Amy Maneker on EHR Program Maturity and Walmart’s Healthcare Plans

Amy Maneker This Week in Health IT
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Amy Maneker, M.D. joins us to discuss EHR usability, best practices, and informatics. We ask the question, how are we doing and what can we do better. Also, we explore Walmart's healthcare plans and take a look at the most recent California legislation to combat opioids.

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Bill Russell:                   00:07                Welcome to this week in health it where we discussed the news information and emerging thought leaders from across the healthcare industry. This is episode number 37.

Bill Russell:                   00:15                Today we look at, we look beyond Amazon to Walmart to explore their plans and healthcare. Um, and plus we take a closer look at what California legislation California is doing around the opioid epidemic and, uh, look forward to digging into that again this week. Uh, it’s a very important topic. I’m at the Becker’s conference this week and hearing a lot of conversations around what health systems are doing, uh, to address this situation. This podcast is brought to you by health lyrics, health systems are moving to the cloud to gain agility, efficiency, and new capabilities, work with a trusted partner that has been moving health systems to the cloud since 2010 visit health to schedule your free consultation. My name is Bill Russell, recovering healthcare cio, writer and advisor with the previously mentioned health lyrics. And, uh, so before I get to our guest today, a just call out once again our a youtube page.

Bill Russell:                   01:08                And, uh, if you get a chance this week can health, a great resource for your staff. Over 300 videos curated on different topics I want to call attention to next week. We’re going to have a, a special episode, a little different episode. I’ve interviewed a handful of people at the, uh, at the Becker’s conference here in Chicago, and I gave a all, all five of the people that I interviewed Ed marks and among others, uh, David Chow among others who are here. I gave them all the same five questions they all answer them so you’ll get a little perspective of a cross section of what large and small hospitals are doing in different, uh, uh, we have some children’s hospitals all over the board. Uh, some really interesting conversations. Look forward to bringing that to you next week. No video next week. But, uh, some, some great audio from a bar tables with background noise and those kinds of things.

Bill Russell:                   02:04                My sound engineer, we’ll have some fun this week. So I’m doing this podcast has been a great mix of, of having, uh, some friends on the show. And meeting new friends, uh, with great backgrounds that agree to come on the show. Today’s guest was introduced to me by sue shade, a, who’s one of the original guests on the show who I’m always greatly appreciative of the people who took a risk early on to come on the show. Uh, amy is our guest today, Amy is board certified in pediatrics and clinical informatics. And today we’re joined by Dr Amy. Maneker morning. Amy, welcome to the show. Well, you have a, you have a great background. I’m, I’m really excited to, uh, to get into this board certified in pediatrics but also board certified in clinical informatics. Can you give us a little, uh, I don’t think all of our guests are familiar, including myself with a board certified clinical informatics, so you could give us some background on that. So, um,

Amy Maneker MD:        03:01                clinical informatics became a board specialty, I want to say in 2013 and you need to be, have a primary board certification and then you can do a clinical informatics board certification. My generation can grandfather in with some fairly stringent criteria for experience and then take the exam and then we’re transitioning to do a fellowship, just like any other board specialty. So you know, someone may do a residency in internal medicine and a fellowship in gastroenterology and get board certified. They can now also do a residency in pediatrics or internal medicine and a fellowship in clinical informatics and there’s a fairly um, growing opportunities have to do fellowships like, so there’s a number of programs that have developed in clinical informatics arena.

Bill Russell:                   03:51                Yeah, it’s pretty interesting to me how many physicians are, um, are making this move into informatics, making the move, uh, into really trying to address this challenge with ehr usage and those kinds of things. Last night on either side of me at the dinner table were physicians who are the, they’re living in the informatics world. So I, the, the, the roles expanding and I assume this, the, the, we’re going to see more people become board certified in clinical informatics as it moves along.

Amy Maneker MD:        04:23                Yeah. I expect so

Bill Russell:                   04:25                So, uh, let me give people some of your background. So a university of Pennsylvania Undergrad, a penn medicine residency at Presbyterian in New York City fellowship in pediatric emergency medicine, a rainbow babies and children’s hospital in Cleveland. Cleveland’s where you ended up settling down and eventually made the move into informatics. Uh, give us an idea of your journey, how you went from practicing medicine everyday to, uh, making that transition. Was that, does that happen for you when the Emr Sorta came into your environment and you stepped into a role or, or did it happen?

Amy Maneker MD:        05:00                I get asked this question? A lot? Because of both my age group and being female, I’m a relatively unique person in the clinical informatics space. So I often get asked this a little bit of an interesting story. It was, it was by accident, so I went to this a phenomenal medical school. That was probably the highlight of my education. And I think at Penn Med they groomed you to change the world, not to necessarily see one patient at a time, although it’s fine to see one patient. So I think I always thought I would think broader. So I finished my residency, I finished my fellowship. So Pete’s emergency medicine by that time I have two young kids and a husband works a lot and I’m just paddling my canoe and I’m working and I got. I’m very good at organizing and kind of just pulling all the pieces, kind of like project management and innately.

Amy Maneker MD:        05:51                And so I got tapped on the shoulder very early to do a lot of administrative tasks. I won’t list them for you. They were great to learn how healthcare works, but they didn’t really inspire passion in me. And then I kind of. I’d been acting as an interim division chief. They higher division chief, this is like 15 years ago. And so when they call me, did the, I don’t know whose office and says, Hey, you know, you’re really flexible and open minded and you have this time, could you help out with this multimillion, hundreds of millions of dollars emr implementation across the nine hospital academic health system. I’m like, sure. You know, and I actually didn’t really know. In fact, my kids I think were laughing hysterically at the time. I didn’t know a lot about technology or computers, but I really felt like as soon as I got involved, I thought this is transformational, this is the tool that can improve quality and value of health care for America.

Amy Maneker MD:        06:51                And so I came in from, from uh, as I say, I came in from above. I didn’t come in like, Hey, I write code, I know about sequel, I learned about all the tools and I know about sql code in and know sequel and which, you know, the value of each, but it’s really the goal is to improve quality and value of healthcare. So I kind of got bit by the bug and you know, things that you’re passionate about, you learn very quickly. And then I did some additional education and you know, in short order I basically functioned at that hospital. The cmio was only 40 percent and I basically did the other 60 percent in the similar, you know, different title, but similar role and rest is history. The rest is history. Does that answer?

Bill Russell:                   07:39                That’s a great answer. My Microsoft updates just popped up on my screen here. So it, it, it’s one of those things about a podcast, you do, you, uh, you know, you have to shut down your email and all these other things that pop up and you just forget that one thing. So, you know, that’s, that’s a fascinating story and I think we’re finding that more and more that physicians have gotten pulled in, they’ve either gotten pulled in or they look at it and go, this can be done better. Uh, you know, this Emr could be done better and they step up and they go, let’s tackle this challenge or this problem. And it, it’s, it’s a, as you say, you know, coming in from A. I’m, I’m the other side, right? So I come in from the, I know technology backwards and forwards. And uh, the first thing when they say, Hey, consolidate these, uh, these nine Emr across 16 hospitals, first thing I say is, yeah, I can’t do that.

Bill Russell:                   08:34                I need, I need help. And so I went out into the organization and found someone like you who really a physician who really understood, um, the first of all had a passion and understood, uh, what, what data and what the Emr could do for healthcare, but also, uh, it was phenomenal with relationships. It’s, it’s, it’s 80 percent, if not 90 percent a people job. I mean, you are organizing corralling people. And um, what was, what was that aspect of it like for you in terms of, um, you know, so you get this Emr role and you know, as a physician, you’re managing your own practice and managing your patients and those kinds of things. And then you step into this role where you’re really corralling, um, hundreds of people, if not thousands of people trying to get them to make a pretty significant transition. Uh, what, what did you learn about the people aspect of it and really motivating people and making that move.

Amy Maneker MD:        09:34                So I want to comment first about the patient aspect. So people sometimes say to me, Oh, do you miss taking care of patients? And I still do, but a very small amount. But when you’re, when you’re working in informatics, you’re affecting whole populations of patients. So in some ways it’s much more impactful than seeing one patient at a time. So if you build an Emr to do, make the right thing to do the easy thing to do and improve care, you’re much more impactful than that one kid who I saw. So that was just the patient come in and I’m sorry, your question is how do you get people? I think a lot of it is, it’s two things. It’s one you became an evangelical and you get people to understand the value and also informatics. You know, everyone thinks, oh, just put a hard stop putting alert, do an in basket message and all those inherent things.

Amy Maneker MD:        10:27                In fact, one of the things we’ll talk about later today is what everyone thinks will solve it doesn’t. And so I think it’s also getting people say, well, what are you really trying to achieve? And let us work on how the software can do that. And so one of the most things I say most commonly meetings is what are we trying to achieve here? And so it’s not just in the software, it’s just in general, like pulling everyone back and saying, okay, so if that’s what we’re trying to achieve, let’s agree to that and then figure out the best path forward. So I think a lot of it is, um, corralling, educating, and then a lot of it is also listening to people. And then a lot of it is storytelling, you know, hey, I understand your concerns, like open notes, isn’t, is an international a lot of press lately and a lot of people have concerns, but start telling the story of the places that have done it successfully and of the patients value and have the data and um, and it’s much less threatening when you start telling a story and resonating with quality and value of healthcare and what it means to the patients and what it means to your practice.

Bill Russell:                   11:37                Yeah, absolutely. So now you’re stepping into the consulting realm with Starbridge Advisors thisis a new chapter for you. So, uh, so if people are interested in working with you, they actually, they actually can through starbridge So that’s exciting. Um, so what are things I like to do with our guests is ask them a pretty open ended question. What are some of the things you’re working on a today that you’re excited about or what are some of the things that are going on right now? It’s really the floor is yours. You can talk about anything. Some people feel bad, they feel like they need to talk about their kids or that kind of stuff.

Amy Maneker MD:        12:10                I have a good one. So I think one of the hottest topics both for me personally and across the industry and I suspect is how do we address the Emr, whatever brand you’re or roll in provider efficiency and satisfaction. You know, people say physicians are burned out. I was at a social event the other night and the neurosurgeon next to me kind of heard what I did and immediately started complaining about clicks to me no joke doesn’t work anywhere where I’ve worked, but I hear about the clicks and so I think we’re really trying to. We’re beginning to adjust that and one of the most helpful tools. So I did a project on that at my last organization, but his class is doing this arch collaborative and I think we’re getting some really good, fascinating data and so what class is doing is they’re asking, I think they’re high close to 120 organizations and they basically say hey, to all the users. Does your, do you agree? How do you feel about you? Does your EHR enable you to deliver high quality care? And then kind of like when we do population health, you look for the bright spots. So what are the characteristics of places that where everyone says, yeah, it’s pretty good here, the Emr, so it’s not what you think. So are you ready for the big surprises?

Bill Russell:                   13:23                Sure. Love it. So you’re going to share some of the things that arch collaborative, uh, found.

Amy Maneker MD:        13:29                Yep. With their initial findings and that I’ve had, and I’ve also had personal similar experiences. So I think it’s more powerful to talk about this national data. So they found, I’m going to give the big surprises first that it spend, It doesn’t correlate. Voice recognition doesn’t correlate and scribes doesn’t correlate with improved user satisfaction.

Bill Russell:                   13:54                Wow. That’s hard to believe. Actually. You hear that a lot. If you know, if I didn’t have to do the data entry this, this whole thing would be fine. That’s an interesting finding.

Amy Maneker MD:        14:03                So and in fact this week I’m Jama had an article about scribes and satisfaction and I’m 18 PCP practices which shows the opposite. So then now that I’ve kind of rained up, know everyone’s assumptions, what are successful organizations and and what they found and I personally found is it’s really about how do you help support the users to use the Emr and it’s, it’s, it’s robust, high quality. He or at least the perception of really good training at first it’s ongoing support and the ability to personalize which I tied ongoing support and one of the things that I really think, and it hasn’t been borne out yet in the it hasnt gotten its granulate. It’s ongoing ownership and engagement of the physicians. They need to have some ownership and engagement. Not each and every one, but like someone in each specialty needs to own the content and understand the software and that’s what really makes a difference. So she is the organizations that haven’t had good data, have keep trying to, it looks like they throw money and technology at it. Well, the organizations with high user satisfaction seem to have a more of a culture of support and a relationship with it. And the other thing is that everyone complains about entering the data. And this is my concern about the Jama articles. No one talks about getting the data out, which is as important as entering the data. Sorry, now escalate.

Bill Russell:                   15:39                So I’m curious. So if somebody wants to go to the class site and download a pdf on some of the high level findings on the arch collaborative, it’s pretty, uh, pretty, pretty good reading. So what did they find about being able to customize the environment? So, um, you know, I, I know in our emr implementation there was a lot of, a lot of conversation around customizing the workflows or customizing, the order sets or customizing the uh, the experience, uh, you know, for instance, a, a cardiologist doesn’t want to look at the same things as a, uh, as an er doc for, for example. So um, so people want to be able to personalize, personalize, that’s a better word for it.

Amy Maneker MD:        16:29                So thats what we typically call it and they’re finding the value of personalization. And here’s the interesting thing is it does correlate and it’s not just about data entry. It’s, once again it’s about data retrieval, so people need to be able to purse personalization and many of these Emr is have unbelievably robust ability to personalize but someone has to help someone do it and make the time because like if you’re going to build some, you know, patient lists or whatever views you’re doing it once, you’re not going to remember it. And so personalized personalization of the Emr is wildly underutilized. It’s there, but people don’t know how to do it or if the time. And so if what they’re finding is if people have the top do personalized, they have much better user satisfaction and I would offer you need some support, I mean someone to help you and you probably need some physician ownership and engagement because someone in your specialty has to say, Hey, here’s what’s my people really need any there, make it happen or help them make it happen. The personalization,

Bill Russell:                   17:35                We could do the whole show on this, my other question is on training because, you know, one of the, one of the challenges obviously is making that time, making it available and even when you do make the time available and you’re going to compensate the physicians for the training time, those kinds of things, um, you still only have a, you know, 85 percent hit rate and 50 percent don’t want to participate in the training. Um, and then you get after the fact and sure enough, there’s a huge correlation between the physicians who did not get training and the physicians who did go through the training, uh, and you end up spending an awful lot on elbow support at that point and uh, helping them to personalize it. What did, what do you find to be, or what did the arch collaborative find to be a successful model for ensuring effective training across the board?

Amy Maneker MD:        18:25                So what we’re finding is that there’s no one clear model. One thing we are finding is there’s an initial training and then there’s ongoing training. And I think we never realized, you know, in many other industries where people use software so intensively. So accountants, engineers, they get ongoing training and I think none of us knew we put in this emr and now we’re all learning. You’re going to do ongoing training and what I think where no one has quite gotten down to, is there a particular model for that right now? And I think it’s, it’s all over the map of how you can do it. And even when I did an organization, we did a buy specialty, we did a different for each, for many different specialties based on number of providers, just based on all kinds of nuances. So I suspect that underneath it all, there’s some key factors you have to do, but how you do it could be very variable, you know, based on your environment, based on your resources, based on personalities.

Bill Russell:                   19:24                Yeah. You know, we’ll probably have to dedicate a whole show at some point for Emr limitations. There’s so much great, great body of knowledge and, and uh,

Amy Maneker MD:        19:33                this is beyond, this is really more than implementation. In fact, I think this is really the year two, three, four. This is years later when everyone’s suffering and miserable and talking about the clicks like the neurosurgeon the other night and what they’re finding is it is they need support and training.

Bill Russell:                   19:52                Yeah, so it’s implementation and ongoing optimization, but really what it is, it’s a shift from a project mentality to a product mentality, which it’s a project mentality is, hey, we’ve got it in, we’re done. And you see implementation as a project and optimization as a project and really it should be a product mentality and a product mentality is a, you know, you, you’re looking at this thing over the life of people using the software and you go, uh, and you create roadmaps and you create a enhancements and you’re constantly listening and updating, but you’re taking a more of a longterm view instead of a start and finish kind of view. It’s a,

Amy Maneker MD:        20:34                I think, product mentality and I think training, support, whatever you want to call it, is an ongoing thing. And I want to call out optimization because of a number of us including the arch collaborative. We called it the optimization fallacy. And what we’re learning is if you just go in and optimize, you come out and you aren’t really that successful and many times a large part of the optimization is successful training and support. And in fact, in my experience at another organization, it was mostly training and support with a few minor bill changes made the biggest difference.

Bill Russell:                   21:09                We’ve already taken the first 25 minutes of the show on this. We havent even gotten to the new story. So I’m going to, uh, I’ll kick it. So we do two things in the news and soundbites. I’ll do the first story. I’ll do it pretty quick because we talk about this topic pretty often, but we always talk about it feels like to me. We always talk about it from an Amazon perspective. And uh, I want to talk about the other player in this space that has over $140, million weekly customers, most of which are lower income seniors and those kinds of things. And they have stated their intention to step into this a care navigation primary care role. And that’s Walmart. And there was a CNN money article, a Walmart wants to bring, everyday low price to healthcare, and they talk about, you know, their anthem deal, uh, to entice more medicare enrollees to buy over the counter medications.

Bill Russell:                   22:02                Uh, they talk about tapping the Humana executive, uh, Sean Sliwinski, uh, to lead the health and wellness division. They also talked about the fact that they were in, in a, uh, negotiations to a are not negotiated, but they were looking to buy pill pack before Amazon actually purchased them. So what, what does, uh, an organization like this offer? And it’s kind of interesting because as you look at this article, you realize, uh, they’re already one of the leading pharmacies in the nation. They have a, as we said, 100 and some odd million people, 140 million people walking through their doors every week, 3000 instore vision centers, free health screenings at over 4,700 locations up to four times a year. Uh, you can, uh, they actually have people who are helping people to enroll in the affordable care act and Medicare advantage plans. They even tried their hand at a urgent care clinics in Georgia, South Carolina and Texas and uh, they haven’t expanded that.

Bill Russell:                   23:01                So I imagine, you know, it’s, it’s just a pilot and they’re seeing how it works and they’re going to work out the kinks of that, but just their sheer reach and their, their volume, uh, makes them a, uh, makes them a viable player in this space. What they’re really looking to do is to tie up those, uh, medicare, Medicaid, uh, markets and start to a market. There are other, uh, services to them, right? So they can, uh, they can offer help with food and, and healthy grocery items. And, and, uh, it’s not necessarily a medical play per se, it’s more of a retail play. But by, uh, by taking advantage of their footprint and their relationship and their data. I mean, if we go to informatics, which is your background, they know a lot about these, uh, these people who are coming into their store, as we’ve talked about with Amazon before.

Bill Russell:                   23:58                If you look at somebody like Amazon shopping history, you can tell an awful lot about that person. And Walmart has that kind of data, um, and so they might be able to step into a gap because of their knowledge level that a, that a health system might not be able to, to help guide and direct somebody from that navigation role. So let’s turn this to a question. So you are your first engagement with a starbridge bridge advisors. You’re hired by Walmart. They want you to be their physician advisor. Um, what, what gaps do you think they can fill? I mean, we’ve talked about a lot of gaps that they’re stepping into, but are there gaps that they can step into and fill that that would be interesting given their, they’re a breath of locations and number of people that are already walking into their doors.

Amy Maneker MD:        24:50                So I think the one thing I would like them not to do is not to create silos. So you don’t want them taking action and not sharing that data. So whether it’s through an Hie or shared platform, you want to make sure the data is shared. And then I guess it’s really the next thing is they could really play a very valuable role in closing care gaps. So you know, as that article mentions, a lot of people in certain parts of the country go to the Walmart is like the community center there. There are a few times a week they could give flu shots, they could give pneumovax, they could do diabetic foot exams, but that would not be helpful if they’re not sending that data back. And so that those care gaps are closed in the patient’s record.

Bill Russell:                   25:34                That’s interesting because cvs did implement epic. I don’t know if Walmart implemented in an Emr. I don’t know. Have you read anything about that? I don’t.

Amy Maneker MD:        25:45                You know, I don’t know. I will say that when I read that article that you sent, it made me think one that Walmart is in some ways maybe the big sleeper here that we’re all focusing on others. And that occurred to me as well. And it doesn’t have to be that they implement epic. There are other ways, but it’s more that the data is shared because I think there’s, you know, if we talk about the overall greater good, not just the retail space, the good for Walmart, there’s some real value they could bring by cause they’re seeing these, you know, huge volumes of patients that have significant medical issues and that they could close care gaps. And as I said, just, you know, diabetic foot exams, flu shots, pneumovax.

Bill Russell:                   26:28                So, so let’s talk about sharing data. So you have all these new partnerships, cigna express scripts, cvs, Aetna, and now, now we’re talking about Walmart, which isn’t of itself as a cvs, aetna or cigna express scripts. I mean they’re there in all those spaces and trying to get into insurance and other things. So, um, what data are we sharing? So we’re the health. I want a health system side. You’re a, you’re now an advisor for Walmart. We sit down at the table. What information do you want from me as the health system? And uh, and actually I’ll have you answered both questions. What information do you think the health system should get back from? From Walmart?

Amy Maneker MD:        27:07                Well, I think at minimum they want it to flow effortlessly if they close care gaps. So if the patient, if they give out flu shots, they wanted to go into their system. So you know that patient got a flu shot. So a, the patient isn’t bothered getting a call, being the, you know, they don’t, they don’t spend resources tracking them down. So I think any care they give you want it to flow effortlessly. And then I think if we got to the next level, it’s like what social determinants of health or What data could you get? Well there’s a privacy issue, but would you want them to share data on their buying history to have to help stratify their health risk, help report on their health risk. I mean, I think that’s getting to the whole next level. I was just starting really simple that if they were going to get into healthcare space, just make sure the data gets fed back so that someone has a complete picture at the patient level and then the population level of who’s gotten what care.

Bill Russell:                   28:04                Yeah, it’s interesting. Right. You know, potentially rather than doing a massive, a emr implementation across all of Walmart, you know, they, they could, we talked about this last week. They could tap apple on the, on the shoulder and say, look, you’re starting to get data from the Emr through fire. We’d like to give apple the information. So patient comes in, we give them a flu shot, we give, we put that into their apple record. Then when they go back, they’re actually the carrier of the data and they go, okay, they can approve to upload it to whatever care provider they go see. now Obviously some of this stuff’s pretty sophisticated at this point given where we’re at, but that’s the, that’s the promise of fire and that’s the promise of sort of the consumer records starting to follow people around.

Amy Maneker MD:        28:50                Correct. And you know, I purposely did not mention implementing an Emr because I didn’t think that was kind of the direction walmart would go. I was more about sharing the data back to my question, what are we trying to achieve? What we’re trying to achieve is getting the data to the patient has a complete record. How to do it is a different story. We often get caught up, especially in software of the how and forgetting the what we’re trying to achieve. Go right down the rabbit hole of what we want. Hey, I want to. I want a hard stop. And you’re like, yeah, maybe not.

Bill Russell:                   29:23                Yeah, I mean a walmart, I, I don’t know what the cvs a epic implementation costs, but uh, you know, a Walmart implementation, I’m sure it is well over a billion dollars. So it’s not A. Yeah, we go down a rabbit hole that’s going to cost a billion dollars. So it’s interesting how that uh, I’m going to kick it to you for your story can tee it up for us and let’s discuss it.

Amy Maneker MD:        29:43                So my story is the La Times story on the cures act that goes into effect October, second in California that requires that a physician’s check the PDMP, and I’ll be honest with you, it was really, I used this article is a, uh, an excuse to talk about This iss prescription opioid and heroin epidemic awareness week and I know it’s a hot topic. So it’s funny. The two hot topics are user satisfaction with the Emr, which we just talked about and physician burnout and the opioid epidemic and you know, I don’t have to remind everyone that drug overdoses involving opioids come more than 42,000 people in 2016. In fact, there’s a very interesting quote by a physician that transplant surgeon who he went to get organs in like the first in one day was three young people who died of opioid overdoses. And so he really got converted to addressing that as well.

Amy Maneker MD:        30:37                And he said his quote is becoming a new opioid use is Probably the most common surgical complication in the US. And so I think what’s going on in California is well intentioned. I’m not going to get caught up in all the challenges because it’s very challenging to check the PDMP, but I do want to comment that on the cms onc has put as part of this prescription opioid and heroin epidemic awareness week, they put some really nice tools out. Um, so they put um, some like electronic opioid clinical decision support, some standards out and they have this nice little infographic that I don’t think we all realize that health, it is probably one of the, there’s lots of tickets to, but it’s probably one of the key things to combat this epidemic. And some of the things are really simple. And it was funny. I’ve implemented this and Judy Faulkner actually mentioned it on the stage at ugm some of the little thing can make a big difference.

Amy Maneker MD:        31:37                So if you just change your defaults to the day supply being three for opioid, that’s huge impact and in fact This transplant surgeon talks about, hey, we used to give people 30 pills of opioids when they left, even from, you know, my acl, repair my wisdom teeth out. And that is a huge risk factor. So sometimes it’s the little things, I think the risk with the California law is actually asking, you’re putting the burden on physicians, now you have to go check the PDMP and I think to really be do that effectively. It has to be integrated into the Emr. And so I think there’s some real downside to the California law, but I think you’ve got to, we’re all going to need to integrate the PDMP locally in to the Emr.

Bill Russell:                   32:24                So I was a cio in California. And so the challenge with this always becomes know where’s the burden going to fall? It’s, you know, it isn’t going to fall down to the doctors where you just put it in a whole bunch of stop manual stops and checks alerts and call out to this database. Oh, by the way, you have to launch another window, go into, you know, this, this thing or, or quite frankly, or we’re not looking at discrete data. So they’re, they’re filtering through a whole bunch of pdfs to find the data they want and we going to put the burden on them. Uh, but regardless, a lot of these policy things tend to create a, just a ton of work. Um, and so the burden falls somewhere. How do we make sure that this burden doesn’t fall unduly on the physicians?

Amy Maneker MD:        33:16                You know I completely agree. I think one of the first things is you have to put the PD. You have to make an integrated and effortless and serve up. So it’s not another task. It’s when you go to prescribe an opioid, that information is served up to you and the perfect world. You actually, um, it, the data is more than just the PDMP is like, it looks at overdose experiences and other things and so even can do some logic to say, hey, this patient’s at risk because I think this whole thing of hey, you go look, you go interpret the data is really onerous. And so I think you have, in the perfect world, you have to have both integrated and put some logic into until the data is, as part of the workflow is offered. Does that make sense?

Bill Russell:                   34:02                Yeah. And then the other question I have, it may sound insensitive. I don’t mean it to be, but the, um, because clearly the risk of an opioid overdose is, is, uh, is tragic and difficult, but um, you know, h cap, we talked about this last week, so h gap calls for a, there’s a question of did you manage the pain effectively? And one of the things that physicians have talked about is we give them so many days of opioids to make sure that the h cap score is so that we manage their pain because the other thing is you don’t give them enough of the opioids. They just had an acl replacement and they have to keep coming in because it’s a physical. They have to show up and you have to have a conversation with them in order to give them an opioid. And they’re like, you know, I had to come into the hospital four times to get my pain medication refilled and the h caps comes in and they go, did they manage my pain? No, they didn’t. And you take a hit on the h caps. Is that a real problem? I mean, do we have things that are sort of competing or post here?

Amy Maneker MD:        35:05                Well, let’s back up, you know, I’m been in this long enough that I remember the day and age when they’re like, oh, the fifth vital sign is going to be pain and it’s, you know, addressing everyone’s pain and no, you can’t get addicted to opioids and we need to give better pain meds and so I don’t know that we know it, but it feels like we created this a little bit and, and I think in the future we’re going to maybe that h cap question needs to be removed because of we need to address pain differently. We need to change the patient expectations and so if everyone’s afraid of that grade, we’re not going to be able to do that. But at the end, no, it’s a real conundrum and I can’t help but think that part of it was part of this epidemic was created by farm apart multifactorial, but part of it was created by the healthcare system. You can’t help but think that there was a role there.

Bill Russell:                   35:59                Healthcare is. Healthcare is complex. It’s not simple. So. I’m so, I’m going to move to the soundbite section, you know, there’s, during the section, throughout some questions, one to three minute answers. If you go longer. I’m not going to stop you. Um, so, uh, here we go. Let’s just jump into it. So you’re a physician, And you’r technologist. So, uh, how are we doing? And we talked about this a little bit, but we have all this technology. We’ve, we’ve put it out there, especially the EHR, you know, how are we doing amongst the physicians, the clinicians have, you know, just in general are, are, are we making progress or are we still sort of in the stuck in the mire?

Amy Maneker MD:        36:39                I think we’re doing better than maybe we think we are. So we really do need to address it. And I think physicians in particular, but all the users are struggling and we talked about it. Maybe a lot of it is, is we’re seeing more and more that we need ongoing support and training. But I think we’re, and let me back up. I think we need to change the narrative and people need to start seeing the Emr as their friend. And get the ongoing support and training they need, but I think we’re also forgetting what life was like. So you know, I’m in the trenches and I hear physicians, there’s a lot of complaining. The neurosurgeon yelling at me about the clicks, but you know, we forget. I used to, I’ve been an ed physician for a long time and a patient used to come in and tell me this story about this whole workup, whole old story and I basically would be, I’m not kidding, you will be looking at a white piece of paper, you know, hi to writing it down and starting all over again.

Amy Maneker MD:        37:37                And now I can say, Oh, and I saw you saw Dr Jones last week and I see these sets of labs and those all look good. Well let me do this and then do that. And what value both to the healthcare system. It makes my life easier, but what a value to the patient. And so I think the narrative, there’s such physician burnout, we’re not supported in our use of the Emr, so we’re blaming it. We need to get over that. We need to provide ongoing training and support and we need to start seeing the value and we also need to put time and energy and I think you summed it up. It’s not a project, it’s a product, so we need to put time and energy into improving the content and the decision support in the Emr. I think we just talked about that with the opioids, like we need to serve it up and Organizations need to realize it’s an ongoing. It’s never end. It’s not a project. It’s a never ending tool that we need to support and we need a provider, physician level ownership engagement to help someone develop something like, Hey, here’s what I need in the workflow to be able to check the patient’s opioid. Here’s where I need it and what I need. So I think we’ve made huge strides and we need to change the narrative and acknowledged the strides. I think we don’t want to be complacent. There’s a long way to go.

Bill Russell:                   38:54                Yeah, and it’s the narrative and the stories. I remember a Dr. Gandhi was sharing her story and she goes, without the Emr, this wouldn’t be possible. And, and uh, John Halamka was, this was what I was up at Harvard at their school of Public Health at John Hopkins, shared a story about Vioxx and without informatics know that would have gone on a lot longer than it did. And, and, and there’s, there’s a lot of those kinds of things

Amy Maneker MD:        39:17                the lead story in Detroit.

Bill Russell:                   39:19                Yeah. And we just, we need to keep telling me stories of, Hey, data informatics is going to, is impacting, um, you know, the Ebola. I mean, we were able to roll out a whole bunch of things when that was, that scare happened a couple years back. We were able to roll out a whole bunch of things because of the Emr that probably would have taken months or you know, or potentially even a year to roll out across 16 hospitals. So.

Amy Maneker MD:        39:47                And I was actually in a place where, I don’t know if you’re remember, one of the nurses had been to the Akron Cleveland area. No, Oh she had gone bridesmaid shopping or I can’t remember. And so we had a rollout all those screening questions, but we could, you know, which you never could have done. So I do we need to change the narrative, but I also think you’re right, it’s a product and the users need ongoing support and training to be able to use it efficiently. So one of my, well I think it’s one of the next question, so I’ll be quiet.

Bill Russell:                   40:18                So, uh, I’m going to go back to the arch collaborative here. So, uh, one of the Emr implementations that you are a part of a, received an 84 percent score on their class. That emr experience score, um, two things. One is talk a little bit about that score and the value of that score. And the second is training, but were there some other things that your team did to achieve that, that level of proficiency?

Amy Maneker MD:        40:46                So I do want to call it that. That was way beyond the implementation that was five or six years later. So back to being a product. Got It. I think the score just gives you an idea of where you stand relative to nationally. And then it gives you some, you can really dig into it and get granular. And so what we learned there is that we really had some real opportunities in personalization, but what we did, in fact, this was one of my favorite parts of the story I love to tell is, um, we, it was part of a larger organizational initiative and we, instead of being reactive about emrs role in provide our efficiency, we were proactive and we said, okay, we’re going to do advanced training and we’re going to have ownership and engagement. We’re going to draft physicians to have part of their job be the Emr and out of that we’re going to have good enhancements, optimization, and good configuration in the Emr.

Amy Maneker MD:        41:43                So advanced provider training. Initially the response was, I have a very funny slide and these are their cartoons, but they’re real people. And so one person, a leader said, we don’t need training. You just need to get rid of the clicks. And the, another person leader said, my docs are really smart, just fix the 10 things they tell you to fix. And we smiled and we created this advanced provider training which was specialty specific. So you train the cardiologists together, they don’t need to know the same as the Er docs and you also need, this is the ownership engagement. You need a champion, a physician from within to decide the content. So one of my favorite jokes was, I would say brought to you by, you know, Dr Smith, not the training team, so if you didn’t have a good champion, you didn’t have good training.

Amy Maneker MD:        42:30                And then also do it in production so they can clean up and do their in basket. So we did all that remember. They’re demanding, we don’t need training. And we did it and we smile and we kept saying and we got great results and then this is a slide with a cartoon, but these are true results. The person who said we just got rid of the click said, well, I need you to train my hundred 60 primary care providers. When can you do that? And then the other person literally said, this is when the cartoon, but it was a true thing. Hey, this is what we’ve always been asking for, thanks for doing it. So I think people don’t realize the value of training and if that neurosurgeon the other night yelling at me, you literally at a social event, if I had said to him, hey, it’s really training and support, he wouldn’t have bought it and I get it.

Amy Maneker MD:        43:15                And then the funniest is so after we did some pilots, I used to get hate mail when when I couldn’t accommodate a specialty so you know, endocrinology we can’t get you for a few months and people would complain and then people would say, so when are we getting that training again? So this was two, two hour sessions in the room and was recording and, and people were complaining you didn’t get to us. That wasn’t what I expected. So I think the other secret sauce, which I should mention is that organization always from a Gecko from their go live five years before had this very robust of just star what they called provider liaisons at the elbow support. And I think that team was the secret sauce that got us the five years with before and then they were those of the secret sauce that kind of really helped with the execution of the training help with figuring out the personalization later and would partner with that physician champion or what we then called an epic medical lead. And that’s the ongoing ownership and engagement. So I think those were the ingredients that were specific to that one organization, but they were also a few. They, they map back to what the arch collaboratives finding on a national level. It’s just how you do it. Can vary,

Bill Russell:                   44:32                you know, it’s interesting. One of the things we’ve, we’ve talked about on the show and I’ve talked about with other people in the industry is just, you know, the, the training we need now is not necessarily technology or even medical it’s, you know, a sociology background would be good because it’s, it’s changing the culture. It’s, it’s understanding the culture. It’s, um, and it’s really moving that needle and what you described as you’ve created a culture, you’ve changed the culture in the process of rolling out the EMR. And that’s um, you know, that and that, and that ends up being one of the critical success factors is, you know, is it you’re rolling something to these people or are they, um, are they a part of, of changing the way that medicine is delivered in that a organization and do they feel like they’re a part of it? Are they a part of a community? Are they part of a learning community? It’s, it’s all that stuff is, is just um, you know, it’s, it’s a new tool, a new tool set for all of us.

Amy Maneker MD:        45:35                I think in that particular organization it was years after the implementation, an implementation, again, we’ve all learned is one the import of robust training, but of ownership and engagement and not just for the go live, it’s a product and so you need physicians and all kinds of people. But you know, I’m a physician to own and be engaged in the content and the workflows of the EMr forever. And you know, in order to get a doc to do something, you need to enable them. So you need to sometimes give them time. You need to empower them. So when they make a decision and you need to set expectations, so hey, remember I took the cardiology, you’re the champion for training, here’s the, here’s some time you get to make the decisions, but you’re going to get consensus and some expectations and then ongoing you know, what their role is. I think we didn’t know all that and so we implemented the Emr and then the docs kind of thought, oh I’ve put the content and we’re good.

Bill Russell:                   46:32                All right. So last two questions here. So you built out a clinical informatics teams. What are some of the key roles that you had to fill in and where to find that talent?

Amy Maneker MD:        46:42                So I’m going to talk about the physicians or some other key roles. It’s you need to draft physician informaticists and I would offer that the vast majority of the time you have to train them or find training for them. So often you have to find them from within your organization because of the informatics team was they were part time informatics and the majority of time clinicals. So you have to draft them and you don’t want. And I actually, I think the answer is you want to recruit them because you actually don’t want to draft them. You want volunteers, you don’t want people who are drafted, quite frankly, I used the wrong term. So you really get the message out there that it’s an opportunity and it’s not the technology. You get people to understand that it’s really a quality of process improvement tool and then train them in informatics and I think you’d be amazed how many great docs really do want to improve quality and process and I think that’s the hook and the guy walks into my office and this would happen to me, hey, I know sql code.

Amy Maneker MD:        47:42                I’m like, congratulations. Was less likely to be a good fit for the team than the person who said, hey, I have all these ideas how we could be doing better care and then introduce them. Hey, here’s the tool how to do it. Because it really is a tool to improve quality and value of healthcare. And then it’s creating a team and really teaching everyone informatics and the verbiage and then also teaching them the. They have to understand whatever your Emr is better because they need to know the language. We speak to the analyst and then they become, they can speak medicalese and they can resonate with the other clinicians, you know, docs, nurses, whoever, and they can speak to the analyst team and then they can, they can make things happen.

Bill Russell:                   48:28                Uh, that’s a good segway to where have you found that informatics program has the greatest impact on care?

Amy Maneker MD:        48:37                So have the clinical informatics. I think it’s in quality and in quality and value and workflows. It’s twofold. It’s making the Emr and more usable and understanding the clinician’s needs and maybe training and support. But why are you doing that? You always have to remember, my favorite question is what are we trying to achieve if you’re trying to improve quality and value of healthcare? And so once you get past people using it, so why is that data asked in the Emr? Um, let’s use that data elsewhere. Let’s make the Emr work for us and serve up some information. And we talked about that. Don’t make me go out and check the PDMP. Serve up the info, even serve up when that patient’s at risk and I think if you can get a good informatics team, they will be able to help the organization build that Emr to do some work and really improve care.

Bill Russell:                   49:27                Absolutely. So amy, thank you for coming on the show. Is there a way for people to follow you online or

Amy Maneker MD:        49:35                It’s probably best connect with me through linkedin? I’m on twitter at Maneker_amy, but I mostly listened on twitter. I don’t really tweet. I mostly follow all kinds of things. You, Start Bridge Advisors, but linkedin is a good way to reach me. Just the spelling

Bill Russell:                   49:56                with all that experience. If people wanted to uh, uh, talk to you about stuff they can, they can go through starbridge and, and uh, and have amy working with you tomorrow, which would be, uh, I think, uh, uh, you know what I know if I were still in my role, I would love to have you to share your experience. It’s, it’s, uh, it’s great. And I think that’s what we’re finding now is people have experienced, it’s a, you know, we’re now a decade or more into this Ehr, journey and uh, we’re, we’re getting smarter and we’re getting more experience and more success stories and the more we can spread those around, uh, the better care is going to be in all these communities that we serve. So, um, so again, thank you for coming on the show. You can not, you can follow me @thepatientsCio on twitter, uh, on the lyrics website I do writing as well. Don’t forget the show’s twitter account @thisweekinhit and check out the website the videos I talked about the youtube channel And please come back every Friday for more news, information and commentary from industry influencers, that’s all For now.


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