DOCtalk by Dr. Gregg 3/26/14

Is Being OK OK?

In the fields of healthcare and technology, perfection is essential. In healthcare, anything less may get you sued. In the tech world, if it doesn’t get you sued, you certainly won’t be in business for long if your tech offerings are filled with glaring flaws. (Imagine how long you’d keep using your iPad or smart phone if it remained annoyingly glitchy.)

Contrast this with the popular mantra, “Don’t let perfection become the enemy of the good.” This is such a perfectly human sentiment; it recognizes both our penchant for overthinking and our inherent inability to ever be truly perfect.

Whether you’re OK with “OK,” “O.K.,” “ok,” or “okay,” being OK implies acceptability. It implies good enough. It implies sufficiency. It implies decent. But, is it OK in healthcare IT to be OK?

Trying to make everyone happy is quixotic. It’s never going to happen. Someone won’t like how you did this, or they won’t like how you said that, or they just won’t like your approach. Thus, you just know that all of your best efforts are, at some point with some person, going to fail. Despite all the minutia minding and detail addressing, someone will be displeased with you.

In healthcare, you try to do your best. You try to address your customers’ needs as best you can, try to make sure to “do no harm,” try to attend to the pertinent details, all while hoping that payment reform and insurance requirement changes and federal or state regs will allow you to keep trying to serve your patients…and pay your bills.

In the land of HIT, it’s pretty much the same. There’s no health IT vendor on the planet who has 100 percent customer satisfaction. No matter how good your tools are, no matter how cutting edge your designs, no matter how responsive your tech support, someone somewhere is going to find fault. (I must admit that sometimes I’m one of them!) No HIT vendor anywhere does everything well…despite what their marketing folks may say.

When I look at EMRs or EHRs, one of the most important things I look for is a sufficient number of “happy factors” that make my overall user experience pleasant enough that I can overlook the missed or poorly addressed elements. Honestly, there haven’t been that many systems that engender a feeling of “Oooo…this is cool” often enough. Many have some of those moments; few have enough of them.

When HIT consulting, I try to stress the end user experience to the vendors, even while understanding their resource limitations and developmental timeframe restraints. Vendors can spend all of their resources trying to make each little detail perfect. But, there are so many darn details in any EHR/EMR, that I’m sure even Epic doesn’t have the resources to attend to each one completely, despite its Fort Knox of cash and (not so) small city of employees. Top off all the medical minutia with the seemingly endless requirements for MU, ICD-10, PCMH, ACO, HIPAA, P4P, PQRI, and a laundry list of other acronyms requiring attention, and it’s easy to see that the details demanding developer deliberation are virtually limitless.

Is it possible, then, in either healthcare or health IT to decide that good enough is good enough? Can you be OK with being OK?

You can. I’m certain of it. (Frankly, I don’t see any other option most days!) And, OK is good. You may not be able to “please ‘em all,” but if you strive for perfection and achieve OK-ness, that’s really an accomplishment. Humans are not, almost by definition, perfect. You can sometimes be great, sometimes be not-so-great, and overall be perfectly OK. You take your best shot each day and hope you hit somewhere in the good part of the old Pareto’s Principle (80/20 Rule.)

The hard part isn’t achieving perfection. That’s a pipe dream. The hard part is learning to be OK with being OK, even as you still strive for more. You always want to try for perfect, but you have to be able to see that less than perfect can still be good.

Good.

Fine.

OK.

Psychiatrist Dr. Thomas Harris once told us that we’re all OK in “I’m OK – You’re OK.” Even if you don’t agree with his overall approach, the sentiment stands: it’s just fine to be OK, in healthcare IT or anywhere. Just be a grand OK. Be an exceptional OK.

OK?

From the trenches…

“I’ll lean on you and you lean on me and we’ll be okay.” – Dave Matthews

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, an HIT and marketing consultant, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

News 3/25/14

EHR usage in small physician offices has helped spur overall EHR adoption to 61 percent, according to an SK&A report on physician office EHR use. Other key findings:

• The adoption rate for single doctor offices grew from 42.3 to 53.7 percent from 2013 to 2014.
• EHR adoption rates increase as the number of physicians practicing at each site rises; as the number of exam rooms at each site increases; and, as average daily patient volume rises.
• Physicians working for integrated health systems have higher adoption levels than providers working under other type ownership models.
• Epic, eClinicalWorks, and Allscripts lead other vendors in terms of market share.

St. Francis Health System (OK) will go live across its 70 physician offices in May and at its hospitals in June.

The AAFP offers an online PCMH planner to help practices achieve medical home practice transformation by assessing a practice’s current program and identifying specific goals to fill any gaps. The subscription-based planner starts at $100 for members and $149 for non-members.

How do these things still happen? A Topeka, KS man opens a dumpster in his office complex and finds discarded medical records, complete with patient names and social security numbers. Perhaps not coincidentally a document scanning service has an office in the same complex. The state attorney general’s office have removed the charts for further investigation.

The Naval Branch Health Clinic Albany (FL) announces the availability of secure email between patients and providers using RelayHealth’s secure messaging service.

GMed introduces a revenue cycle management service that complements its existing gastroenterology-specific EHR and practice management, report writing, and patient portal platform.

The Robert Wood Johnson Foundation launches Flip The Clinic, an initiative meant to transform the average doctor visit to be more satisfying. The idea is to have the Flip The Clinic website serve as a hub for patients, providers, and other stakeholders to share ideas for improving the physician visit experience so that it’s more satisfying for patients and optimizes physician expertise. I like the concept and the mission, but I’m not convinced it’s something the average patient (or physician) will take the time to find and participate in. I hope I’m wrong.

The use of copy and paste functionality in EHRs should only be permitted in the presence of strong technical and administrative controls, which include organizational policies and procedures, requirements for participation in user training and education, and ongoing monitoring. That’s the recommendation of AHIMA in a newly published position paper that warns users that the efficiency and time savings benefits of copy/paste functionality should be weighed against the potential for creating inaccurate, fraudulent, or unwieldy documentation. The use of copy and paste functionality is too entrenched in EHRs to be eliminated so kudos to AHIMA for offering solid and realistic recommendations to reduce the potential risks.

The Federation of State Medical Boards is considering a policy that could impact the delivery of telemedicine services by requiring a physician to be licensed where the patient is located. The policy also requires the same standards of care apply for both virtual and face-to-face encounters.

Email Inga.

News 3/20/14

Saint Peter’s Healthcare System (NJ) selects athenahealth’s athenaOne EHR, PM, and communication system for its 176 hospital- and clinic-based physicians.

American Family Care, which operates 160 urgent care facilities across 26 states, agrees to pay the federal government $1.2 million to resolve allegations that it knowingly submitted claims using billing codes higher than appropriate for the actual service rendered. The case stems from a whistleblower lawsuit filed by one of the organization’s former claims processing directors.

Nationwide 62 million people have no or inadequate access to primary care given local shortages of physicians, according to a report by the National Association of Community Health Centers. Not surprisingly the Association recommends the government provide community health centers with plenty of funding to help address access challenges, but I think the fix requires more than just more money. I’m reminded of a session during  HIMSS featuring occasional HIStalk contributor Lyle Berkowitz, MD, who correctly stresses the need for innovation and technology in healthcare to improve access:

If we don’t adopt new technology and change the way we deliver care, it will be harder and harder to get to see a doctor, it will cost more, the rich will cope, the poor will suffer. Many will die earlier than they would have if cost effective treatments were available. We have to act now before the healthcare system goes into meltdown.”

The Drummond Group certifies Kareo EHR for MU 2014 Stage 2.

CMS releases Road to 10, a free online resource to help physicians in small practices in their transition to ICD-10. The tool to build an action plan (actually a  “catch-up plan”) looks pretty handy and allows providers to customize their roadmap based on practice size, specialty, and  the type of technology used in the practice.

Not so surprising findings from a RWJF-funded study: physician practices participating in ACOs tend to be relatively large, members of an IPA or PHO, less likely to be hospital-owned, and more likely to use care management processes and EHRs as compared to practices not participating in ACOs. Researchers found that 61 percent of practices have no plans to participate in ACO, which raises the question of how to get the balance of practices on board with ACOs, if in fact the ACO model proves to provide better and more cost-effective care.

Welcome to new HIStalk Practice Platinum Sponsor Arcadia Healthcare Solutions, which is headquartered just outside of Boston and has additional offices in New York, Seattle, and Nashville. Arcadia provides services and technology for EHR outsourcing; data integration and population analytics; and care delivery transformation and coaching. Clients of the 12-year-old company include five Pioneer ACOs, leading academic medical centers, national health systems, managed care organizations, and several Blues. Arcadia’s advisors can help practices  improve key ambulatory network measures 15 to 30 percent in six months by bringing together EHR and claims data and helping providers use it. Some of its EHR optimization accomplishments include reducing log-in time by 50 percent, improving system performance by 27 percent, and increasing physician satisfaction by 20 percent. Arcadia provides expert advisors rather than, as it says, “high-priced management consultants who leave nothing behind but PowerPoint.” Thanks to Arcadia Healthcare Solutions for supporting both HIStalk and HIStalk Practice.

InstaMed launches InstaMed Go, which allows providers to collect patient payments via smartphones from any location with the payments posted automatically to their practice management systems and receipts emailed to patients.

Email Inga.

News 3/18/14

From Soothsayer: “Re: Castlight Health fallout. Given Castlight’s tremendous IPO success, look for more HIT companies to follow suit. A few we might see within the year: Practice Fusion, CareCloud, and ZocDoc.” Castlight’s share price surged 149 percent during its Friday IPO, giving the company a valuation of more than $3 billion. That’s a pretty impressive debut, especially considering Castlight had $13 million in revenues and a $62 million net loss in 2013. There’s clearly a lot of interest in the HIT sector so I’m with Soothsayer on this one.

CMS wants to recoup improper payments made through its PQRS and e-prescribing incentive program and will launch a four-year program to look for potential errors, inconsistencies, and gaps related to data handling, program requirements, and clinical quality measure specifications. According to a Federal Register notice, CMS will survey 400 group practices, registries, and data submission vendors and perform a limited number of follow-up interviews.

Disturbing: researchers from the University of Illinois at Chicago find that transitioning from ICD-9 codes to ICD-10 could lead to a significant loss of data, based on an analysis 220 hematology-oncology and outpatient diagnostic codes. Specifically researchers found the transition affected eight percent of state Medicaid codes and one percent of codes in the University of Illinois Cancer center; potential costs associated with the information loss totaled $479,299. What’s particularly troubling is that the study focused on hematology-oncology codes, which involve fewer ICD-10 codes and thus less convoluted mappings than codes in other specialties.

The House passes legislation to permanently repeal Medicare’s SGR payment formula, but, full passage of the law is unlikely because it includes a provision to delay the ACA’s mandate requiring all individuals obtain health insurance. Without a repeal or a temporary patch, doctors face a 24 percent cut in Medicare reimbursements as of April 1.

UnitedHealthcare, Aetna, BlueCross BlueShield, and Humana tell the AAFP they’ll be ready for ICD-10 by the October 1 deadline, though some of the carriers express concerns that small, private practices are behind in their preparations.

What employed physicians like most about not being self-employed: not having to deal with the business of running an office and not having to deal with insurers and billing. According to a Medscape survey of 4,600 doctors, employed physicians complain about the lack of input into how they practice, but 70 percent of physicians who were once self-employed report being happier employed.

On the heels of a recent study questioning the effectiveness of the PCMH model in improving care and reducing costs, the NCQA previews 2014 PCMH recognition standards, which include more emphasis on team-based care. Other areas that NCQA is “raising the bar,” include:

• Care management focus on high-need populations
• Alignment of quality improvement activities
• Additional integration of behavioral health

Email Inga.

Practice Wise 3/13/14

Open letter to EHR users

Now I know for sure this is going to put in me in the unpopular kids group, but I have to say it! EHR users are costing vendors excessive amounts of support time and resources supporting users who refuse to admit they might actually be causing the problem.

I’m not saying this as a rebuke to users who truly have EHR problems and vendors who won’t/don’t address them effectively. However, as an organization that provides both consulting services and direct support, we see this scenario way too often and I think it’s time to address it head on!

For example, a customer complains that the system keeps doing something nefarious and is out to ruin their practice. Vendor asks typical level one support questions such as ‘are you sure you have not hit the (any) key?’ Customer insists they are not hitting that key, and is not shy in stating how offended they are that the vendor would even consider that ‘they’ might be causing their own problem. After hours of support, escalation and development time spent on this issue, customer is audited on site, they hit the key they swear they never hit, and sheepishly say, ‘oh, I guess I sometimes do hit that key’. And instead of swallowing a little humble pie and offering an apology, they deflect by saying something else like ‘but the system does this other thing that is really ruining my practice!’

Seriously, what EHR users really need to understand is that most software vendors have the same goals as they do: to have a successful implementation with expert users who fully utilize the system for optimum use. There are certainly vendors who have badly designed products and poor support. Let’s just assume we are not talking about any of them here.

This behavior is top down in most practices. The most successful implementations and ongoing adoption of all things EHR are in practices where the doctors themselves display a positive attitude about the change, are engaged in the process, and are supportive of their team as they all struggle to grasp the new program and develop the muscle memory that leads to mastery. There are fewer of these practices overall. The general experience is that doctors believe EHR is being forced on them, that no vendor could ever make a product that doesn’t slow them down, that it doesn’t print out documents that sound like they would speak, etc. And when the project starts at that level of negativity, it permeates the whole team.

What happens in an EHR implementation is that a magnifying glass is held over all your processes and procedures. If you are a well-developed process-based organization, this is a good thing, your shining moment. If you are an organization that has just always done things on the fly or ‘this way because that’s how it’s always been done’ and not open to new processes that might actually improve your practice, you will have a hard time hearing valuable recommendations from your consultants and implementation team.

When the internal practice attitude towards the project is negative, the doctors become abusive to their team and to the vendors who support them. I don’t use this word lightly. Talk to any implementation person and they can rattle off a litany of horror stories of doctors throwing fits, calling them idiots, throwing laptops across the room, etc. Here’s my theory (not very scientific, purely observational): doctors are used to being smart and good at what they do. This process unmoors them to some extent. Once they accept the process and decide to move forward, they generally do well the first week of go-live because they believe they shouldn’t know the system, so they don’t typically get snarky that week. However, week two rolls around and they assume that since they are smart and quick learners, that they should have mastered the darn thing, and then the snarky, rude behavior comes out. When the staff sees/hears the doctors abusing the vendors, they do the same when they are frustrated because they believe it’s how to get things done in the practice.

I’ve worked in other industries besides healthcare, and never in my professional life have I experienced this kind of rude abuse by a customer to a vendor as I have in this field.

Here’s my message to providers: we are here to help you. If your practice succeeds, we succeed. Your implementation failure is our failure. We want you to be the best users you can be, and we want you to master the system to the fullest. However, when you don’t speak nicely to us, call us names, make threats etc., we are less likely to want to go that extra mile to hold your hand in your time of need.

I had an IT vendor tell me on the phone the other day that he doesn’t care that the darn doctor can’t access the VPN from home and fixing it is low on his priority list because the doctor is so rude to him and always hangs up on him when he doesn’t get the answer that he wants.

That’s what happens when you’re rude to your support vendors: we tend to put you at the bottom of our priority list. Here are a few ideas of ways you can navigate through this difficult transition, with everyone pulling for your team and working towards your success:

1. Accept that you are changing your processes and getting an EHR. Doesn’t matter why, it just is, so accept it and get over it.
2. Project a positive attitude within your organization, encourage your partners and staff to do the same. Be the champion!
3. Buy the hardware as recommended by your EHR vendor. Don’t try and cut corners and save money buying your own computers and equipment at discount sales if you really don’t understand the hardware specifications. Your IT vendor is not a magician; if you don’t buy what’s recommended, he can’t make it do what you need it to do, and you’ll be frustrated and likely blame the IT vendor and the software vendor.
4. Take advantage of ALL training opportunities offered by your vendor. The more effort you put into your training, the less frustrated you’ll be. This is one area that frustrates the vendors; doctors are ‘too busy’ to do the training, yet want to be masters of the system. It’s not magic; it’s learning. You had to go to med school to become a doctor – they didn’t just hand you a degree. Same theory here!
5. Put effort into doing the customizations offered to tailor the system to your practice. Many systems have great malleability and trainers who can help you design your workflows in a way that helps you document in your comfort zone. This effort on the front end will reduce your stress on the back end.
6. Create a position for an EHR super user in practice. The person’s sole responsibility is to make sure your needs are getting met, your changes are addressed quickly, and is dedicated to you. Treat that person nicely even when they can’t give you exactly what you want. You cannot expect your vendors to drop everything and meet your demands all the time, especially when you make demands and don’t ask nicely for help.
7. BE NICE to everyone. We are all doing the best we can at any given moment to support you! We all have the same goals – your successful implementation and continued success in your practice.

I love working in healthcare and supporting doctors. Some call me crazy! However, I think most doctors really do have the best intentions and just need to know that in the end, it will all work out fine. At least we’re not asking you to work 100 hour/week rotations. You survived residency, you’ll survive this too!

Julie McGovern is CEO of Practice Wise, LLC.