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Healthcare IT Job Satisfaction – Fun Friday

Posted on February 23, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

It’s Friday and so as we head into the weekend it’s time for some fun. This is especially needed with HIMSS only 10 days away. This first cartoon hits on the impact of technology on our health, but also on the impact of EHR and technology on doctors. Especially healthcare IT software with really bad UIs. You know what I’m talking about.

And this one for my coffee loving friends:

When It Comes To Security Threats, Doctors Are Less Aware

Posted on February 22, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new study suggests that while most healthcare employees aren’t very aware of privacy and security threats, doctors may be further behind.

According to the Verizon Enterprises Data Breach Investigations Report, 78% of healthcare employees were less than prepared for such risks. Given the threat environment out there, that’s bad enough. Other aspects of the survey found that 24% of healthcare employees had trouble identifying some common signs of malware, as compared with 12% of respondents in the general population.

However, physicians appear to be even less prepared than their healthcare peers. For example, 24% of physicians and other types of direct healthcare providers showed a lack of awareness of phishing emails, a deficit which could cause big problems. (Their rate of identifying phishing emails was three times worse than their non-physician counterparts.) Half of the physicians studied scored in the overall “risk” category, which meant that their actions could impose a privacy or security threat.

Looking again at the healthcare industry as a whole, 23% of respondents failed to report a variety of potential security or privacy incidents such as unsecured personnel files and potentially malware-infected computers. Twenty-one percent of survey respondents didn’t recognize some forms of personally identifiable information, but perhaps more alarmingly, more clinicians exhibited risky behaviors in this category than their non-clinician peers.

In wrapping up the report, the authors make the important point that educating healthcare workers and clinicians on HIPAA rules is far from enough to help organizations protect themselves cyberattackers. “Keeping within HIPAA regulations, while vital, does not educate users on how to spot a phishing attack,” they wrote. “[And] mere compliance does not equate to a fully security-aware culture.”

Ultimately, the study makes a point that can’t be made too often. When security education occurs in silos, be they HIPAA compliance, abating risks of internal malfeasance and errors or training employees to catch sneak attacks such as phishing emails, no one of these strategies is enough to protect organizations from cyber-intrusions.

The key, as the authors rightly point out, is to cultivate a risk-aware culture across the healthcare organization’s entire population, including (perhaps most particularly) clinicians who make the closest use of the data.

EMR-Based Alert System Can Identify Possible Child Abuse Victims

Posted on February 21, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Sometimes, it’s pretty easy for a physician to tell that a child might be experiencing physical abuse at home. However, sometimes physicians are rushed and may not do an adequate screening for abuse, the signs of which aren’t always available at first glance.

However, a group of researchers has developed an algorithm, drawing on patient records in the EMR, which it says can improve screening rates for physical abuse and identify such cases earlier.

The project, the write-up of which appears in the Journal of the American Medical Informatics Association, coded triggers to identify children less than two years old at risk for physical abuse into the EMR using a freestanding pediatric hospital with a level 1 trauma center. The researchers embedded 30 age-specific triggers in the EMR.

During the test, the system ran a “silent mode,” in which study personnel saw data on children whose clinical symptoms triggered the alert system but physicians did not. During the period between October 21, 2014 through April 6, 2015, 226 children triggered the alert, the mean age of whom was 6.5 months.

During the pilot the system detected 98.5% of children less than two years of age with signs of probable or definite child abuse, according to the study authors.

If these algorithms are that successful in identifying at-risk children, one would hope that the system moves from pilot to widespread rollout fairly soon. In theory, the system should help clinicians who encounter children in potential danger, especially ones presenting with serious injuries in the emergency department, be better prepared to identify these children and take appropriate action.

Ultimately, this study suggests that even if such clinicians are alert and careful, triggers generated by an EMR might be more effective at detecting these cases. After all, while clinicians must juggle multiple patients in an extremely hectic environment, especially in the ED, EMRs don’t get tired and they don’t need to check a signs and symptoms list manually to detect signs of trouble.

Of course, while these triggers can be very helpful in investigating signs of abuse, clinicians would be ill-advised to rely on them entirely, as there’s no substitute for experience and medical judgment. Also, there’s always a risk that adding another alert to the cacophony of existing alerts could lead to it going unnoticed. Still, it seems certain that if nothing else, this is a promising approach to protecting children from harm.

Most Health Organizations Now Integrating SDOH Into Pop Health Management Programs

Posted on February 20, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new survey has found that healthcare organizations have begun to actively integrate social determinants of health into the population health management strategies.

The research, conducted by Change Healthcare and the HealthCare Executive Group, found that 80% of organizations had begun to track and use data on social determinants. This is a huge step up from just a few years ago, when discussions around SDOH and their use in population health management were more speculative than practical.

Perhaps the most interesting technique organizations are using is enlisting doctors in this effort. About 21% are training doctors to identify social determinants, a step which, in my opinion, is long overdue. Given how taxing this might be for physicians at first, it’s good to see that just a hair under 21% have also rolled out point-of-care checklists designed to help clinicians identify potential social determinants.

Other strategies respondents are using to leverage SDOH info include integrating community programs and resources into their population health management programs (42%), integrating medical data with financial, census and geographic data (34%), offering social assessment tools with health risk assessments (33%), incorporating social determinants into the clinical workflow (27 percent) and using third-party software, data and/or services (19%).

On a side note, the research data also suggests that another set of tools in PHM — mobile and digital health technologies — haven’t found their footing. When asked what’s limiting widespread consumer adoption of these tools, top reasons respondents cited included security and privacy concerns (49%), limited functionality (35%), a duplicative, redundant and confusing app environment (34%), problems with system interoperability (33%), a lack of healthcare literacy (33%) and poor user interface design (32%).

The latter data pointing to low mobile/digital health adoption came as a surprise to me. I like to think I can see through health IT industry hype, but maybe I’ve been fooled somehow. The data I’ve seen to date (some of it, admittedly, collected by vendors) has suggested for years that mobile healthcare adoption was climbing dramatically and that more recently, other digital health tools have begun to follow suit. I guess I missed something.

Given this lag, I’m glad to see that healthcare organizations are enlisting physicians, point-of-care checklists, clinical integration and other tactics to make use of SDOH data. We all know on a gut level that if the patient can’t get to the doctor, lacks social support or lives in a “food desert” where finding unprocessed foods and healthy produce may be quite difficult, preaching at them about their health concerns isn’t going to help. It’s high time we help physicians collect this information and find ways to close some of these gaps.

So Much To Do with So Little Time – President’s Day

Posted on February 19, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

It’s President’s Day in the US which means a lot of people have the day off from work and school. Unfortunately, in healthcare it’s largely just another day. My heart goes out to each of you who have to work today.

I started a tradition of posting quotes from past US Presidents on President’s Day and so I’m going to continue that tradition today. The following quote is from Franklin D. Roosevelt and seems very appropriate to the work we do in healthcare IT. Technology has opened up so many doors to new opportunities. However, it feels like we have less time than ever to pursue those opportunities.

Happy President’s Day!

The Role of Practice Automation in Healthcare Communication

Posted on February 16, 2018 I Written By

The following is a guest blog post by Naveen Sarabu, Vice President of Product Management, AdvancedMD.

Practice automation was born out of the demand for quicker, more efficient manual processes. One of these manual processes is getting back to basics by using plain, old-fashioned communication – whether among members of a healthcare team, or between a physician and patient. Through automation we seek to deliver the right data to the right people exactly when they need it for the optimal provision of care. Likewise, we also seek to cut down on the manual processes that bog us down and add complexity. Many ambulatory practices struggle to find a solution that meets the complex demands of treating patients. Many admit that communication remains one of their greatest struggles – and miscommunication is one of the biggest frustrations for patients.

Doctors’ offices and hospital counterparts in the U.S. have shouldered $1.7 billion in malpractice costs due to poor communication—that’s 30 percent of all malpractice cases.

Automating manual processes of a physician practice enables the distribution of vital patient information in a fast, efficient, and accurate way. By leveraging an integrated physician-patient workflow system, physicians gain benefits of both accuracy and time in the sharing of clinical and billing information. This defines the next generation of the EHR: managing patient data among systems with authentic, automated data transfer and overall ease of use.

Task-based challenges

In a sense, many elements of communication, or information transfer points, are categorized as “tasks” by physicians. Obviously, every doctor in every office has his or her own way of organizing to-do’s. Rigid or cookie-cutter solutions can be more trouble than they’re worth for the busy ambulatory practice. The sheer volume of tasks and relentlessness of practice-specific workflow elements remain a huge burden to physicians and staff members. Without a straightforward means to categorize and execute frequently performed tasks such as prescriptions, refills, charge slips, notes, and orders, action items can fall through the cracks and leave room for errors.

Practices can address this by selecting flexible and customizable solutions that spell out all the moving parts of a practice and put them at the physician’s fingertips, much like an automated workflow analyst would. Visual tools like dashboards are helpful in presenting all tasks in a single snapshot, allowing physicians to manage to-do’s quickly and with ease to execute and communicate what must come next. Patient cards organized by specialty and workflow give physicians a snapshot of what’s really most important in a given moment. An integrated EHR dashboard not only helps physicians negotiate high-priority tasks of significant volume, it orients them to the vital patient information required for sound decision-making.

Impact of physician mobility on communication

A key asset of running a fully-automated ambulatory practice is the feasibility of team members accessing the same systems in real time, from any location. This has multiple benefits, including improved communication accuracy and workflow efficiencies.

“Many different user types [in my practice] from the nurse, to the office manager, to the biller, are all working with the same data on the same platform with real-time access. The seamless continuity is what I like about it,” said Larry J. Winikur, MD, pain management physician in Danville, Va.

Physician mobility is achieved through cloud-based technology and allows providers and staff members to communicate seamlessly from several practice locations: a home office, a patient’s home, the hospital or while traveling. It helps physicians respond to patient and staff messages quickly and stay on top of pressing work issues no matter where they are, preventing a backlog of tasks once they return onsite.

Surgical Specialists of Jackson (Miss.), treats more than 500 active patients, including those in rural areas. According to office manager Kristen Humphrey, having mobile capabilities as a result of complete practice automation has improved the quality of care the practice provides to patients. “When we have a physician seeing patients an hour away in a rural county, he takes the iPad and is able to log into the patients’ medical record and get any information he needs,” leveraging a seamless connectivity to the practice from our office in Jackson. “It makes life really easy,” Humphrey says.

Remote access also offers the feasibility of treating patients with video-based telemedicine, during hospital rounding, or home or hospice care. EHR mobile access is, without a doubt, a top priority for busy practices as they build out the future of their business.

The building blocks of patient engagement

As practices compete with other practices and larger health systems to secure and retain patients, these patients have developed a consumer-like healthcare mentality. Most patients want as much information about their condition as possible, so they can take a proactive role in their care. Patients want to engage with their physicians, by communicating openly and regularly about options and treatment decisions.

A fully-automated ambulatory practice utilizes patient engagement tools to secure satisfaction, retention, and referrals. Consider the ease with which patients can make appointments – online self-scheduling is a critical piece of functionality. Automated check-in tools such as an iPad kiosk are especially favorable to patients who can complete intake and consent forms electronically, eliminating the possibility of transcription errors that occur when data is transferred from paper to digital. A robust patient portal enables physicians to communicate with patients privately and efficiently; to share educational materials or share lab results.

Appointment reminders can also serve as simple communication tools that enhance not only the patient experience, but also the practice bottom line.

Dr. Winikur utilized a patient reminder system to help decrease costly no-show appointments in his busy schedule. The solution helped engage patients and reduced no-shows at his practice from about 12 percent to approximately two percent of appointments, which positively impacts his revenue.

The mobility benefits previously mentioned also allow physicians to demonstrate superior attention to patient needs. “I can pull up patient information no matter where I am in the world with internet access,” Winikur says. When patients receive a quick and effective response to inquiry, they perceive their doctor is in the office (even if he’s not!), which helps increase patient satisfaction.

Other important automated tools include post-visit surveys that enable patients to provide honest, timely feedback about the care they’ve received. These surveys can also trigger patients to post positive experiences to Google and social media outlets. In the event of a negative experience, patients can first communicate privately with the practice to resolve any potential problem or miscommunication.

The bottom line

In today’s competitive healthcare climate, patients have many options for their care. Practices that transition to cloud-based technology platforms with fully automated and customizable workflow elements show greater respect to the needs and time of their patients, increase revenues, and place greater value on their own needs and time. They also prove to be on the cutting edge of technology by streamlining processes and enhancing communication to deliver safer and more accurate care.

About Naveen Sarabu
Naveen Sarabu is Vice President of Product Management at AdvancedMD. Naveen has more than 15 years of experience developing innovative healthcare software solutions for the ambulatory, acute and accountable care organization (ACO) markets, including for Allscripts, Hill-Rom, and NTT DATA. Naveen received an MBA from University of North Carolina-Chapel Hill and an undergraduate degree from National Institute of Technology, Warangal, India.

Are EMR Clicks the Problem? – Deep Thought Thursday

Posted on February 15, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I agree with David Chou here when it comes to needing to make EMRs easier. However, I don’t believe reducing the number of clicks is the real issue. Clicks are just a symptom of the real problem. The real problem is regulations and reimbursement requirements that need revision and simplification.

If we simplified regulations and reimbursement requirements, EHRs would be significantly more usable and would require fewer clicks.

The next question you should ask yourself is whether this administrative simplification will happen first or whether the technology will evolve to the point where it can automatically document the patient visit to any level of complexity while not disrupting the physician workflow.

Where’s your bet? On government and payer changes? Or on technology?

My bets on technology even if Seema Verma, CMS Administrator, is calling for administrative simplification. However, we’re certainly not there yet on either front.

The Increasing Role of Surveys in Reimbursement, Profitability, and Quality Care

Posted on February 14, 2018 I Written By

The following is a guest blog post by Jim Higgins, Founder & CEO at Solutionreach. You can follow him on twitter: @higgs77

Delivery of high-quality, patient-centered care has become the hallmark of the medical industry. The most commonly used indicators for measuring the quality of care are patient satisfaction and the patient experience. How patients feel about their experience is critical to overall practice success because it has been proven to impact health outcomes, patient retention, and medical malpractice claims.

The emerging standard for measuring patient satisfaction is the use of patient surveys. Patient satisfaction surveys are not only important when required for reimbursement, but also for practices focused on improving their patient-centered care (that should be everyone). A well written survey can be a very powerful and reliable tool. It can provide more information about what is going on in your practice. It demonstrates that your practice is working to improve. It shows patients that quality is your focus.

What are the key reasons that every practice should start implementing patient surveys?

Patient Surveys Increasingly Drive Reimbursement

Because both practice and hospital reimbursement are increasingly tied to health outcomes and patient satisfaction, patient surveys have become the go-to guide for improving the patient experience.

Currently, CMS (the Centers for Medicare and Medicaid Services) uses the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to measure how patients feel about their hospital experience. They then take those results and compare them to hospitals locally, regionally and nationally and assign them a score. Those scores have been a big part of the Hospital Value-Based Purchasing program for nearly six years.

This past year, we have seen the implementation of MACRA. Under MACRA, physician and hospitals patient satisfaction scores are calculated. By 2019, these scores will impact Medicare reimbursements.

It is highly likely that this trend towards survey-based reimbursement will continue to grow. Even if your practice is not currently required to use patient satisfaction surveys for reimbursement, it is probable that you will at some point in the future. By sending out surveys now, you can get a better handle on changes that need to be made to secure high scores for future reimbursement.

Patient Surveys Increase Profitability

High patient satisfaction levels impact a practice’s profitability for reasons beyond just reimbursement. Studies have found a significant correlation between high patient satisfaction and the overall profitability of a practice. Consider this:

  • A good patient experience significantly lowers your risk of a malpractice suit. In fact, for each drop in satisfaction score, a provider is nearly 22 percent more likely to be hit by a lawsuit.
  • One surprising effect of an improved patient experience is reduced staff turnover. Because a better patient experience often involves implementing more efficient and effective processes, staff are able to work in a more pleasant environment. One provider saw their turnover rate drop 5 percent after efforts to improve the patient experience.
  • A good patient experience leads to lower patient turnover. This one is more obvious. Today’s consumer-minded patients are looking for a great experience. One study found that practices with poor patient-physician relationships are three times more likely to move to a new practice than those with good patient-physician relationships.

It’s easy to see why the use of a patient survey to track and improve the patient experience is quickly becoming best practice. As Joe Greskoviak, president and COO of Press Ganey explained, “We are seeing a shift in the way organizations look at the engagement of their patient populations. The ability to use patient experience as a competitive and strategic differentiator to gain market share is a valuable tool,” Mr. Greskoviak said.

Patient Surveys Lead to Quality Improvement

As dozens of studies have found, there is quantifiable evidence that tracking the patient experience leads to quality improvement in multiple ways. These studies have found that:

  • A good patient experience improves both prevention and disease management. In one study, diabetic patients increased their ability to self-manage their disease and, subsequently, improved their quality of life simply due to a good experience with their provider.
  • Positive patient experiences lead to a higher likelihood of care adherence for the patient. This is especially true for those with chronic conditions who meet regularly with their provider.
  • Patients who have a good patient experience and a positive view of their provider have better health outcomes compared to patients that have poor patient experiences. Heart attack patients who were highly satisfied with their practice saw significant improvements over their less satisfied peers one year post-attack.

Understanding how your patients feel through patient satisfaction surveys is an invaluable tool. These surveys can be as important to the success as your healthcare credentials. If implemented and used properly, a patient survey can help you increase profitability, healthcare outcomes, and reimbursement.

Solutionreach is a proud sponsor of Healthcare Scene. As the leading provider of patient relationship management solutions, Solutionreach is dedicated to helping practices improve the patient experience while saving time for providers and staff. Learn more about the Patient-Provider relationship survey here.

There’s a Disturbance in the Force We Know as MACRA

Posted on February 13, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Yesterday Anne Zieger wrote about AAFP’s proposals to reduce the EHR Administrative Burdens and then we got this tweet from CMS Administrator Seema Verma:

That’s some really strong language from the CMS Director.

If you care about this topic, you should go and read all of Seema Verma’s tweets, but here are two more for those who don’t want to read them all:

Change is in the air it seems. Many providers are rejoicing if you look through the replies to Seema Verma’s tweets.

Dr. Ronald Hirsch asked the question that I’m sure many doctors were asking:

The short answer is no MACRA and MIPS aren’t going away. If my understanding of policy is right, Seema Verma doesn’t have the authority to make MACRA go away. That would take actions from Congress and I don’t know anyone holding their breath on that one. However, Seema can streamline the way MACRA and MIPS are implemented to make it much easier for doctors. That seems to be what’s happening now.

What will this mean for the future of MACRA? I don’t think anyone knows the answers to that question. However, what does seem clear from these tweets is that change is in the air. We’ll have to wait and see what those changes are and who influences the changes they make.

What do you think this means for MACRA and MIPS? I’d love to hear your thoughts in the comments.

AAFP Proposes Tactics For Reducing EHR Administrative Burdens

Posted on February 12, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

The American Academy of Family Physicians has proposed a series of approaches it says will reduce the administrative burdens EHRs impose on primary care doctors.

The recommendations, which come in the form of a letter to CMS, address health IT simplification, prior authorization and standardization of quality measurement. However, the letter leads off with EHR concerns and much of the content is focused on making physician IT use easier.

Few would argue that the average physician spends too much time struggling with EHR-related administrative work. The AAFP backs this assertion up with a couple of studies, including one finding that primary care physicians spend almost 6 hours per day interacting with EHRs. It also cites research concluding that four types of specialist spent almost 2 hours using the EHR for every hour of direct patient care.

To address these concerns, the AAFP recommends taking the following steps:

  • Eliminating HIT utilization measures in MIPS: The group argues that such measures are not needed anymore now that MIPS includes quality, cost and practice improvement measures.
  • Updating documentation requirements: With the agency’s Evaluation and Management recommendation guidelines having been developed 20 years ago, prior to the widespread use of EHRs, it’s time to rethink their use, the letter asserts. Today, the group says, they have a negative impact on EHR usability and hinder interoperability. The group recommends eliminating documentation requirements for codes 99211-99215 and 99201-99205 entirely and allowing any care team member to enter medical information.
  • Rethinking data exchange policies: The AAFP is asking CMS and ONC to focus on how and when data is exchanged rather than demanding that specific data types be included. The group also urges CMS and ONC to penalize healthcare organizations not appropriately sharing information, using its authority granted by the 21st Century Cures Act.
  • Creating standardized clinical data models: To share data effectively across the healthcare ecosystem, the AAFP argues, it’s necessary to develop nationally-recognized, consistent data models that can be used to share data efficiently. It recommends that such principles be developed by physicians and other clinicians rather than policymakers, vendors or engineers.

I don’t know about you, but I find much of this to be a no-brainer. Of course, the decades-old E/M guidelines need to be reformed, consistent data models must emerge if we hope to improve interoperability and physicians need to lead the charge.

Unfortunately, it’s hard to tell whether CMS and ONC are willing and prepared to listen to these recommendations. In theory, leaders at ONC should be only too glad to help providers achieve these goals and CMS should support their efforts. But given how obvious some of this is, it should have happened already. The fact that it hasn’t points up how hard all of this could be to pull off.