, “This is totally focused on care.”

I really want this to work and be successful in a big way. This could pave the way for many other collaborative efforts that could be game-changers for the physicians in the trenches. The groups intend to exchange some data by the end of this year, so it should be fun to watch.

If any of the CMIOs from the Consortium organizations are HIStalk readers, I’d love to chat with you about the gory/geeky details of the project (preferably over a glass of wine and some chorizo fondue, but I’ll settle for Skype). Drop me a note if you’re interested in chatting.

E-mail Dr. Jayne.