Commentary

Carolyn M. Clancy, MD, was named Interim Under Secretary for Health for the VA on July 2, 2014, just as the wait time crisis seemed to be spinning out of control. Her appointment and the confirmation of Secretary Robert A. McDonald less than a month later proved essential to calming the furor but were admittedly just the first steps in a long-term process to increase veterans’ access to care and develop better systems and procedures across the agency.

Six months after her appointment, Federal Practitioner talked with Dr. Clancy about the pace of change and the role of health care providers in improving care for veterans. In the interview, Dr. Clancy clearly noted that many VA facilities already represent the best of U.S. health care and that the path forward requires sharing of best practices. Many other facilities, of course, will have to change, but Dr. Clancy insisted it is “an incredible opportunity” for the VA to learn as a system. Perhaps most heartening to VA practitioners, Dr. Clancy also recognized that “you can’t provide veteran-centered care without employees who are inspired to do their very, very best.”

To be sure, any successful change in VA procedures and culture will require buy-in not only from across the agency, but also from veterans and Congress. Dr. Clancy has already received 2 votes of confidence: The Paralyzed Veterans of America and the Vietnam Veterans of America jointly called on President Obama to make Dr. Clancy’s appointment permanent. The White House and congressional leaders, however, have yet to schedule hearings or comment publicly.

Below is an edited and condensed version of the interview. To hear the complete interview, including an in-depth discussion of the Blueprint for Excellence, visit http://www.fedprac.com/multimedia/multimedia-library.html.

Taking Measure of VA Strengths

Interim Under Secretary for Health Carolyn M. Clancy, MD. I came to this system in August of 2013 after more than 20 years at HHS, all working for an agency that had the lead charge for funding research to improve quality and safety in health care; and I had spent the last 10 years prior to coming here as the director of that agency. I came to VHA because I thought this system was unique among all systems, public and private, in this country and had the strongest foundation in place to deliver 21st century health care. And at least as important—probably more so—was the sense of mission among all of the employees I met. These were people I’ve known in academia, people I met on the interviews, people I’ve intersected with for a number of years in the research community. You can’t replicate it, and you can’t buy it; and I figured the combination of a strong foundation and mission meant that this was one of the best systems to work for.

I still think that. Some of our best facilities could compete head to head with any facilities in the private sector. There is no question about that. We have some systems, facilities, and clinics that are struggling as well, which is also very typical of the private sector.

What we have is an incredible opportunity, first, because we have a fabulous mission. We have highly committed and dedicated employees. We have an incredible opportunity to actually learn as a system. There has been a lot of discussion at a number of levels about how health care in the new century needs to be a learning health care system. We actually have the capability of delivering on that promise. So I’m very, very excited.

VA Clinical Staff and Recruitment

Dr. Clancy. I have often observed that change can be scary, but it’s also incredibly liberating. Some of our most dedicated employees, I know, can be frustrated, because they feel like they’re doing their part; but they aren’t always sure that the members of the team are as dedicated as they are or are going to catch the ball. And there’s no question that you don’t get to high-quality care without a good team. In other words, superb health care and exceptional veteran experience is a team sport by definition.

So I think it will actually help the vast majority of our frontline clinicians. It’ll be much, much easier for them to deliver the kind of care they want to deliver every single day but sometimes feel like they get stuck in workarounds.

As you have probably read and have heard me say, one of the biggest challenges of our crisis—now quite open to everyone—is how we had limited availability and limited capacity to meet the needs of the veterans we had the privilege of serving. So we are on a very, very big recruitment drive for all kinds of clinicians. And in addition to the incredible mission, we have taken some steps to make salaries a bit more competitive with the private sector. I want to underline a bit. You wouldn’t be coming to VA because you wanted to become wealthy, but we recognize that people have to pay student loans and so forth. And speaking of student loans, we have a variety of programs to help people pay down their educational debt.

And all of these things actually help, but the opportunity to deliver care that is really focused squarely on the needs of the individual veteran. That, I think, is what people will ultimately find far more exciting than any anxiety about change. …

The answer to the question about who are we recruiting is: yes. We’re recruiting all of those people [physicians and midlevel providers]. We often speak about the health care market in this country as if there were one health care market. And actually, U.S. health care, of which VA is very much a part, particularly now with the new law, is very much a series of local and regional markets. So to some extent, the ratios and the types of people that we’re going to need will depend on the specific community; but we’re looking for people in all of those areas.

Changing VA Culture

Dr. Clancy. There are a number of things that impact culture. Some of it is about stories. And I have to say that every day I get to be inspired by real-life stories of veterans and... their caregivers. Some of those caregivers are their family members or close friends: people who love them. And many of them are people who work for us in the Veterans Health Administration, people who just go the extra mile because it’s the right thing to do. Nobody said they had to do it. We don’t have a policy or a directive for it. To them, it’s as natural as gravity. …

Secretary McDonald often uses this diagram, an inverted pyramid that I love, where he starts off by having a regular pyramid; and he said, “This is how we think of a lot of organizations with the Secretary sitting right up here at the pinnacle, and veterans and everybody else are kind of down on the lowest tier.” And he said, “It’s exactly wrong. How I think about it is—” So, he flips it. We have people who provide direct care to veterans. We have people who help those people, and then we have people who help the people who are helping the people provide the care to veterans. And so that means that customer service is everybody’s job. It means that helping people on the front lines who are our colleagues—and we’re all in this together—make sure that they can deliver the care that veterans need. That is everybody’s job.

And I actually think it’s going to be a very, very easy sell. Reinforcing all of this is being transparent about data and how we’re doing. So we’re now starting to look internally at how our facilities compare with local counterparts in their particular community, and I think you will be seeing that become more public in the near future. We just have to make it a little more visually compelling.

This is how we learn. It isn’t to say, “Gee, look, you didn’t do as well as other facilities.” It’s to say, “Huh, you know, this facility actually has improved dramatically. Why don’t we go learn what they did?” which I think is consistent with [Federal Practitioner’s] focus on best practices. This is the big, big challenge and the opportunity for health care in general.

Blueprint for Excellence
 

In the wake of the wait time crisis, Carolyn M. Clancy, MD, has been tasked with implementing the Blueprint for Excellence. Its intent, according to the VA, is to “frame a set of activities that simultaneously address improving the performance of VHA health care now, developing a positive service culture, transitioning from ‘sick care’ to ‘health care’ in the broadest sense, and developing agile business systems and management processes that are efficient, transparent and accountable.”

All the changes at the VA will align with 10 strategies for sustained excellence, which focus on improving performance, promoting a positive culture of service, advancing health care innovation, and increasing operational effectiveness and accountability. The strategies include: 

1. Operate a health care network that anticipates and meets the unique needs of enrolled veterans, in general, and the service-disabled and most vulnerable veterans, in particular.
2. Deliver high-quality, veteran-centered care that compares favorably to the best of the private sector in measured outcomes, value, efficiency, and patient experience.
3. Leverage information technologies, analytics, and models of health care delivery to optimize individual and population health outcomes.
4. Grow an organizational culture, rooted in VA’s core values and mission, that prioritizes the veteran first; engaging and inspiring employees to their highest possible level of performance and conduct.
5. Foster an environment of continuous learning, responsible risk taking, and personal accountability.
6. Advance health care that is personalized, proactive, and patient-driven and engages and inspires veterans to their highest possible level of health and well-being.
7. Lead the nation in research and treatment of military service-related conditions.
8. Become a model integrated health services network through innovative academic, intergovernmental, and community relationships, information exchange, and public-private partnerships.
9. Operate and communicate with integrity, transparency, and accountability that earns and maintains the trust of veterans, stewards of the system (Congress, Veterans Service Organizations), and the public.
10. Modernize management processes in human resources, procurement, payment, capital infrastructure, and information technology to operate with benchmark agility and efficiency.

To listen to Dr. Clancy’s in-depth discussion of the Blueprint for Excellence, visit http://www.fedprac.com/multimedia/multimedia-library/article/carolyn-clancy-on-implementing-the-blueprint-for-excellence-at-the-va/f7313e00ff18fcbcf4fcaead862c285a/ocregister.html.

Measuring Success or Failure

Dr. Clancy. We will be measuring this in a lot of different ways. First is that VA is, I believe, unique among federal departments in having a very deep all-employee survey. We also participate in the broad Federal Employee Viewpoint Survey. ... In addition to that, we field our own survey internally and take that very, very seriously.

So literally, as the electrons are rolling in, we have a National Center for Organization and Development, which is sharing their results with me and looking at [the data] across the entire system by network, by facility. How are we doing? Where are there challenges? Where are there opportunities? Who’s doing incredibly well that we might learn something about how they’re doing that in order to help those facilities that are having more challenges? That is a very, very current source of information.

And the reason it’s so important is you can’t provide veteran-centered care without employees who are inspired to do their very, very best. And people who are inspired to do their very best, by definition, are not terribly unhappy. So that’s a very, very important source.

And I’ll also say that in health care, in general, as well as here, we’re seeing very important correlations between responses to employee surveys and such indicators as avoidable patient harms, rates of hospital-associated infections or health care-associated infections, and so forth. So we know that the two are very highly correlated.

The other reason that the survey is incredibly important is that most service industries have known for a long time that the best source of innovation are the people who are providing the service and care every single day. So again, that gets back to people feeling motivated and empowered and inspired. …

Time Frame for Change

Dr. Clancy. I think that people are seeing changes already. Now I’m just judging from my own e-mails and other things that we get; and we touch base regularly with veterans service organizations, with many, many stakeholders and take that input very, very seriously, because they are incredible partners in helping us identify and solve problems, because what I really worry about are veterans who are encountering difficulties, who may be fearful or hesitant in some fashion to bring that to our attention.

So I think, in a qualitative sense, we are seeing some positive signals but also recognizing that the scale of changes we’re talking about will take some time. But we will continue to see qualitative differences and, I think, real, tangible differences in the care that veterans get as the months proceed from here. I remain very optimistic about the future of this system and the size of the opportunity that we have.

Our laserlike focus for this coming year is access and exceptional veteran experience. You know, navigating health care can be pretty challenging. I know this because I’m from a very, very large extended family; and nobody else is in health or medicine, so I get regular reports. And whether you’re enrolled in our system or get your care elsewhere, it is not always easy.

But we have the incredible privilege of serving people who essentially wrote a blank check on our behalf when they agreed to serve the country. And so access is not something that, for the most part, is monitored closely in the private sector. It is certainly not publicly reported. We are making a very, very strong commitment, not just to improving, but to being able to show people the results.

Carolyn M. Clancy, MD, was named Interim Under Secretary for Health for the VA on July 2, 2014, just as the wait time crisis seemed to be spinning out of control. Her appointment and the confirmation of Secretary Robert A. McDonald less than a month later proved essential to calming the furor but were admittedly just the first steps in a long-term process to increase veterans’ access to care and develop better systems and procedures across the agency.

Six months after her appointment, Federal Practitioner talked with Dr. Clancy about the pace of change and the role of health care providers in improving care for veterans. In the interview, Dr. Clancy clearly noted that many VA facilities already represent the best of U.S. health care and that the path forward requires sharing of best practices. Many other facilities, of course, will have to change, but Dr. Clancy insisted it is “an incredible opportunity” for the VA to learn as a system. Perhaps most heartening to VA practitioners, Dr. Clancy also recognized that “you can’t provide veteran-centered care without employees who are inspired to do their very, very best.”

To be sure, any successful change in VA procedures and culture will require buy-in not only from across the agency, but also from veterans and Congress. Dr. Clancy has already received 2 votes of confidence: The Paralyzed Veterans of America and the Vietnam Veterans of America jointly called on President Obama to make Dr. Clancy’s appointment permanent. The White House and congressional leaders, however, have yet to schedule hearings or comment publicly.

Below is an edited and condensed version of the interview. To hear the complete interview, including an in-depth discussion of the Blueprint for Excellence, visit http://www.fedprac.com/multimedia/multimedia-library.html.

Taking Measure of VA Strengths

Interim Under Secretary for Health Carolyn M. Clancy, MD. I came to this system in August of 2013 after more than 20 years at HHS, all working for an agency that had the lead charge for funding research to improve quality and safety in health care; and I had spent the last 10 years prior to coming here as the director of that agency. I came to VHA because I thought this system was unique among all systems, public and private, in this country and had the strongest foundation in place to deliver 21st century health care. And at least as important—probably more so—was the sense of mission among all of the employees I met. These were people I’ve known in academia, people I met on the interviews, people I’ve intersected with for a number of years in the research community. You can’t replicate it, and you can’t buy it; and I figured the combination of a strong foundation and mission meant that this was one of the best systems to work for.

I still think that. Some of our best facilities could compete head to head with any facilities in the private sector. There is no question about that. We have some systems, facilities, and clinics that are struggling as well, which is also very typical of the private sector.

What we have is an incredible opportunity, first, because we have a fabulous mission. We have highly committed and dedicated employees. We have an incredible opportunity to actually learn as a system. There has been a lot of discussion at a number of levels about how health care in the new century needs to be a learning health care system. We actually have the capability of delivering on that promise. So I’m very, very excited.

VA Clinical Staff and Recruitment

Dr. Clancy. I have often observed that change can be scary, but it’s also incredibly liberating. Some of our most dedicated employees, I know, can be frustrated, because they feel like they’re doing their part; but they aren’t always sure that the members of the team are as dedicated as they are or are going to catch the ball. And there’s no question that you don’t get to high-quality care without a good team. In other words, superb health care and exceptional veteran experience is a team sport by definition.

So I think it will actually help the vast majority of our frontline clinicians. It’ll be much, much easier for them to deliver the kind of care they want to deliver every single day but sometimes feel like they get stuck in workarounds.

As you have probably read and have heard me say, one of the biggest challenges of our crisis—now quite open to everyone—is how we had limited availability and limited capacity to meet the needs of the veterans we had the privilege of serving. So we are on a very, very big recruitment drive for all kinds of clinicians. And in addition to the incredible mission, we have taken some steps to make salaries a bit more competitive with the private sector. I want to underline a bit. You wouldn’t be coming to VA because you wanted to become wealthy, but we recognize that people have to pay student loans and so forth. And speaking of student loans, we have a variety of programs to help people pay down their educational debt.

And all of these things actually help, but the opportunity to deliver care that is really focused squarely on the needs of the individual veteran. That, I think, is what people will ultimately find far more exciting than any anxiety about change. …

The answer to the question about who are we recruiting is: yes. We’re recruiting all of those people [physicians and midlevel providers]. We often speak about the health care market in this country as if there were one health care market. And actually, U.S. health care, of which VA is very much a part, particularly now with the new law, is very much a series of local and regional markets. So to some extent, the ratios and the types of people that we’re going to need will depend on the specific community; but we’re looking for people in all of those areas.

Changing VA Culture

Dr. Clancy. There are a number of things that impact culture. Some of it is about stories. And I have to say that every day I get to be inspired by real-life stories of veterans and... their caregivers. Some of those caregivers are their family members or close friends: people who love them. And many of them are people who work for us in the Veterans Health Administration, people who just go the extra mile because it’s the right thing to do. Nobody said they had to do it. We don’t have a policy or a directive for it. To them, it’s as natural as gravity. …

Secretary McDonald often uses this diagram, an inverted pyramid that I love, where he starts off by having a regular pyramid; and he said, “This is how we think of a lot of organizations with the Secretary sitting right up here at the pinnacle, and veterans and everybody else are kind of down on the lowest tier.” And he said, “It’s exactly wrong. How I think about it is—” So, he flips it. We have people who provide direct care to veterans. We have people who help those people, and then we have people who help the people who are helping the people provide the care to veterans. And so that means that customer service is everybody’s job. It means that helping people on the front lines who are our colleagues—and we’re all in this together—make sure that they can deliver the care that veterans need. That is everybody’s job.

And I actually think it’s going to be a very, very easy sell. Reinforcing all of this is being transparent about data and how we’re doing. So we’re now starting to look internally at how our facilities compare with local counterparts in their particular community, and I think you will be seeing that become more public in the near future. We just have to make it a little more visually compelling.

This is how we learn. It isn’t to say, “Gee, look, you didn’t do as well as other facilities.” It’s to say, “Huh, you know, this facility actually has improved dramatically. Why don’t we go learn what they did?” which I think is consistent with [Federal Practitioner’s] focus on best practices. This is the big, big challenge and the opportunity for health care in general.

Blueprint for Excellence
 

In the wake of the wait time crisis, Carolyn M. Clancy, MD, has been tasked with implementing the Blueprint for Excellence. Its intent, according to the VA, is to “frame a set of activities that simultaneously address improving the performance of VHA health care now, developing a positive service culture, transitioning from ‘sick care’ to ‘health care’ in the broadest sense, and developing agile business systems and management processes that are efficient, transparent and accountable.”

All the changes at the VA will align with 10 strategies for sustained excellence, which focus on improving performance, promoting a positive culture of service, advancing health care innovation, and increasing operational effectiveness and accountability. The strategies include: 

1. Operate a health care network that anticipates and meets the unique needs of enrolled veterans, in general, and the service-disabled and most vulnerable veterans, in particular.
2. Deliver high-quality, veteran-centered care that compares favorably to the best of the private sector in measured outcomes, value, efficiency, and patient experience.
3. Leverage information technologies, analytics, and models of health care delivery to optimize individual and population health outcomes.
4. Grow an organizational culture, rooted in VA’s core values and mission, that prioritizes the veteran first; engaging and inspiring employees to their highest possible level of performance and conduct.
5. Foster an environment of continuous learning, responsible risk taking, and personal accountability.
6. Advance health care that is personalized, proactive, and patient-driven and engages and inspires veterans to their highest possible level of health and well-being.
7. Lead the nation in research and treatment of military service-related conditions.
8. Become a model integrated health services network through innovative academic, intergovernmental, and community relationships, information exchange, and public-private partnerships.
9. Operate and communicate with integrity, transparency, and accountability that earns and maintains the trust of veterans, stewards of the system (Congress, Veterans Service Organizations), and the public.
10. Modernize management processes in human resources, procurement, payment, capital infrastructure, and information technology to operate with benchmark agility and efficiency.

To listen to Dr. Clancy’s in-depth discussion of the Blueprint for Excellence, visit http://www.fedprac.com/multimedia/multimedia-library/article/carolyn-clancy-on-implementing-the-blueprint-for-excellence-at-the-va/f7313e00ff18fcbcf4fcaead862c285a/ocregister.html.

Measuring Success or Failure

Dr. Clancy. We will be measuring this in a lot of different ways. First is that VA is, I believe, unique among federal departments in having a very deep all-employee survey. We also participate in the broad Federal Employee Viewpoint Survey. ... In addition to that, we field our own survey internally and take that very, very seriously.

So literally, as the electrons are rolling in, we have a National Center for Organization and Development, which is sharing their results with me and looking at [the data] across the entire system by network, by facility. How are we doing? Where are there challenges? Where are there opportunities? Who’s doing incredibly well that we might learn something about how they’re doing that in order to help those facilities that are having more challenges? That is a very, very current source of information.

And the reason it’s so important is you can’t provide veteran-centered care without employees who are inspired to do their very, very best. And people who are inspired to do their very best, by definition, are not terribly unhappy. So that’s a very, very important source.

And I’ll also say that in health care, in general, as well as here, we’re seeing very important correlations between responses to employee surveys and such indicators as avoidable patient harms, rates of hospital-associated infections or health care-associated infections, and so forth. So we know that the two are very highly correlated.

The other reason that the survey is incredibly important is that most service industries have known for a long time that the best source of innovation are the people who are providing the service and care every single day. So again, that gets back to people feeling motivated and empowered and inspired. …

Time Frame for Change

Dr. Clancy. I think that people are seeing changes already. Now I’m just judging from my own e-mails and other things that we get; and we touch base regularly with veterans service organizations, with many, many stakeholders and take that input very, very seriously, because they are incredible partners in helping us identify and solve problems, because what I really worry about are veterans who are encountering difficulties, who may be fearful or hesitant in some fashion to bring that to our attention.

So I think, in a qualitative sense, we are seeing some positive signals but also recognizing that the scale of changes we’re talking about will take some time. But we will continue to see qualitative differences and, I think, real, tangible differences in the care that veterans get as the months proceed from here. I remain very optimistic about the future of this system and the size of the opportunity that we have.

Our laserlike focus for this coming year is access and exceptional veteran experience. You know, navigating health care can be pretty challenging. I know this because I’m from a very, very large extended family; and nobody else is in health or medicine, so I get regular reports. And whether you’re enrolled in our system or get your care elsewhere, it is not always easy.

But we have the incredible privilege of serving people who essentially wrote a blank check on our behalf when they agreed to serve the country. And so access is not something that, for the most part, is monitored closely in the private sector. It is certainly not publicly reported. We are making a very, very strong commitment, not just to improving, but to being able to show people the results.

Carolyn M. Clancy, MD, was named Interim Under Secretary for Health for the VA on July 2, 2014, just as the wait time crisis seemed to be spinning out of control. Her appointment and the confirmation of Secretary Robert A. McDonald less than a month later proved essential to calming the furor but were admittedly just the first steps in a long-term process to increase veterans’ access to care and develop better systems and procedures across the agency.

Six months after her appointment, Federal Practitioner talked with Dr. Clancy about the pace of change and the role of health care providers in improving care for veterans. In the interview, Dr. Clancy clearly noted that many VA facilities already represent the best of U.S. health care and that the path forward requires sharing of best practices. Many other facilities, of course, will have to change, but Dr. Clancy insisted it is “an incredible opportunity” for the VA to learn as a system. Perhaps most heartening to VA practitioners, Dr. Clancy also recognized that “you can’t provide veteran-centered care without employees who are inspired to do their very, very best.”

To be sure, any successful change in VA procedures and culture will require buy-in not only from across the agency, but also from veterans and Congress. Dr. Clancy has already received 2 votes of confidence: The Paralyzed Veterans of America and the Vietnam Veterans of America jointly called on President Obama to make Dr. Clancy’s appointment permanent. The White House and congressional leaders, however, have yet to schedule hearings or comment publicly.

Below is an edited and condensed version of the interview. To hear the complete interview, including an in-depth discussion of the Blueprint for Excellence, visit http://www.fedprac.com/multimedia/multimedia-library.html.

Taking Measure of VA Strengths

Interim Under Secretary for Health Carolyn M. Clancy, MD. I came to this system in August of 2013 after more than 20 years at HHS, all working for an agency that had the lead charge for funding research to improve quality and safety in health care; and I had spent the last 10 years prior to coming here as the director of that agency. I came to VHA because I thought this system was unique among all systems, public and private, in this country and had the strongest foundation in place to deliver 21st century health care. And at least as important—probably more so—was the sense of mission among all of the employees I met. These were people I’ve known in academia, people I met on the interviews, people I’ve intersected with for a number of years in the research community. You can’t replicate it, and you can’t buy it; and I figured the combination of a strong foundation and mission meant that this was one of the best systems to work for.

I still think that. Some of our best facilities could compete head to head with any facilities in the private sector. There is no question about that. We have some systems, facilities, and clinics that are struggling as well, which is also very typical of the private sector.

What we have is an incredible opportunity, first, because we have a fabulous mission. We have highly committed and dedicated employees. We have an incredible opportunity to actually learn as a system. There has been a lot of discussion at a number of levels about how health care in the new century needs to be a learning health care system. We actually have the capability of delivering on that promise. So I’m very, very excited.

VA Clinical Staff and Recruitment

Dr. Clancy. I have often observed that change can be scary, but it’s also incredibly liberating. Some of our most dedicated employees, I know, can be frustrated, because they feel like they’re doing their part; but they aren’t always sure that the members of the team are as dedicated as they are or are going to catch the ball. And there’s no question that you don’t get to high-quality care without a good team. In other words, superb health care and exceptional veteran experience is a team sport by definition.

So I think it will actually help the vast majority of our frontline clinicians. It’ll be much, much easier for them to deliver the kind of care they want to deliver every single day but sometimes feel like they get stuck in workarounds.

As you have probably read and have heard me say, one of the biggest challenges of our crisis—now quite open to everyone—is how we had limited availability and limited capacity to meet the needs of the veterans we had the privilege of serving. So we are on a very, very big recruitment drive for all kinds of clinicians. And in addition to the incredible mission, we have taken some steps to make salaries a bit more competitive with the private sector. I want to underline a bit. You wouldn’t be coming to VA because you wanted to become wealthy, but we recognize that people have to pay student loans and so forth. And speaking of student loans, we have a variety of programs to help people pay down their educational debt.

And all of these things actually help, but the opportunity to deliver care that is really focused squarely on the needs of the individual veteran. That, I think, is what people will ultimately find far more exciting than any anxiety about change. …

The answer to the question about who are we recruiting is: yes. We’re recruiting all of those people [physicians and midlevel providers]. We often speak about the health care market in this country as if there were one health care market. And actually, U.S. health care, of which VA is very much a part, particularly now with the new law, is very much a series of local and regional markets. So to some extent, the ratios and the types of people that we’re going to need will depend on the specific community; but we’re looking for people in all of those areas.

Changing VA Culture

Dr. Clancy. There are a number of things that impact culture. Some of it is about stories. And I have to say that every day I get to be inspired by real-life stories of veterans and... their caregivers. Some of those caregivers are their family members or close friends: people who love them. And many of them are people who work for us in the Veterans Health Administration, people who just go the extra mile because it’s the right thing to do. Nobody said they had to do it. We don’t have a policy or a directive for it. To them, it’s as natural as gravity. …

Secretary McDonald often uses this diagram, an inverted pyramid that I love, where he starts off by having a regular pyramid; and he said, “This is how we think of a lot of organizations with the Secretary sitting right up here at the pinnacle, and veterans and everybody else are kind of down on the lowest tier.” And he said, “It’s exactly wrong. How I think about it is—” So, he flips it. We have people who provide direct care to veterans. We have people who help those people, and then we have people who help the people who are helping the people provide the care to veterans. And so that means that customer service is everybody’s job. It means that helping people on the front lines who are our colleagues—and we’re all in this together—make sure that they can deliver the care that veterans need. That is everybody’s job.

And I actually think it’s going to be a very, very easy sell. Reinforcing all of this is being transparent about data and how we’re doing. So we’re now starting to look internally at how our facilities compare with local counterparts in their particular community, and I think you will be seeing that become more public in the near future. We just have to make it a little more visually compelling.

This is how we learn. It isn’t to say, “Gee, look, you didn’t do as well as other facilities.” It’s to say, “Huh, you know, this facility actually has improved dramatically. Why don’t we go learn what they did?” which I think is consistent with [Federal Practitioner’s] focus on best practices. This is the big, big challenge and the opportunity for health care in general.

Blueprint for Excellence
 

In the wake of the wait time crisis, Carolyn M. Clancy, MD, has been tasked with implementing the Blueprint for Excellence. Its intent, according to the VA, is to “frame a set of activities that simultaneously address improving the performance of VHA health care now, developing a positive service culture, transitioning from ‘sick care’ to ‘health care’ in the broadest sense, and developing agile business systems and management processes that are efficient, transparent and accountable.”

All the changes at the VA will align with 10 strategies for sustained excellence, which focus on improving performance, promoting a positive culture of service, advancing health care innovation, and increasing operational effectiveness and accountability. The strategies include: 

1. Operate a health care network that anticipates and meets the unique needs of enrolled veterans, in general, and the service-disabled and most vulnerable veterans, in particular.
2. Deliver high-quality, veteran-centered care that compares favorably to the best of the private sector in measured outcomes, value, efficiency, and patient experience.
3. Leverage information technologies, analytics, and models of health care delivery to optimize individual and population health outcomes.
4. Grow an organizational culture, rooted in VA’s core values and mission, that prioritizes the veteran first; engaging and inspiring employees to their highest possible level of performance and conduct.
5. Foster an environment of continuous learning, responsible risk taking, and personal accountability.
6. Advance health care that is personalized, proactive, and patient-driven and engages and inspires veterans to their highest possible level of health and well-being.
7. Lead the nation in research and treatment of military service-related conditions.
8. Become a model integrated health services network through innovative academic, intergovernmental, and community relationships, information exchange, and public-private partnerships.
9. Operate and communicate with integrity, transparency, and accountability that earns and maintains the trust of veterans, stewards of the system (Congress, Veterans Service Organizations), and the public.
10. Modernize management processes in human resources, procurement, payment, capital infrastructure, and information technology to operate with benchmark agility and efficiency.

To listen to Dr. Clancy’s in-depth discussion of the Blueprint for Excellence, visit http://www.fedprac.com/multimedia/multimedia-library/article/carolyn-clancy-on-implementing-the-blueprint-for-excellence-at-the-va/f7313e00ff18fcbcf4fcaead862c285a/ocregister.html.

Measuring Success or Failure

Dr. Clancy. We will be measuring this in a lot of different ways. First is that VA is, I believe, unique among federal departments in having a very deep all-employee survey. We also participate in the broad Federal Employee Viewpoint Survey. ... In addition to that, we field our own survey internally and take that very, very seriously.

So literally, as the electrons are rolling in, we have a National Center for Organization and Development, which is sharing their results with me and looking at [the data] across the entire system by network, by facility. How are we doing? Where are there challenges? Where are there opportunities? Who’s doing incredibly well that we might learn something about how they’re doing that in order to help those facilities that are having more challenges? That is a very, very current source of information.

And the reason it’s so important is you can’t provide veteran-centered care without employees who are inspired to do their very, very best. And people who are inspired to do their very best, by definition, are not terribly unhappy. So that’s a very, very important source.

And I’ll also say that in health care, in general, as well as here, we’re seeing very important correlations between responses to employee surveys and such indicators as avoidable patient harms, rates of hospital-associated infections or health care-associated infections, and so forth. So we know that the two are very highly correlated.

The other reason that the survey is incredibly important is that most service industries have known for a long time that the best source of innovation are the people who are providing the service and care every single day. So again, that gets back to people feeling motivated and empowered and inspired. …

Time Frame for Change

Dr. Clancy. I think that people are seeing changes already. Now I’m just judging from my own e-mails and other things that we get; and we touch base regularly with veterans service organizations, with many, many stakeholders and take that input very, very seriously, because they are incredible partners in helping us identify and solve problems, because what I really worry about are veterans who are encountering difficulties, who may be fearful or hesitant in some fashion to bring that to our attention.

So I think, in a qualitative sense, we are seeing some positive signals but also recognizing that the scale of changes we’re talking about will take some time. But we will continue to see qualitative differences and, I think, real, tangible differences in the care that veterans get as the months proceed from here. I remain very optimistic about the future of this system and the size of the opportunity that we have.

Our laserlike focus for this coming year is access and exceptional veteran experience. You know, navigating health care can be pretty challenging. I know this because I’m from a very, very large extended family; and nobody else is in health or medicine, so I get regular reports. And whether you’re enrolled in our system or get your care elsewhere, it is not always easy.

But we have the incredible privilege of serving people who essentially wrote a blank check on our behalf when they agreed to serve the country. And so access is not something that, for the most part, is monitored closely in the private sector. It is certainly not publicly reported. We are making a very, very strong commitment, not just to improving, but to being able to show people the results.

Let’s talk about your average workday. Is it a long day? Or is it a half-day that feels like a two-thirds day? Does it start with early morning rounds or taking your daughter to day care … or both? Breakfast? Eaten at home or behind the wheel? Do you have a break at lunchtime? How do you invest that time? Or has someone invested it for you by scheduling a #$@%&*! department meeting?

When does your day end? After the last patient is seen? Or do you stay until your charting is done? Do you make end-of-the-day rounds? Does your office scheduling reasonably approximate the reality of when you would like to leave?

Even more importantly, how does your day end? Are you wasted physically and mentally? Is the last hour and a half a stress packed, clock-watching ordeal because you have to pick up your daughter from day care? And/or be home in time to prepare dinner? Or even just eat? Have you given up on sharing the meal with your family but have promised your son that you will be home to tuck him in and give him a good-night kiss? Did you stop promising to read him a story months ago because you were never there in time?

I suspect that once you have had a cup of coffee, negotiated your commute, and settled into your office routine, the mornings are less taxing than your afternoons. Particularly if your routine includes a drop-dead time commitment when you must leave to do after school pickups and make or join the family for dinner. Do you think the quality of your doctoring is as good in the afternoon as it was in the morning? Be honest! Because I have some data that shouldn’t surprise you.

In a study entitled “Time of day and the decision to prescribe antibiotics (JAMA Intern. Med. 2014;174:2029-31), a group of physicians at Brigham and Women’s Hospital in Boston analyzed the billing and electronic health records of 21,000 clinic visits of adults diagnosed with an acute respiratory illness. The investigators found that the likelihood that a patient would be prescribed antibiotics increased throughout both the morning and afternoon office visit sessions. By the end of each 4-hour session, 5% more patients received antibiotics than at the beginning of the session.

You could argue that, for some, an as-yet-undiscovered quirk of pulmonary bacterial pathogens prompts their victims to schedule appointments later in the day. The authors of the study, however, suggest that the physicians were suffering from “decision fatigue,” a phenomenon that has apparently been described in other professionals, including judges.

But what is decision fatigue? Isn’t it really just a description of one of the things that can happen when we get tired? Everyone with a job is making decisions. “Should I mop behind the toilet or just make a quick swipe where it’s obvious?” Or, “Is it really that important to make sure I have correctly tightened that bolt on that carburetor?”

If you are physically tired or squeezed by commitment to be out of the office at a specific time for another obligation, priority lists can reshuffle as the end of the day approaches. And the quality of care can suffer. Taking the extra time to explain to a patient why antibiotics aren’t appropriate for his or her situation may drop behind the speedier alternative of simply writing a prescription.

I’m sure that this study from a Harvard-affiliated hospital could be repeated using any one of a variety of quality of care measures. It should prompt all of us to rethink how we are structuring our lives. Are you staying up too late watching television or whatever? Has your decision of where to live locked you into a time-gobbling commute? Do you invest your lunch break in a restorative activity, such as a brisk walk outside? Is your office schedule realistic? Have you accepted inflexible commitments at the end of the day that make it impossible for you to spend extra time with a patient when it would probably improve the quality of his care?

Practicing good medicine boils down to making sure that we are in good physical and mental health and have fostered a work environment that fosters good decisions. Fatigue happens, but our patients shouldn’t have to suffer the consequences when it happens to us.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected].

Let’s talk about your average workday. Is it a long day? Or is it a half-day that feels like a two-thirds day? Does it start with early morning rounds or taking your daughter to day care … or both? Breakfast? Eaten at home or behind the wheel? Do you have a break at lunchtime? How do you invest that time? Or has someone invested it for you by scheduling a #$@%&*! department meeting?

When does your day end? After the last patient is seen? Or do you stay until your charting is done? Do you make end-of-the-day rounds? Does your office scheduling reasonably approximate the reality of when you would like to leave?

Even more importantly, how does your day end? Are you wasted physically and mentally? Is the last hour and a half a stress packed, clock-watching ordeal because you have to pick up your daughter from day care? And/or be home in time to prepare dinner? Or even just eat? Have you given up on sharing the meal with your family but have promised your son that you will be home to tuck him in and give him a good-night kiss? Did you stop promising to read him a story months ago because you were never there in time?

I suspect that once you have had a cup of coffee, negotiated your commute, and settled into your office routine, the mornings are less taxing than your afternoons. Particularly if your routine includes a drop-dead time commitment when you must leave to do after school pickups and make or join the family for dinner. Do you think the quality of your doctoring is as good in the afternoon as it was in the morning? Be honest! Because I have some data that shouldn’t surprise you.

In a study entitled “Time of day and the decision to prescribe antibiotics (JAMA Intern. Med. 2014;174:2029-31), a group of physicians at Brigham and Women’s Hospital in Boston analyzed the billing and electronic health records of 21,000 clinic visits of adults diagnosed with an acute respiratory illness. The investigators found that the likelihood that a patient would be prescribed antibiotics increased throughout both the morning and afternoon office visit sessions. By the end of each 4-hour session, 5% more patients received antibiotics than at the beginning of the session.

You could argue that, for some, an as-yet-undiscovered quirk of pulmonary bacterial pathogens prompts their victims to schedule appointments later in the day. The authors of the study, however, suggest that the physicians were suffering from “decision fatigue,” a phenomenon that has apparently been described in other professionals, including judges.

But what is decision fatigue? Isn’t it really just a description of one of the things that can happen when we get tired? Everyone with a job is making decisions. “Should I mop behind the toilet or just make a quick swipe where it’s obvious?” Or, “Is it really that important to make sure I have correctly tightened that bolt on that carburetor?”

If you are physically tired or squeezed by commitment to be out of the office at a specific time for another obligation, priority lists can reshuffle as the end of the day approaches. And the quality of care can suffer. Taking the extra time to explain to a patient why antibiotics aren’t appropriate for his or her situation may drop behind the speedier alternative of simply writing a prescription.

I’m sure that this study from a Harvard-affiliated hospital could be repeated using any one of a variety of quality of care measures. It should prompt all of us to rethink how we are structuring our lives. Are you staying up too late watching television or whatever? Has your decision of where to live locked you into a time-gobbling commute? Do you invest your lunch break in a restorative activity, such as a brisk walk outside? Is your office schedule realistic? Have you accepted inflexible commitments at the end of the day that make it impossible for you to spend extra time with a patient when it would probably improve the quality of his care?

Practicing good medicine boils down to making sure that we are in good physical and mental health and have fostered a work environment that fosters good decisions. Fatigue happens, but our patients shouldn’t have to suffer the consequences when it happens to us.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected].

Let’s talk about your average workday. Is it a long day? Or is it a half-day that feels like a two-thirds day? Does it start with early morning rounds or taking your daughter to day care … or both? Breakfast? Eaten at home or behind the wheel? Do you have a break at lunchtime? How do you invest that time? Or has someone invested it for you by scheduling a #$@%&*! department meeting?

When does your day end? After the last patient is seen? Or do you stay until your charting is done? Do you make end-of-the-day rounds? Does your office scheduling reasonably approximate the reality of when you would like to leave?

Even more importantly, how does your day end? Are you wasted physically and mentally? Is the last hour and a half a stress packed, clock-watching ordeal because you have to pick up your daughter from day care? And/or be home in time to prepare dinner? Or even just eat? Have you given up on sharing the meal with your family but have promised your son that you will be home to tuck him in and give him a good-night kiss? Did you stop promising to read him a story months ago because you were never there in time?

I suspect that once you have had a cup of coffee, negotiated your commute, and settled into your office routine, the mornings are less taxing than your afternoons. Particularly if your routine includes a drop-dead time commitment when you must leave to do after school pickups and make or join the family for dinner. Do you think the quality of your doctoring is as good in the afternoon as it was in the morning? Be honest! Because I have some data that shouldn’t surprise you.

In a study entitled “Time of day and the decision to prescribe antibiotics (JAMA Intern. Med. 2014;174:2029-31), a group of physicians at Brigham and Women’s Hospital in Boston analyzed the billing and electronic health records of 21,000 clinic visits of adults diagnosed with an acute respiratory illness. The investigators found that the likelihood that a patient would be prescribed antibiotics increased throughout both the morning and afternoon office visit sessions. By the end of each 4-hour session, 5% more patients received antibiotics than at the beginning of the session.

You could argue that, for some, an as-yet-undiscovered quirk of pulmonary bacterial pathogens prompts their victims to schedule appointments later in the day. The authors of the study, however, suggest that the physicians were suffering from “decision fatigue,” a phenomenon that has apparently been described in other professionals, including judges.

But what is decision fatigue? Isn’t it really just a description of one of the things that can happen when we get tired? Everyone with a job is making decisions. “Should I mop behind the toilet or just make a quick swipe where it’s obvious?” Or, “Is it really that important to make sure I have correctly tightened that bolt on that carburetor?”

If you are physically tired or squeezed by commitment to be out of the office at a specific time for another obligation, priority lists can reshuffle as the end of the day approaches. And the quality of care can suffer. Taking the extra time to explain to a patient why antibiotics aren’t appropriate for his or her situation may drop behind the speedier alternative of simply writing a prescription.

I’m sure that this study from a Harvard-affiliated hospital could be repeated using any one of a variety of quality of care measures. It should prompt all of us to rethink how we are structuring our lives. Are you staying up too late watching television or whatever? Has your decision of where to live locked you into a time-gobbling commute? Do you invest your lunch break in a restorative activity, such as a brisk walk outside? Is your office schedule realistic? Have you accepted inflexible commitments at the end of the day that make it impossible for you to spend extra time with a patient when it would probably improve the quality of his care?

Practicing good medicine boils down to making sure that we are in good physical and mental health and have fostered a work environment that fosters good decisions. Fatigue happens, but our patients shouldn’t have to suffer the consequences when it happens to us.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected].

“It is all in your head.” Patients hate to hear that. I am not sure why physicians still say it.

Lots of “real disease” is in your head: multiple sclerosis, strokes, pain, and depression. That does not mean that there is not organic pathology.

The report from the evidence-heavy Institute of Medicine (IOM) validates what so many patients have known all along: Chronic fatigue syndrome is a valid diagnosis.

No, we do not have laboratory or radiologic markers of the disease. Of course, there are not biomarkers of many other diseases, including posttraumatic stress disorder, pain, and depression.

What is tremendously important about this report is that it scientifically validates the experiences of so many patients – patients who previously have been dismissed by their physicians, thereby adding to their misery.

To reiterate the conclusions of the report:

“Myalgic encephalomyelitis/chronic fatigue syndrome – commonly referred to as ME/CFS – is a legitimate, serious, and complex systemic disease that frequently and dramatically limits the activities of affected individuals.” In the report, the IOM developed new diagnostic criteria for the disorder that include five main symptoms. In addition, it recommended that the disorder be renamed “systemic exertion intolerance disease” and be assigned a new code in the International Classification of Diseases, Tenth Edition.

The report goes on to say that between 836,000 and 2.5 million Americans suffer from ME/CFS, and an estimated 84%-91% of people with ME/CFS are not diagnosed. The disease’s symptoms can be treated, even though a cure does not exist. Its cause remains unknown, although in some cases symptoms have been triggered by an infection.

Less than one-third of medical schools include ME/CFS-specific information in the curriculum. Most patients (67%-77%) said that it took more than a year to receive a diagnosis – about 29% of these patients said it took more than 5 years. The direct and indirect economic costs of ME/CFS to society have been estimated at $17 billion to $24 billion annually, $9.1 billion of which has been attributed to lost household and job productivity.

Clearly, it is a disorder that physicians should take seriously. Especially psychiatrists, who know many diseases are “all in the head.”

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry.

“It is all in your head.” Patients hate to hear that. I am not sure why physicians still say it.

Lots of “real disease” is in your head: multiple sclerosis, strokes, pain, and depression. That does not mean that there is not organic pathology.

The report from the evidence-heavy Institute of Medicine (IOM) validates what so many patients have known all along: Chronic fatigue syndrome is a valid diagnosis.

No, we do not have laboratory or radiologic markers of the disease. Of course, there are not biomarkers of many other diseases, including posttraumatic stress disorder, pain, and depression.

What is tremendously important about this report is that it scientifically validates the experiences of so many patients – patients who previously have been dismissed by their physicians, thereby adding to their misery.

To reiterate the conclusions of the report:

“Myalgic encephalomyelitis/chronic fatigue syndrome – commonly referred to as ME/CFS – is a legitimate, serious, and complex systemic disease that frequently and dramatically limits the activities of affected individuals.” In the report, the IOM developed new diagnostic criteria for the disorder that include five main symptoms. In addition, it recommended that the disorder be renamed “systemic exertion intolerance disease” and be assigned a new code in the International Classification of Diseases, Tenth Edition.

The report goes on to say that between 836,000 and 2.5 million Americans suffer from ME/CFS, and an estimated 84%-91% of people with ME/CFS are not diagnosed. The disease’s symptoms can be treated, even though a cure does not exist. Its cause remains unknown, although in some cases symptoms have been triggered by an infection.

Less than one-third of medical schools include ME/CFS-specific information in the curriculum. Most patients (67%-77%) said that it took more than a year to receive a diagnosis – about 29% of these patients said it took more than 5 years. The direct and indirect economic costs of ME/CFS to society have been estimated at $17 billion to $24 billion annually, $9.1 billion of which has been attributed to lost household and job productivity.

Clearly, it is a disorder that physicians should take seriously. Especially psychiatrists, who know many diseases are “all in the head.”

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry.

“It is all in your head.” Patients hate to hear that. I am not sure why physicians still say it.

Lots of “real disease” is in your head: multiple sclerosis, strokes, pain, and depression. That does not mean that there is not organic pathology.

The report from the evidence-heavy Institute of Medicine (IOM) validates what so many patients have known all along: Chronic fatigue syndrome is a valid diagnosis.

No, we do not have laboratory or radiologic markers of the disease. Of course, there are not biomarkers of many other diseases, including posttraumatic stress disorder, pain, and depression.

What is tremendously important about this report is that it scientifically validates the experiences of so many patients – patients who previously have been dismissed by their physicians, thereby adding to their misery.

To reiterate the conclusions of the report:

“Myalgic encephalomyelitis/chronic fatigue syndrome – commonly referred to as ME/CFS – is a legitimate, serious, and complex systemic disease that frequently and dramatically limits the activities of affected individuals.” In the report, the IOM developed new diagnostic criteria for the disorder that include five main symptoms. In addition, it recommended that the disorder be renamed “systemic exertion intolerance disease” and be assigned a new code in the International Classification of Diseases, Tenth Edition.

The report goes on to say that between 836,000 and 2.5 million Americans suffer from ME/CFS, and an estimated 84%-91% of people with ME/CFS are not diagnosed. The disease’s symptoms can be treated, even though a cure does not exist. Its cause remains unknown, although in some cases symptoms have been triggered by an infection.

Less than one-third of medical schools include ME/CFS-specific information in the curriculum. Most patients (67%-77%) said that it took more than a year to receive a diagnosis – about 29% of these patients said it took more than 5 years. The direct and indirect economic costs of ME/CFS to society have been estimated at $17 billion to $24 billion annually, $9.1 billion of which has been attributed to lost household and job productivity.

Clearly, it is a disorder that physicians should take seriously. Especially psychiatrists, who know many diseases are “all in the head.”

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry.

Can dermatologists influence the political process? This age-old question raises its head when things are happening that we do not like or that we believe could be done better. Even though dermatologists have skills and expertise that allow us to be effective in our medical practice, most of us feel incompetent when it comes to dealing with the government. The political process is not the primary focus of our time and energy, not a topic in continuing medical education, and definitely not a place of comfort. At my medical school commencement ceremony, Leon Jaworski, a special prosecutor during Watergate, gave an address in which he scolded the medical community for not being more involved in the political process, insisting that society would benefit from our participation. This message was a lightning bolt out of the blue for me. It was the first time in all my medical school years that any respected senior figure had broached the concept that a physician’s role includes engagement in the workings of government. Jaworski was insistent, and he was right.

Influencing the political process (ie, advocating effectively) requires skills and expertise that can be acquired with attention to 3 primary principles: interfacing with legislators, establishing credibility, and joining forces within professional societies.

How to Interface With Legislators

Interfacing with legislators is exactly that: interFACEing. Based on 4 online surveys of congressional staff members (2010-2013) by the Congressional Management Foundation, the most influential way to communicate with a senator or representative is an in-person visit.¹ Successful politicians regard keeping in touch with their constituents to be the most critical factor in their effectiveness.

Getting face time with a legislator can be difficult. In the short-term, the most successful strategy is for the request to come from a constituent who is affiliated with an association or corporation that represents the interests of many constituents. In the long-term, personal visits, letters (e-mail is preferred for security reasons), and telephone calls are most important when they come from constituents who are well known, highly regarded, and have gone out of their way to be helpful to the legislator’s office, which means we need to pay attention to building a relationship with our legislators. For example, I had a long-standing, one-sided correspondence with former representative Barney Frank (Democrat, Massachusetts), writing him regularly on issues that concerned me. I once chided him for not showing up for a vote I thought was important and in return I received a 3-page handwritten letter from him concerning his absence. YES! He knew my name, he knew what was important to me, and he had enough regard for my opinion to answer me personally.

Building a relationship with a staffer can be as important or sometimes even more important than with the legislators themselves. Staffers have direct access to legislators and understand the best way to facilitate moving your information and concerns forward. Meet with them, keep their contact information on hand, and direct your questions and comments to them. Staffers know how you can be helpful to their office, whether it is by supplying information, providing feedback on a position or comment, or hosting a neighborhood coffee gathering in your home so the legislator can meet other constituents. Attending events in your district or offering a simple fundraiser in your home for local and state legislators is an excellent way to be involved with candidates in a way that promotes a future relationship. When the Stark exemption was being discussed in relation to anatomic pathology at an in-office laboratory, I offered a tour of my Mohs unit to a staffer so she could see how integral and important it is for surgeons to perform histology examinations to ensure proper patient care. She did not take me up on the offer, but she subsequently called me with a question concerning a similar issue.

It is not optimal to develop relationships solely with legislators from the political party with which you identify. Dermatologists’ professional interests of concern will likely require bipartisan support for resolution.

Establish Your Credibility

Do some homework on your key issues; find the facts that support your position and also be sure to understand the opposition’s concerns. Be able to present your viewpoint in a focused and concise way with a clear sense of what you are asking the legislator to do.

Keep in mind that you want to develop a long-term, trusted relationship. It is important to be respectful and leave general political feelings out of the meeting. Schedule a meeting with the intention of presenting only 2 or 3 concrete requests. During the visit, it helps to set the context for the conversation if you reference a particular bill. Staffers often ask questions about the bill if it is not one they are currently following, which allows you to become a dependable source of good information. You can engage with staffers or legislators by asking them directly and politely for their views and position on the issue. It often is effective to leave them with a 1- to 2-page summary for review and to follow up later with a formal thank you for their time.

Participate in Professional Societies

Join professional societies to acquire the information you need, refine and consolidate messaging, and represent a larger constituency. Most of the societies that dermatologists belong to, including the American Academy of Dermatology Association, the American Society for Dermatologic Surgery Association, and the American College of Mohs Surgery, have identified legislative priorities and promote coordinated visits to Congress. The American Academy of Dermatology Association organizes its annual Legislative Conference in Washington, DC, each fall, which includes an in-depth program of speakers, discussions, and information concerning priority issues. Messages are refined and appointments are made for visits with legislators and/or their staffers. Your small group will include experienced colleagues so that you develop your skills with their mentorship. Many state societies also train their members to be effective at advocacy at the State House. Finally and most importantly, a sizeable war chest (yes, your dollars are needed too) for SkinPAC, the American Academy of Dermatology Association Political Action Committee, creates notice and respect for dermatology’s commitment to the issues of importance to the profession.

Dermatologists Have Impacted Legislation

Interaction by individual dermatologists with legislators has had a direct impact on health care issues. A Medicare Advantage Participant Bill of Rights recently was introduced and has garnered bipartisan support in the Senate due to meetings between dermatologists and key members of Congress and the Obama administration about concerns with narrow physician networks. There is a robust bipartisan Congressional Skin Cancer Caucus that representatives have joined because of discussions with their constituent dermatologists. The strong testimonies of 2 dermatologists in Maryland has picked up 3 more yes votes for passing a bill that prohibits use of tanning devices in minors younger than 18 years in that state. California dermatologists also put enough pressure on their state senators to defeat the elimination of the in-office exception to self-referral for anatomic pathology services.

Final Thoughts

Dermatologists do have a voice. We do have influence. We must “sit at the table.”² Build a relationship with your legislators. Develop your message and become a trusted voice. Join forces with other dermatologists. “Let’s grab the front seat together.”²

Can dermatologists influence the political process? This age-old question raises its head when things are happening that we do not like or that we believe could be done better. Even though dermatologists have skills and expertise that allow us to be effective in our medical practice, most of us feel incompetent when it comes to dealing with the government. The political process is not the primary focus of our time and energy, not a topic in continuing medical education, and definitely not a place of comfort. At my medical school commencement ceremony, Leon Jaworski, a special prosecutor during Watergate, gave an address in which he scolded the medical community for not being more involved in the political process, insisting that society would benefit from our participation. This message was a lightning bolt out of the blue for me. It was the first time in all my medical school years that any respected senior figure had broached the concept that a physician’s role includes engagement in the workings of government. Jaworski was insistent, and he was right.

Influencing the political process (ie, advocating effectively) requires skills and expertise that can be acquired with attention to 3 primary principles: interfacing with legislators, establishing credibility, and joining forces within professional societies.

How to Interface With Legislators

Interfacing with legislators is exactly that: interFACEing. Based on 4 online surveys of congressional staff members (2010-2013) by the Congressional Management Foundation, the most influential way to communicate with a senator or representative is an in-person visit.¹ Successful politicians regard keeping in touch with their constituents to be the most critical factor in their effectiveness.

Getting face time with a legislator can be difficult. In the short-term, the most successful strategy is for the request to come from a constituent who is affiliated with an association or corporation that represents the interests of many constituents. In the long-term, personal visits, letters (e-mail is preferred for security reasons), and telephone calls are most important when they come from constituents who are well known, highly regarded, and have gone out of their way to be helpful to the legislator’s office, which means we need to pay attention to building a relationship with our legislators. For example, I had a long-standing, one-sided correspondence with former representative Barney Frank (Democrat, Massachusetts), writing him regularly on issues that concerned me. I once chided him for not showing up for a vote I thought was important and in return I received a 3-page handwritten letter from him concerning his absence. YES! He knew my name, he knew what was important to me, and he had enough regard for my opinion to answer me personally.

Building a relationship with a staffer can be as important or sometimes even more important than with the legislators themselves. Staffers have direct access to legislators and understand the best way to facilitate moving your information and concerns forward. Meet with them, keep their contact information on hand, and direct your questions and comments to them. Staffers know how you can be helpful to their office, whether it is by supplying information, providing feedback on a position or comment, or hosting a neighborhood coffee gathering in your home so the legislator can meet other constituents. Attending events in your district or offering a simple fundraiser in your home for local and state legislators is an excellent way to be involved with candidates in a way that promotes a future relationship. When the Stark exemption was being discussed in relation to anatomic pathology at an in-office laboratory, I offered a tour of my Mohs unit to a staffer so she could see how integral and important it is for surgeons to perform histology examinations to ensure proper patient care. She did not take me up on the offer, but she subsequently called me with a question concerning a similar issue.

It is not optimal to develop relationships solely with legislators from the political party with which you identify. Dermatologists’ professional interests of concern will likely require bipartisan support for resolution.

Establish Your Credibility

Do some homework on your key issues; find the facts that support your position and also be sure to understand the opposition’s concerns. Be able to present your viewpoint in a focused and concise way with a clear sense of what you are asking the legislator to do.

Keep in mind that you want to develop a long-term, trusted relationship. It is important to be respectful and leave general political feelings out of the meeting. Schedule a meeting with the intention of presenting only 2 or 3 concrete requests. During the visit, it helps to set the context for the conversation if you reference a particular bill. Staffers often ask questions about the bill if it is not one they are currently following, which allows you to become a dependable source of good information. You can engage with staffers or legislators by asking them directly and politely for their views and position on the issue. It often is effective to leave them with a 1- to 2-page summary for review and to follow up later with a formal thank you for their time.

Participate in Professional Societies

Join professional societies to acquire the information you need, refine and consolidate messaging, and represent a larger constituency. Most of the societies that dermatologists belong to, including the American Academy of Dermatology Association, the American Society for Dermatologic Surgery Association, and the American College of Mohs Surgery, have identified legislative priorities and promote coordinated visits to Congress. The American Academy of Dermatology Association organizes its annual Legislative Conference in Washington, DC, each fall, which includes an in-depth program of speakers, discussions, and information concerning priority issues. Messages are refined and appointments are made for visits with legislators and/or their staffers. Your small group will include experienced colleagues so that you develop your skills with their mentorship. Many state societies also train their members to be effective at advocacy at the State House. Finally and most importantly, a sizeable war chest (yes, your dollars are needed too) for SkinPAC, the American Academy of Dermatology Association Political Action Committee, creates notice and respect for dermatology’s commitment to the issues of importance to the profession.

Dermatologists Have Impacted Legislation

Interaction by individual dermatologists with legislators has had a direct impact on health care issues. A Medicare Advantage Participant Bill of Rights recently was introduced and has garnered bipartisan support in the Senate due to meetings between dermatologists and key members of Congress and the Obama administration about concerns with narrow physician networks. There is a robust bipartisan Congressional Skin Cancer Caucus that representatives have joined because of discussions with their constituent dermatologists. The strong testimonies of 2 dermatologists in Maryland has picked up 3 more yes votes for passing a bill that prohibits use of tanning devices in minors younger than 18 years in that state. California dermatologists also put enough pressure on their state senators to defeat the elimination of the in-office exception to self-referral for anatomic pathology services.

Final Thoughts

Dermatologists do have a voice. We do have influence. We must “sit at the table.”² Build a relationship with your legislators. Develop your message and become a trusted voice. Join forces with other dermatologists. “Let’s grab the front seat together.”²

Can dermatologists influence the political process? This age-old question raises its head when things are happening that we do not like or that we believe could be done better. Even though dermatologists have skills and expertise that allow us to be effective in our medical practice, most of us feel incompetent when it comes to dealing with the government. The political process is not the primary focus of our time and energy, not a topic in continuing medical education, and definitely not a place of comfort. At my medical school commencement ceremony, Leon Jaworski, a special prosecutor during Watergate, gave an address in which he scolded the medical community for not being more involved in the political process, insisting that society would benefit from our participation. This message was a lightning bolt out of the blue for me. It was the first time in all my medical school years that any respected senior figure had broached the concept that a physician’s role includes engagement in the workings of government. Jaworski was insistent, and he was right.

Influencing the political process (ie, advocating effectively) requires skills and expertise that can be acquired with attention to 3 primary principles: interfacing with legislators, establishing credibility, and joining forces within professional societies.

How to Interface With Legislators

Interfacing with legislators is exactly that: interFACEing. Based on 4 online surveys of congressional staff members (2010-2013) by the Congressional Management Foundation, the most influential way to communicate with a senator or representative is an in-person visit.¹ Successful politicians regard keeping in touch with their constituents to be the most critical factor in their effectiveness.

Getting face time with a legislator can be difficult. In the short-term, the most successful strategy is for the request to come from a constituent who is affiliated with an association or corporation that represents the interests of many constituents. In the long-term, personal visits, letters (e-mail is preferred for security reasons), and telephone calls are most important when they come from constituents who are well known, highly regarded, and have gone out of their way to be helpful to the legislator’s office, which means we need to pay attention to building a relationship with our legislators. For example, I had a long-standing, one-sided correspondence with former representative Barney Frank (Democrat, Massachusetts), writing him regularly on issues that concerned me. I once chided him for not showing up for a vote I thought was important and in return I received a 3-page handwritten letter from him concerning his absence. YES! He knew my name, he knew what was important to me, and he had enough regard for my opinion to answer me personally.

Building a relationship with a staffer can be as important or sometimes even more important than with the legislators themselves. Staffers have direct access to legislators and understand the best way to facilitate moving your information and concerns forward. Meet with them, keep their contact information on hand, and direct your questions and comments to them. Staffers know how you can be helpful to their office, whether it is by supplying information, providing feedback on a position or comment, or hosting a neighborhood coffee gathering in your home so the legislator can meet other constituents. Attending events in your district or offering a simple fundraiser in your home for local and state legislators is an excellent way to be involved with candidates in a way that promotes a future relationship. When the Stark exemption was being discussed in relation to anatomic pathology at an in-office laboratory, I offered a tour of my Mohs unit to a staffer so she could see how integral and important it is for surgeons to perform histology examinations to ensure proper patient care. She did not take me up on the offer, but she subsequently called me with a question concerning a similar issue.

It is not optimal to develop relationships solely with legislators from the political party with which you identify. Dermatologists’ professional interests of concern will likely require bipartisan support for resolution.

Establish Your Credibility

Do some homework on your key issues; find the facts that support your position and also be sure to understand the opposition’s concerns. Be able to present your viewpoint in a focused and concise way with a clear sense of what you are asking the legislator to do.

Keep in mind that you want to develop a long-term, trusted relationship. It is important to be respectful and leave general political feelings out of the meeting. Schedule a meeting with the intention of presenting only 2 or 3 concrete requests. During the visit, it helps to set the context for the conversation if you reference a particular bill. Staffers often ask questions about the bill if it is not one they are currently following, which allows you to become a dependable source of good information. You can engage with staffers or legislators by asking them directly and politely for their views and position on the issue. It often is effective to leave them with a 1- to 2-page summary for review and to follow up later with a formal thank you for their time.

Participate in Professional Societies

Join professional societies to acquire the information you need, refine and consolidate messaging, and represent a larger constituency. Most of the societies that dermatologists belong to, including the American Academy of Dermatology Association, the American Society for Dermatologic Surgery Association, and the American College of Mohs Surgery, have identified legislative priorities and promote coordinated visits to Congress. The American Academy of Dermatology Association organizes its annual Legislative Conference in Washington, DC, each fall, which includes an in-depth program of speakers, discussions, and information concerning priority issues. Messages are refined and appointments are made for visits with legislators and/or their staffers. Your small group will include experienced colleagues so that you develop your skills with their mentorship. Many state societies also train their members to be effective at advocacy at the State House. Finally and most importantly, a sizeable war chest (yes, your dollars are needed too) for SkinPAC, the American Academy of Dermatology Association Political Action Committee, creates notice and respect for dermatology’s commitment to the issues of importance to the profession.

Dermatologists Have Impacted Legislation

Interaction by individual dermatologists with legislators has had a direct impact on health care issues. A Medicare Advantage Participant Bill of Rights recently was introduced and has garnered bipartisan support in the Senate due to meetings between dermatologists and key members of Congress and the Obama administration about concerns with narrow physician networks. There is a robust bipartisan Congressional Skin Cancer Caucus that representatives have joined because of discussions with their constituent dermatologists. The strong testimonies of 2 dermatologists in Maryland has picked up 3 more yes votes for passing a bill that prohibits use of tanning devices in minors younger than 18 years in that state. California dermatologists also put enough pressure on their state senators to defeat the elimination of the in-office exception to self-referral for anatomic pathology services.

Final Thoughts

Dermatologists do have a voice. We do have influence. We must “sit at the table.”² Build a relationship with your legislators. Develop your message and become a trusted voice. Join forces with other dermatologists. “Let’s grab the front seat together.”²

With 2014 behind us, we are finally able to assess the implications of Meaningful Use Stage 2 for Eligible Professionals. It is now clear – as anticipated – that the updated criteria have presented a significant challenge to many. In fact, it is predicted that only a fraction of those who attained Stage 1 of Meaningful Use will attest for Stage 2 for the 2014 year. As a result, physicians who have received financial incentives under the program will now face penalties, and may see a real impact on their bottom lines.

If it’s any consolation, there is hope (and even some evidence) that the Centers for Medicare & Medicaid Services will make a few amendments to the Meaningful Use program over the next few months. This will allow for additional flexibility for providers, and with any luck, will mean more people qualify in 2015. In this column, we’ll highlight the proposed changes and share a few observations from the first year of Stage 2.

Here’s what’s new

On Jan. 29, 2015, CMS released a proposed rule that would adjust the reporting period for 2015 – currently set for the entire year – to 90 days. While this is the same length as 2014, it would give providers an extra 9 months to upgrade software, systems, and work-flows to attest for Stage 2. For those who were able to take advantage of the CEHRT [certified EHR technology] Flexibility and continue Stage 1 in 2014, this may be just the reprieve needed to stay on track. For those who made an unsuccessful attempt at Stage 2 last year, this just makes the second try a bit easier.

In case you are wondering, if you “miss” a year of Meaningful Use, you simply continue as if you made it. In other words, under the current rule, if you are due to start a full year of Stage 2 reporting in 2015, you are still obligated to do so even if you were unsuccessful with 90 days of Stage 2 in 2014. The proposed rule would change that, and keep everyone’s reporting period at 90 days regardless of stage or year. (Remember: A 1% per year penalty is assessed for every year an eligible professional fails to meet the requirements, up to a maximum of 5%. These penalties continue indefinitely.)

CMS is considering other changes as well. Specifically, their press release states they are looking to “modify other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.” As of now, it is unclear what that might include, but a review of the challenges from 2014 may point to some strong possibilities. We’ll start with a principle we’ve dealt with previously:

Interoperability is hard

The most noteworthy changes from Stage 1 to Stage 2 are all requirements to pass information into and out of the EHR. These include: making records available through a secure patient portal, the ability to communicate with patients through electronic means, and the transmission of “summary of care” documents between providers. These requirements also happen to be the most challenging for physicians, because they rely on other systems and individuals to make the connections possible.

Up to this point, EHR vendors have not prioritized adopting established standards for data transmission, and Stage 2 really brought this shortcoming to light. So much so, that CMS considered it a valid reason to invoke the CEHRT Flexibility. By “limited exception” providers could continue with Stage 1 this past year if “their referral partners [did] not upgrade to 2014 Edition Certified EHR Technology” (i.e., doctors are given a pass on the need to send “summary of care” data if there’s no one around to receive it). But secure and reliable electronic communication with other physicians is just one area of struggle. Another that is arguably more difficult is communicating electronically with patients. Compared with the challenges of interoperability, we’ve observed that:

Patient care is even harder

It’s one thing to incentivize (or penalize) physicians for adopting Health Information Technology, but it is an entirely different thing to hold them responsible for whether or not their patients choose to embrace it. Unfortunately, the 2014 Meaningful Use measures seem to do just that. With quotas for providing “secure electronic access” through a patient portal, the MU program forces physicians to engage patients on a new virtual “playing field.” This may seem like a good thing on the surface, but it has been riddled with headaches for providers and patients alike.

With the dawn of EHR portals, physicians suddenly perceive a new level of exposure. Patients can now peer into their charts and uncover unfiltered diagnosis terminology or slightly abnormal lab values that may raise unwarranted concern. As a result, physicians have become much more conscientious about documentation, but most feel this is just one more layer of complexity to slow them down. Additionally, as patients discover the convenience and immediacy of secure e-mail, more care is now being delivered outside the context of an office visit. This requires a huge time commitment from physicians and, in most cases, provides no income – and this time demand is not limited to just the doctors! Office staff have the new and unwelcome task of providing technical support to patients for website problems, lost passwords, etc. All of these underscore this final observation:

This isn’t getting any easier

We realize this last point is self-evident, but its impact is hard to quantify. With every new stage of meaningful use, new requirements aimed at making care more efficient for patients only seem to make delivery of care much less efficient for physicians. As physicians become mired in regulations and visit volumes drop, care will ultimately become less efficient for everyone. In response to these and many other issues, we are hopeful to see some significant adjustments made to the timeline and requirements of meaningful use. In the meantime, we certainly acknowledge the challenges and as always invite your feedback and comments.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

With 2014 behind us, we are finally able to assess the implications of Meaningful Use Stage 2 for Eligible Professionals. It is now clear – as anticipated – that the updated criteria have presented a significant challenge to many. In fact, it is predicted that only a fraction of those who attained Stage 1 of Meaningful Use will attest for Stage 2 for the 2014 year. As a result, physicians who have received financial incentives under the program will now face penalties, and may see a real impact on their bottom lines.

If it’s any consolation, there is hope (and even some evidence) that the Centers for Medicare & Medicaid Services will make a few amendments to the Meaningful Use program over the next few months. This will allow for additional flexibility for providers, and with any luck, will mean more people qualify in 2015. In this column, we’ll highlight the proposed changes and share a few observations from the first year of Stage 2.

Here’s what’s new

On Jan. 29, 2015, CMS released a proposed rule that would adjust the reporting period for 2015 – currently set for the entire year – to 90 days. While this is the same length as 2014, it would give providers an extra 9 months to upgrade software, systems, and work-flows to attest for Stage 2. For those who were able to take advantage of the CEHRT [certified EHR technology] Flexibility and continue Stage 1 in 2014, this may be just the reprieve needed to stay on track. For those who made an unsuccessful attempt at Stage 2 last year, this just makes the second try a bit easier.

In case you are wondering, if you “miss” a year of Meaningful Use, you simply continue as if you made it. In other words, under the current rule, if you are due to start a full year of Stage 2 reporting in 2015, you are still obligated to do so even if you were unsuccessful with 90 days of Stage 2 in 2014. The proposed rule would change that, and keep everyone’s reporting period at 90 days regardless of stage or year. (Remember: A 1% per year penalty is assessed for every year an eligible professional fails to meet the requirements, up to a maximum of 5%. These penalties continue indefinitely.)

CMS is considering other changes as well. Specifically, their press release states they are looking to “modify other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.” As of now, it is unclear what that might include, but a review of the challenges from 2014 may point to some strong possibilities. We’ll start with a principle we’ve dealt with previously:

Interoperability is hard

The most noteworthy changes from Stage 1 to Stage 2 are all requirements to pass information into and out of the EHR. These include: making records available through a secure patient portal, the ability to communicate with patients through electronic means, and the transmission of “summary of care” documents between providers. These requirements also happen to be the most challenging for physicians, because they rely on other systems and individuals to make the connections possible.

Up to this point, EHR vendors have not prioritized adopting established standards for data transmission, and Stage 2 really brought this shortcoming to light. So much so, that CMS considered it a valid reason to invoke the CEHRT Flexibility. By “limited exception” providers could continue with Stage 1 this past year if “their referral partners [did] not upgrade to 2014 Edition Certified EHR Technology” (i.e., doctors are given a pass on the need to send “summary of care” data if there’s no one around to receive it). But secure and reliable electronic communication with other physicians is just one area of struggle. Another that is arguably more difficult is communicating electronically with patients. Compared with the challenges of interoperability, we’ve observed that:

Patient care is even harder

It’s one thing to incentivize (or penalize) physicians for adopting Health Information Technology, but it is an entirely different thing to hold them responsible for whether or not their patients choose to embrace it. Unfortunately, the 2014 Meaningful Use measures seem to do just that. With quotas for providing “secure electronic access” through a patient portal, the MU program forces physicians to engage patients on a new virtual “playing field.” This may seem like a good thing on the surface, but it has been riddled with headaches for providers and patients alike.

With the dawn of EHR portals, physicians suddenly perceive a new level of exposure. Patients can now peer into their charts and uncover unfiltered diagnosis terminology or slightly abnormal lab values that may raise unwarranted concern. As a result, physicians have become much more conscientious about documentation, but most feel this is just one more layer of complexity to slow them down. Additionally, as patients discover the convenience and immediacy of secure e-mail, more care is now being delivered outside the context of an office visit. This requires a huge time commitment from physicians and, in most cases, provides no income – and this time demand is not limited to just the doctors! Office staff have the new and unwelcome task of providing technical support to patients for website problems, lost passwords, etc. All of these underscore this final observation:

This isn’t getting any easier

We realize this last point is self-evident, but its impact is hard to quantify. With every new stage of meaningful use, new requirements aimed at making care more efficient for patients only seem to make delivery of care much less efficient for physicians. As physicians become mired in regulations and visit volumes drop, care will ultimately become less efficient for everyone. In response to these and many other issues, we are hopeful to see some significant adjustments made to the timeline and requirements of meaningful use. In the meantime, we certainly acknowledge the challenges and as always invite your feedback and comments.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

With 2014 behind us, we are finally able to assess the implications of Meaningful Use Stage 2 for Eligible Professionals. It is now clear – as anticipated – that the updated criteria have presented a significant challenge to many. In fact, it is predicted that only a fraction of those who attained Stage 1 of Meaningful Use will attest for Stage 2 for the 2014 year. As a result, physicians who have received financial incentives under the program will now face penalties, and may see a real impact on their bottom lines.

If it’s any consolation, there is hope (and even some evidence) that the Centers for Medicare & Medicaid Services will make a few amendments to the Meaningful Use program over the next few months. This will allow for additional flexibility for providers, and with any luck, will mean more people qualify in 2015. In this column, we’ll highlight the proposed changes and share a few observations from the first year of Stage 2.

Here’s what’s new

On Jan. 29, 2015, CMS released a proposed rule that would adjust the reporting period for 2015 – currently set for the entire year – to 90 days. While this is the same length as 2014, it would give providers an extra 9 months to upgrade software, systems, and work-flows to attest for Stage 2. For those who were able to take advantage of the CEHRT [certified EHR technology] Flexibility and continue Stage 1 in 2014, this may be just the reprieve needed to stay on track. For those who made an unsuccessful attempt at Stage 2 last year, this just makes the second try a bit easier.

In case you are wondering, if you “miss” a year of Meaningful Use, you simply continue as if you made it. In other words, under the current rule, if you are due to start a full year of Stage 2 reporting in 2015, you are still obligated to do so even if you were unsuccessful with 90 days of Stage 2 in 2014. The proposed rule would change that, and keep everyone’s reporting period at 90 days regardless of stage or year. (Remember: A 1% per year penalty is assessed for every year an eligible professional fails to meet the requirements, up to a maximum of 5%. These penalties continue indefinitely.)

CMS is considering other changes as well. Specifically, their press release states they are looking to “modify other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.” As of now, it is unclear what that might include, but a review of the challenges from 2014 may point to some strong possibilities. We’ll start with a principle we’ve dealt with previously:

Interoperability is hard

The most noteworthy changes from Stage 1 to Stage 2 are all requirements to pass information into and out of the EHR. These include: making records available through a secure patient portal, the ability to communicate with patients through electronic means, and the transmission of “summary of care” documents between providers. These requirements also happen to be the most challenging for physicians, because they rely on other systems and individuals to make the connections possible.

Up to this point, EHR vendors have not prioritized adopting established standards for data transmission, and Stage 2 really brought this shortcoming to light. So much so, that CMS considered it a valid reason to invoke the CEHRT Flexibility. By “limited exception” providers could continue with Stage 1 this past year if “their referral partners [did] not upgrade to 2014 Edition Certified EHR Technology” (i.e., doctors are given a pass on the need to send “summary of care” data if there’s no one around to receive it). But secure and reliable electronic communication with other physicians is just one area of struggle. Another that is arguably more difficult is communicating electronically with patients. Compared with the challenges of interoperability, we’ve observed that:

Patient care is even harder

It’s one thing to incentivize (or penalize) physicians for adopting Health Information Technology, but it is an entirely different thing to hold them responsible for whether or not their patients choose to embrace it. Unfortunately, the 2014 Meaningful Use measures seem to do just that. With quotas for providing “secure electronic access” through a patient portal, the MU program forces physicians to engage patients on a new virtual “playing field.” This may seem like a good thing on the surface, but it has been riddled with headaches for providers and patients alike.

With the dawn of EHR portals, physicians suddenly perceive a new level of exposure. Patients can now peer into their charts and uncover unfiltered diagnosis terminology or slightly abnormal lab values that may raise unwarranted concern. As a result, physicians have become much more conscientious about documentation, but most feel this is just one more layer of complexity to slow them down. Additionally, as patients discover the convenience and immediacy of secure e-mail, more care is now being delivered outside the context of an office visit. This requires a huge time commitment from physicians and, in most cases, provides no income – and this time demand is not limited to just the doctors! Office staff have the new and unwelcome task of providing technical support to patients for website problems, lost passwords, etc. All of these underscore this final observation:

This isn’t getting any easier

We realize this last point is self-evident, but its impact is hard to quantify. With every new stage of meaningful use, new requirements aimed at making care more efficient for patients only seem to make delivery of care much less efficient for physicians. As physicians become mired in regulations and visit volumes drop, care will ultimately become less efficient for everyone. In response to these and many other issues, we are hopeful to see some significant adjustments made to the timeline and requirements of meaningful use. In the meantime, we certainly acknowledge the challenges and as always invite your feedback and comments.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Do we physicians need LinkedIn? It depends. LinkedIn is the No. 1 social platform for professionals. However, many physicians feel that if they aren’t looking for a job, then LinkedIn isn’t useful. However, spending an hour to complete your LinkedIn profile may bring you more value than you imagined. That’s because LinkedIn is ranked highly by search engines, which means that when people, including patients or colleagues, search for information about you online, your LinkedIn profile will most likely show up. LinkedIn is important because it helps people find out about your educational background, professional experiences, and personal brand.

Because it’s easy, both to complete your profile and to use, LinkedIn is a good starting point for physicians who are trying to create a digital footprint. Moreover, unlike online physician review sites, you are in control of the content on your LinkedIn profile, so it’s a way for you to build your brand and showcase your expertise.

There are no ratings, but you can be endorsed by other LinkedIn members. Are you board certified? An expert in skin cancer? Do you do clinical research? Your colleagues can (and will) endorse you for those skills. Do the same for them. Importantly, when patients search for you, they will see that your colleagues have endorsed you for your excellence in those areas.

Ready to start using LinkedIn? It’s easy: Go to LinkedIn.com, select “register,” then fill out your profile. Be sure to include your educational background, medical expertise, areas of interest, professional experience, and links to your practice site online. Be thorough, because members with more complete profiles rank higher in search results.

Here are 15 tips for maximizing LinkedIn:

1. Upload a professional photo of yourself. According to LinkedIn data, users with photos are seven times more likely to be contacted about opportunities.

2. Use keywords to optimize your profile, including the name and geographic location of your practice.

3. List at least five skills that represent you accurately as a physician. For dermatologists, they might include, “Mohs” or “psoriasis expert.” (Resist the temptation to embellish.)

4. Build your network organically by starting with connections to people you already know. Unlike with Twitter or other social platforms, expert LinkedIn users do not accept connection requests to people they don’t know. If you really want to connect with someone, then ask a mutual connection for an introduction.

5. Aim for a minimum of 50 connections, which will improve your ranking on search results.

6. Include a link to your practice website, as well as contact information including your office address and phone number. LinkedIn is highly ranked by search engines, so it can drive traffic to your practice’s site, potentially leading to new clients.

7. Unlike with Twitter and Facebook, which encourage users to post personal experiences, LinkedIn content should be professional. Post pictures of your kid’s birthday party on Facebook. Post an article you’ve written about eczema on LinkedIn. Share links to quality content that will be valuable to your network.

8. Participate by sharing an academic or news article, recommending someone, or commenting on a group discussion. Shorts bursts of activity are fine on this social platform.

9. Be generous but selective with your recommendations, as they are a reflection of you. If you wouldn’t recommend that person in real life, then don’t recommend him or her on LinkedIn.

10. When asking someone for a recommendation, be specific. Specify which skills you’d like them to mention.

11. Consider joining LinkedIn Groups that match your professional expertise and interests. Participating in groups is a great way to show your expertise and manage relationships. Some examples of groups to which physicians belong include “Healthcare Physician Practice Management,” “The Medical Doctor (MD) Network,” and “Networking for Business Professionals and Doctors.”

12. To broaden your professional horizons, consider joining LinkedIn Groups that aren’t in your specialty. For example, you might be a practicing dermatologist who is hoping to start a telemedicine program. In that case, you should consider joining telemedicine or mHealth groups.

13. Include a link to your LinkedIn profile in your e-mail signature, on business cards, and on your practice website.

14. If you used LinkedIn to share original content such as blog posts or academic articles, or to stay abreast of news in your field, then consider using Pulse, an app that makes it easier to consume information on mobile devices.

15. Use the LinkedIn Events Page to promote upcoming events.

So next time you’re on LinkedIn, ask me to endorse you. So long as it’s not for president, I got you.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Do we physicians need LinkedIn? It depends. LinkedIn is the No. 1 social platform for professionals. However, many physicians feel that if they aren’t looking for a job, then LinkedIn isn’t useful. However, spending an hour to complete your LinkedIn profile may bring you more value than you imagined. That’s because LinkedIn is ranked highly by search engines, which means that when people, including patients or colleagues, search for information about you online, your LinkedIn profile will most likely show up. LinkedIn is important because it helps people find out about your educational background, professional experiences, and personal brand.

Because it’s easy, both to complete your profile and to use, LinkedIn is a good starting point for physicians who are trying to create a digital footprint. Moreover, unlike online physician review sites, you are in control of the content on your LinkedIn profile, so it’s a way for you to build your brand and showcase your expertise.

There are no ratings, but you can be endorsed by other LinkedIn members. Are you board certified? An expert in skin cancer? Do you do clinical research? Your colleagues can (and will) endorse you for those skills. Do the same for them. Importantly, when patients search for you, they will see that your colleagues have endorsed you for your excellence in those areas.

Ready to start using LinkedIn? It’s easy: Go to LinkedIn.com, select “register,” then fill out your profile. Be sure to include your educational background, medical expertise, areas of interest, professional experience, and links to your practice site online. Be thorough, because members with more complete profiles rank higher in search results.

Here are 15 tips for maximizing LinkedIn:

1. Upload a professional photo of yourself. According to LinkedIn data, users with photos are seven times more likely to be contacted about opportunities.

2. Use keywords to optimize your profile, including the name and geographic location of your practice.

3. List at least five skills that represent you accurately as a physician. For dermatologists, they might include, “Mohs” or “psoriasis expert.” (Resist the temptation to embellish.)

4. Build your network organically by starting with connections to people you already know. Unlike with Twitter or other social platforms, expert LinkedIn users do not accept connection requests to people they don’t know. If you really want to connect with someone, then ask a mutual connection for an introduction.

5. Aim for a minimum of 50 connections, which will improve your ranking on search results.

6. Include a link to your practice website, as well as contact information including your office address and phone number. LinkedIn is highly ranked by search engines, so it can drive traffic to your practice’s site, potentially leading to new clients.

7. Unlike with Twitter and Facebook, which encourage users to post personal experiences, LinkedIn content should be professional. Post pictures of your kid’s birthday party on Facebook. Post an article you’ve written about eczema on LinkedIn. Share links to quality content that will be valuable to your network.

8. Participate by sharing an academic or news article, recommending someone, or commenting on a group discussion. Shorts bursts of activity are fine on this social platform.

9. Be generous but selective with your recommendations, as they are a reflection of you. If you wouldn’t recommend that person in real life, then don’t recommend him or her on LinkedIn.

10. When asking someone for a recommendation, be specific. Specify which skills you’d like them to mention.

11. Consider joining LinkedIn Groups that match your professional expertise and interests. Participating in groups is a great way to show your expertise and manage relationships. Some examples of groups to which physicians belong include “Healthcare Physician Practice Management,” “The Medical Doctor (MD) Network,” and “Networking for Business Professionals and Doctors.”

12. To broaden your professional horizons, consider joining LinkedIn Groups that aren’t in your specialty. For example, you might be a practicing dermatologist who is hoping to start a telemedicine program. In that case, you should consider joining telemedicine or mHealth groups.

13. Include a link to your LinkedIn profile in your e-mail signature, on business cards, and on your practice website.

14. If you used LinkedIn to share original content such as blog posts or academic articles, or to stay abreast of news in your field, then consider using Pulse, an app that makes it easier to consume information on mobile devices.

15. Use the LinkedIn Events Page to promote upcoming events.

So next time you’re on LinkedIn, ask me to endorse you. So long as it’s not for president, I got you.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Do we physicians need LinkedIn? It depends. LinkedIn is the No. 1 social platform for professionals. However, many physicians feel that if they aren’t looking for a job, then LinkedIn isn’t useful. However, spending an hour to complete your LinkedIn profile may bring you more value than you imagined. That’s because LinkedIn is ranked highly by search engines, which means that when people, including patients or colleagues, search for information about you online, your LinkedIn profile will most likely show up. LinkedIn is important because it helps people find out about your educational background, professional experiences, and personal brand.

Because it’s easy, both to complete your profile and to use, LinkedIn is a good starting point for physicians who are trying to create a digital footprint. Moreover, unlike online physician review sites, you are in control of the content on your LinkedIn profile, so it’s a way for you to build your brand and showcase your expertise.

There are no ratings, but you can be endorsed by other LinkedIn members. Are you board certified? An expert in skin cancer? Do you do clinical research? Your colleagues can (and will) endorse you for those skills. Do the same for them. Importantly, when patients search for you, they will see that your colleagues have endorsed you for your excellence in those areas.

Ready to start using LinkedIn? It’s easy: Go to LinkedIn.com, select “register,” then fill out your profile. Be sure to include your educational background, medical expertise, areas of interest, professional experience, and links to your practice site online. Be thorough, because members with more complete profiles rank higher in search results.

Here are 15 tips for maximizing LinkedIn:

1. Upload a professional photo of yourself. According to LinkedIn data, users with photos are seven times more likely to be contacted about opportunities.

2. Use keywords to optimize your profile, including the name and geographic location of your practice.

3. List at least five skills that represent you accurately as a physician. For dermatologists, they might include, “Mohs” or “psoriasis expert.” (Resist the temptation to embellish.)

4. Build your network organically by starting with connections to people you already know. Unlike with Twitter or other social platforms, expert LinkedIn users do not accept connection requests to people they don’t know. If you really want to connect with someone, then ask a mutual connection for an introduction.

5. Aim for a minimum of 50 connections, which will improve your ranking on search results.

6. Include a link to your practice website, as well as contact information including your office address and phone number. LinkedIn is highly ranked by search engines, so it can drive traffic to your practice’s site, potentially leading to new clients.

7. Unlike with Twitter and Facebook, which encourage users to post personal experiences, LinkedIn content should be professional. Post pictures of your kid’s birthday party on Facebook. Post an article you’ve written about eczema on LinkedIn. Share links to quality content that will be valuable to your network.

8. Participate by sharing an academic or news article, recommending someone, or commenting on a group discussion. Shorts bursts of activity are fine on this social platform.

9. Be generous but selective with your recommendations, as they are a reflection of you. If you wouldn’t recommend that person in real life, then don’t recommend him or her on LinkedIn.

10. When asking someone for a recommendation, be specific. Specify which skills you’d like them to mention.

11. Consider joining LinkedIn Groups that match your professional expertise and interests. Participating in groups is a great way to show your expertise and manage relationships. Some examples of groups to which physicians belong include “Healthcare Physician Practice Management,” “The Medical Doctor (MD) Network,” and “Networking for Business Professionals and Doctors.”

12. To broaden your professional horizons, consider joining LinkedIn Groups that aren’t in your specialty. For example, you might be a practicing dermatologist who is hoping to start a telemedicine program. In that case, you should consider joining telemedicine or mHealth groups.

13. Include a link to your LinkedIn profile in your e-mail signature, on business cards, and on your practice website.

14. If you used LinkedIn to share original content such as blog posts or academic articles, or to stay abreast of news in your field, then consider using Pulse, an app that makes it easier to consume information on mobile devices.

15. Use the LinkedIn Events Page to promote upcoming events.

So next time you’re on LinkedIn, ask me to endorse you. So long as it’s not for president, I got you.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Hello Dr. Danielsen,

Your statement about the profit-driven health system captured my attention.

The US health care system is probably the most expensive in the world, and yet it was rated the worst in terms of its overall ranking for quality of care, access, and efficiency. (I got this information while I was in graduate school studying health care policy.) This resonates with your statement about the entrepreneurial and corporatized US health care system.

I surmise that the high cost of health care may be partly due to the over-utilization of services, and technology and drug charges that may not be necessarily effective. As a researcher, I support the role of Comparative Effectiveness Research as a cost-efficiency strategy by identifying and eliminating the "me too" drugs and services that are found to be less or not efficacious.

As a supporter of the PA profession, I think PAs are part of the solution to help mitigate the deficiency in access to health care. In addition, using PAs in place of physicians for certain services can defray the rising cost of health care. There's been data to show that PAs can perform 80% of the duties performed by physicians. PAs should find the right platform to be heard and integrated into all state or federal health care programs.

Maribelle Guloy, MSHS, CCRP
Executive Director
Clinical Research
Montebello, California 

Hello Dr. Danielsen,

Your statement about the profit-driven health system captured my attention.

The US health care system is probably the most expensive in the world, and yet it was rated the worst in terms of its overall ranking for quality of care, access, and efficiency. (I got this information while I was in graduate school studying health care policy.) This resonates with your statement about the entrepreneurial and corporatized US health care system.

I surmise that the high cost of health care may be partly due to the over-utilization of services, and technology and drug charges that may not be necessarily effective. As a researcher, I support the role of Comparative Effectiveness Research as a cost-efficiency strategy by identifying and eliminating the "me too" drugs and services that are found to be less or not efficacious.

As a supporter of the PA profession, I think PAs are part of the solution to help mitigate the deficiency in access to health care. In addition, using PAs in place of physicians for certain services can defray the rising cost of health care. There's been data to show that PAs can perform 80% of the duties performed by physicians. PAs should find the right platform to be heard and integrated into all state or federal health care programs.

Maribelle Guloy, MSHS, CCRP
Executive Director
Clinical Research
Montebello, California 

Hello Dr. Danielsen,

Your statement about the profit-driven health system captured my attention.

The US health care system is probably the most expensive in the world, and yet it was rated the worst in terms of its overall ranking for quality of care, access, and efficiency. (I got this information while I was in graduate school studying health care policy.) This resonates with your statement about the entrepreneurial and corporatized US health care system.

I surmise that the high cost of health care may be partly due to the over-utilization of services, and technology and drug charges that may not be necessarily effective. As a researcher, I support the role of Comparative Effectiveness Research as a cost-efficiency strategy by identifying and eliminating the "me too" drugs and services that are found to be less or not efficacious.

As a supporter of the PA profession, I think PAs are part of the solution to help mitigate the deficiency in access to health care. In addition, using PAs in place of physicians for certain services can defray the rising cost of health care. There's been data to show that PAs can perform 80% of the duties performed by physicians. PAs should find the right platform to be heard and integrated into all state or federal health care programs.

Maribelle Guloy, MSHS, CCRP
Executive Director
Clinical Research
Montebello, California 

Religious exemptions to vaccinations are a contradiction in terms and should be eliminated, Dr. Paul A. Offit opines in his op-ed in The New York Times, “What Would Jesus Do About Measles?”

Measles is back in the United States because of a lack of herd immunity that has three sources: Nineteen states have philosophical exemptions to vaccination, 47 states have religious exemptions, and parents are not afraid of measles, according to Dr. Offit.

But Dr. Offit, a pediatrician who is chief of the division of infectious diseases and the director of the vaccine education center at Children’s Hospital of Philadelphia, said he is afraid of measles because he has seen what an outbreak can do. In the Philadelphia outbreak between October 1990 and June 1991, more than 1,400 people were infected with measles, and 9 children died. The outbreak centered around two fundamentalist Christian churches, the members of which did not vaccinate their children and did not take them to the hospital when they were infected. One-third of those who were infected during the outbreak belonged to one of the two churches and six of the nine children who died were members of the congregations, according to a Centers for Disease Control and Prevention report.

To read the entire article go to: The New York Times Feb. 10, 2015

Religious exemptions to vaccinations are a contradiction in terms and should be eliminated, Dr. Paul A. Offit opines in his op-ed in The New York Times, “What Would Jesus Do About Measles?”

Measles is back in the United States because of a lack of herd immunity that has three sources: Nineteen states have philosophical exemptions to vaccination, 47 states have religious exemptions, and parents are not afraid of measles, according to Dr. Offit.

But Dr. Offit, a pediatrician who is chief of the division of infectious diseases and the director of the vaccine education center at Children’s Hospital of Philadelphia, said he is afraid of measles because he has seen what an outbreak can do. In the Philadelphia outbreak between October 1990 and June 1991, more than 1,400 people were infected with measles, and 9 children died. The outbreak centered around two fundamentalist Christian churches, the members of which did not vaccinate their children and did not take them to the hospital when they were infected. One-third of those who were infected during the outbreak belonged to one of the two churches and six of the nine children who died were members of the congregations, according to a Centers for Disease Control and Prevention report.

To read the entire article go to: The New York Times Feb. 10, 2015

Religious exemptions to vaccinations are a contradiction in terms and should be eliminated, Dr. Paul A. Offit opines in his op-ed in The New York Times, “What Would Jesus Do About Measles?”

Measles is back in the United States because of a lack of herd immunity that has three sources: Nineteen states have philosophical exemptions to vaccination, 47 states have religious exemptions, and parents are not afraid of measles, according to Dr. Offit.

But Dr. Offit, a pediatrician who is chief of the division of infectious diseases and the director of the vaccine education center at Children’s Hospital of Philadelphia, said he is afraid of measles because he has seen what an outbreak can do. In the Philadelphia outbreak between October 1990 and June 1991, more than 1,400 people were infected with measles, and 9 children died. The outbreak centered around two fundamentalist Christian churches, the members of which did not vaccinate their children and did not take them to the hospital when they were infected. One-third of those who were infected during the outbreak belonged to one of the two churches and six of the nine children who died were members of the congregations, according to a Centers for Disease Control and Prevention report.

To read the entire article go to: The New York Times Feb. 10, 2015