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EPtalk by Dr. Jayne 1/25/24

January 25, 2024 Dr. Jayne No Comments

I had dinner the other night with a group of family physicians. It was an interesting bunch. Three of them have left employed practice models to open their own primary care practices. One is practicing with the local visiting nurse association. Another is working as the medical director for a local hospice. Several are on faculty at residency training programs, and two of us are clinical informaticists.

As one can imagine, telehealth was a hot topic. One of the physicians who is employed by a local health system was complaining about how her organization has brought in a third-party vendor to perform urgent care telehealth visits. In particular, she feels that continuity of care has suffered. One of our colleagues mentioned a recent study that was published in JAMA Network Open that looked specifically at virtual visits that were performed by the patient’s own family physician compared to those that were performed by an outside family physician.

The authors looked at 5 million Ontario residents who met criteria for having a family physician and for having had a virtual visit. They concluded that visits with an outside physician were 66% more likely to be associated with an emergency department visit in the next seven days compared to those visits that were conducted by the patient’s own physician.

If you dig deeper into the results, they looked at a matched subset of patients and found that the changes of an emergency department visit in the next week was even greater for patients with “definite direct-to-consumer telemedicine visits.” They specifically excluded virtual visits that were performed by another physician in the same group as the family physician, since they “sought to contrast the highest-continuity virtual visits (own physician) with lowest-continuity virtual visits (outside of group).” The authors go on to conclude that the findings “suggest that primary care virtual visits may be best used within an existing clinical relationship.”

The authors noted that increased emergency department utilization that were associated with low-continuity visits suggest that “virtual visits may serve a triaging function, allowing for the identification of patients who would benefit from an in-person assessment.” It would be interesting to see a similar study performed in the US, since there are likely differences in service utilization due to the payment landscape here. When patients are worried about co-pays and emergency department costs, they often make different decisions than they might if they were part of a system where they were at less exposure for unexpected healthcare bills. The authors noted that one of the limitations of the study was the lack of ability to identify patients where access was an issue, such as hours of clinic operation, physician availability, or scheduling difficulties.

The next time I see them, I’ll have to get my family medicine colleagues to weigh in on “The Case of the Disappearing Thank Yous,” which was published in JAMA Health Forum earlier this month. It begins by detailing a physician’s dissatisfaction when her employer began to filter messages from patients that said, “Thank you.” Although some may feel that such messages represent clutter, including EHR vendors who have acted on client requests to suppress them, this physician found them meaningful.

It’s the classic case of whether the good of the one outweighs the good of the many, but the author went on to discuss other ways that he feels that appreciation of accomplishments is lacking in healthcare. As an example, he mentions that Medicare costs have stabilized and that important public health worth continues to progress despite the persistence of negative headlines.

He mentions what most of us already know – negative news tends to generate more clicks than positive news. It’s all about monetizing those eyeballs. He notes that “a failure to appreciate past victories can also jeopardize efforts to tackle the health challenges of the future,” especially in the setting of low trust for government agencies which includes those that are involved in public health.

Especially for healthcare workers who have really taken a beating over the last several years, it’s important to feel appreciated. Employers tried to say thank you by issuing challenge coins and sending pizza, but it’s time to figure out how to demonstrate appreciation in a meaningful way. I know I would like to grow old in a society with highly qualified nurses that love their jobs, but the chances of that being a reality are becoming smaller every day. Here’s a challenge to administrators to start figuring out what really matters and putting their money to work.

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I’m always on the lookout for healthcare technology that has an interesting backstory. Habit Camera is a wireless camera that is designed to allow users to inspect areas of the skin that they might not otherwise be able to see. Daily skin inspection is important for many patients, including those with diabetes, limited sensation, or active wounds. The camera connects to a smartphone app to enable live viewing of high definition images as well as video and image capture for sharing with clinicians or caregivers. The company is led by a US Marine Corps veteran who was paralyzed while serving in Afghanistan. He and his wife run the company, which employs veterans and their family members to assemble the devices.

I particularly liked the answer to one of their FAQ questions, which asks, “Is my clinician going to look at pictures if I send them?” The response: “It depends! Your clinician may be interested in doing this, but some may not. If you can’t share an image or video with your clinicians, then it can be really hard to explain what you see over the phone. Until a clinician can see it with their own eyes, they probably will ask you to make an appointment and come into clinic. This can be a bit of a hassle, especially if you have to take off of work and drive far, so we hope that pictures and video can help reduce unnecessary visits. A picture is worth a thousand words.” I don’t care how much a company pays for its marketing experts; you really can’t portray the patient experience any better than that.

What technology vendors have the best messaging? Is there a particular one that you feel just tells it like it is? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/22/24

January 22, 2024 Dr. Jayne No Comments

Many organizations are focusing their healthcare IT and clinical investments on Social Determinants of Health. This could include configuring patient portals to gather relevant information, enhancing EHR workflows to allow clinicians to view and act on patient-specific factors, and looking at the data from a population-based perspective.

For some organizations, the return on investment that is needed to gather the data is clear. For example, a community health center might be the recipient of a grant that provides funding for gathering the data and taking steps to improve outcomes based on that data. For others, the return on investment might be less obvious.

A recent article in JAMA Health Forum reviews the need for benefit-cost analysis as organizations look at making investments in care related to social determinants of health. The authors note that there are many examples of the links between social factors and health outcomes in the literature and that organizations have responded by focusing on those with the strongest links. However, adding benefit-cost analysis to the review process would allow comparison of different interventions to determine which would be likely generate the most benefit.

This approach would allow greater understanding of the importance of spending your healthcare dollars in the right place, with the authors noting, “An effective intervention to address a minor risk factor may generate much larger net benefits than a less effective intervention targeted at a major risk factor.” We all have examples of health systems and other care delivery organizations that have fallen under the spell of shiny objects and then struggle to get return on their investments.

Sometimes those projects are more exciting than others and might bring more publicity, but there may be less clarity around how they will actually improve health or reduce morbidity and mortality. On the other hand, certain interventions can have tremendous outcomes, but aren’t seen as exciting. For example, how many people think that nutrition education is sexy? Talking about balanced meals or food deserts or the benefits of community gardens certainly isn’t as exciting as seeing your orthopedic surgery practice mentioned on the wall of the local baseball stadium, that’s for sure. But which one is likely to drive improved health outcomes for the long haul?

The authors discuss this in the context of organizations that focus their attention on return on investment goals that have short time horizons. This leads to failure of visualization of potential long-term gains. We see this with payers denying expensive therapies that may lead to savings many years down the road, when the patient might be on Medicare and offer no calculable benefit for the payer. The authors summarize this: “In contrast, benefit-cost analysis is generally conducted from a societal perspective and considers benefits and costs across all sectors and populations and over extended time horizons with appropriate discounting of future benefits and costs.”

This got me thinking about how we sometimes don’t give full consideration to the longer-term impacts of the healthcare IT projects that we are doing. Leaders are often under the microscope to show positive financial outcomes almost immediately after a project goes live. They are expected to demonstrate shocking reductions in costs or dramatic increases in revenue, and projects that fail to deliver such splashy results may be at risk for being canceled, or even worse, placed on pause and left in limbo. With complex processes, however, it might not be appropriate to push for a dramatic change.

When there’s a significant change happening, I’m a big fan of using pilots to make sure that process “improvements” aren’t going to create unintended problems. However, the pressure to constantly deliver results may make technology leaders less likely to consider piloting or a slower rollout of change.

Alternatively, an intervention might deliver significant results, but then teams move on to other projects, preventing forward movement in the cycle of continuous improvement. In other situations, the maintenance phase is skipped and processes slowly drift back to inefficiency, ultimately eliminating long-term gains.

If organizations focused more on longer-term analysis and ensuring sustained change, would it make a difference in the projects they select? Unfortunately for many, being able to target long-term goals is a luxury given the fact that a results-oriented culture actually means one of immediate results rather than truly designing models that will be sustainable for the long haul. We see this phenomenon often with the rip-and-replace approach to solutions, when we know in our hearts that the organization never spent the time, effort, or money that was needed to make the first solution successful.

I saw another example of this shortsightedness in my community earlier this month. A local hospital that was looking to reduce headcount decided to shutter its medical weight management clinic. Given the obesity epidemic in the US, this doesn’t seem to make much sense at first glance. However, in our community bariatric surgery is seen as more exciting than medical weight management, primarily because it generates higher operating room utilization and therefore greater hospital revenues.

Unfortunately, patients now have fewer choices and might be pushed towards interventions that aren’t right for them. It would be interesting to look at the modeling of both service lines looking at a three-year, five-year, and 10-year horizon to examine not only which one is more favorable from a revenue standpoint, but which one is likely to deliver the best clinical outcomes. I wonder if they even looked that far.

Other organizational cuts occurred in pediatric and women’s health service lines. That looks like it will create a significant gap in services for local families. It will be interesting to see if other hospitals in the area are able to increase access in the service lines that were cut or whether families will just be left with longer waits for services that were already scarce at times. Even without a detailed analysis, I can’t imagine that making it more difficult for women and children to receive care is in the best interests of the community in the long term.

The organization is classed as a non-profit, so we will see the community benefit statements they put out over the next couple of years, detailing their efforts to serve the underserved. I suspect they hope that no one is looking, and given the way that other hospitals in the area behave, I doubt anyone is.

Is your organization looking at the longer term or bigger pictures, or is the focus on delivering results in the next two quarters? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/18/24

January 18, 2024 Dr. Jayne 2 Comments

The Lown Institute has released its 2023 Shkreli Awards, highlighting “the worst in healthcare profiteering and dysfunction.” The selection panel includes clinicians, journalists, patient advocates, and health policy experts.

In case anyone doesn’t recognize the name, the award is named after so-called “pharma bro” Martin Shkreli, who earned notoriety and scorn by purchasing the rights to manufacture a well-known antiparasitic medication and jacking up its price by 5,000%. Full descriptions along with the judges’ comments can be found on the Lown Institute website, but the winners are below. Given the nature of the activities, I can only imagine what was going on in those that didn’t make the cut.

  1. Columbia University interferes with patients filing sexual assault complaints against one of its physicians.
  2. Stunning CEO salaries at nonprofit hospitals (CommonSpirit Health is specifically called out, but they’re far from alone).
  3. Pharmaceutical companies claim that price negotiations for Medicare drugs are unconstitutional.
  4. Hospitals partner with private equity-backed companies to offer high-interest medical credit cards with rates up to 26%.
  5. Vascular specialist allowed to continue to practice despite discipline in numerous states and failing to be able to write the essay needed to pass an ethics course.
  6. GlaxoSmithKline hides evidence that its heartburn medication Zantac may cause cancer.
  7. Indiana cardiologist accused of implanting unnecessary cardiac stents, including 80+ stents in a single patient.
  8. Hospitals “dump” homeless patients who are unable to fully care for themselves.
  9. Device manufacturer Medtronic incentivizes surgeons to implant devices in patients that may not benefit, all in the name of education.
  10. Lehigh Valley Health – Cedar Crest Hospital threatens to medically deport a comatose patient receiving expensive care

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From BlackBerry Forever, iOS Never: “Re: BlackBerry. I appreciated the picture of your old-school device. I also had the Torch and it was the best of both worlds – touch screen with a keyboard. Did you see the buzz about add-on keyboards at the Consumer Electronics Show?” Clicks Technology is offering the keyboard, which comes in either “Bumblebee yellow” or “London Sky,” which is decidedly grey. The accessory connects via the standard charging port and will start shipping on February 1. I haven’t met anyone who is remotely interested in buying one, so if you like the idea, feel free to weigh in. Personally, I loved the tactile BlackBerry keyboards and could type on them way faster than a touchscreen model. The roller ball mouse thing, not so much. There have to be others out there like me, so we’ll see if this results in an appreciable number of sales.

Another reader clued me in that BlackBerry is exhibiting at CES 2024, accompanied by a Monty Python-esque “I’m not dead yet” meme. Indeed, the company even has a website highlighting its participation, and it looks like it’s mostly tied to automotive technology. I have to admit I haven’t followed the company since my former employer killed off its BlackBerry server back in the day.

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Other interesting items coming out of CES include the Withings BeamO multiscope device. Although it reminds me a bit of an early generation Wii remote, it’s designed to quickly produce vital signs data for use during non-office healthcare encounters. It can deliver temperature, oxygen saturation, heart rate, and electrocardiogram data that can be sent to healthcare providers using an app. Withings has an application in for FDA approval of certain features, such as detection of atrial fibrillation. The device is expected to hit the shelves in July and will retail for $250.

Speaking of cool devices, I see all kinds of wearables out on the trail and at the local YMCA. A recent Stat opinion piece calls for a “data diet” to help curb the growing obsession with data. I’m sure there’s a boom in sales during the early part of the year as people seek digital help tracking their progress towards various New Year’s resolutions and annual goals. The article confirms this, noting that fitness app downloads are more than a third higher in January than at other times. It also notes that the fitness tracking industry rakes in $45 billion annually and that there are 400 personalized nutrition companies out there. The article questions the role of fitness trackers in trying to curb the obesity epidemic and the increase in chronic diseases. It suggests that we’re tracking the wrong data, and that in order to harness technologies like AI to better use our data, we need higher-quality data in the first place. The author shares vignettes of several patients gaming their fitness trackers, one sitting in a meeting but waving his arm trying to clear an alert telling him to move. It will be interesting to see how the fitness tracking movement evolves and whether we start getting better data or just more mediocre data.

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I’m always looking for interesting new companies and was excited to run across CareLuminate. Their premise is straightforward: if one understands how nurses feel about the care being delivered in their workplaces, one can better understand clinical quality and help reduce healthcare costs. CareLuminate can help those who are paying for healthcare (such as employers) steer their workers towards facilities with higher quality. The company’s founders have background in clinical outcomes and industry research, coming from the nursing world and from KLAS Research and specifically its Arch Collaborative. By interviewing nurses directly, the company generates independent and current data that they note hasn’t been “gamed” by health systems. Some of the measures captured in interviews and through available data include nurse perceptions of care safety, patient satisfaction, infection rates, and readmission rates. I’ll be watching them closely to see how they gain traction in the industry. They’re worth checking out.

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Speaking of checking companies out, I was happy to book my first celebrity Booth Crawl for HIMSS24. Since I’ll be the only member of the HIStalk team in attendance at the show, I feel particularly responsible to capture the glitz, glamour, and exhaustion of the event. It’s my first time to schedule a booth crawl on the opening day of the exhibit hall when people are fresh and should be eager to chat.

What are your hopes for the HIMSS24 conference? Is there anything you’d recommend as can’t miss opportunities? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/15/24

January 15, 2024 Dr. Jayne 4 Comments

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I’ve been practicing in the telehealth space since before the pandemic. We deal with a lot of situations that other physicians don’t want to deal with – patients calling for antibiotics, patients with questions about lab results they received through their patient portal after most physician offices are closed, and requests for refills on chronic medications for patients who haven’t been seen by their physicians in a long time period.

Most of the primary care physicians I talk to are grateful that we are out there as a buffer, allowing their patients to receive care without having to be on call 24×7 themselves. However, this week I discovered that apparently a subset of physicians thinks that those of us who practice telehealth exclusively are less than “real” physicians. A newly formed physician education program refused to let me join because I didn’t have an ID badge that has a hospital-style “PHYSICIAN” designation on it. In fact, I don’t have an ID badge at all, which was also an issue.

I submitted a copy of a different photo ID along with a copy of my state medical license, thinking that would suffice. Instead, they asked me for my National Provider Identifier number, which was particularly silly since that can be found via a web search. Once I provided that, they wanted copies of my medical school diploma and residency completion certificate. I’m not sure why a state license wasn’t sufficient, and I hope they had fun trying to read the Latin on my diploma. I had to go digging for those documents since I’m not one of those folks that has them hanging on my office wall. Next time I’ll just use the magic of computers to make a simulated ID badge and be on my way.

The entire experience was annoying, though, and impacts not only telehealth physicians, but any physician who isn’t working in a clinical setting. One doesn’t stop being a physician because they’re not seeing patients. I am definitely going to address this once I am established in the program.

Speaking of annoyances, I had to deal with some annoyances from CMS this week. I received an email from the CMS Identity Management System telling me that my account was going to be deleted due to inactivity. I attempted to log on but couldn’t, and the password recovery system presented a security question that I swear I’ve never seen in my life, because I would have said it was ridiculous if I had. It asked me to provide a telephone number for a relative that was not my own number. I tried to guess when it was that I had set up the account and tried some numbers, which of course were not correct, and the account was locked. The system unhelpfully told me that I needed to call the help desk associated with the application I was trying to access, which was also silly because I have access to multiple applications through the CMS Enterprise Portal. Each of them has their own help desk.

Of course, I was trying to do this at 10 p.m., so I waited until the next business day when I had a gap in my schedule and started calling help desks. The first one was closed because their office hours are only until 4 p.m., and the second one allowed me to hold for 11 minutes and then disconnected me. I called right back and went directly to an agent, so I can only assume their phone system was having a momentary malfunction. The agent clearly had no idea how to help me and was reading from a help desk manual and couldn’t even pronounce some of the application names. He provided another phone number to call. That agent asked me for a bunch of personal data. I finally interrupted and asked whether she’d like to know why I was calling. She seemed surprised that I would want to tell her that. I told her my story, and she said, “Oh, so you just need a password reset?” Bingo! She switched gears and did the reset, giving me a 15-character complex password that I had to write down.

Fortunately, she stayed on the line while I did the reset. The process requires two-factor authentication. I chuckled when I got to the screen that recommended Google Authenticator because it’s supported for “iPhone, Android Phone, and Blackberry.” I wonder how many Blackberry devices they get accessing their system these days. Finally, I was able to set a new password and was on my way. The agent disconnected and I went to set a new security question, since I still had no idea what the answer was for the one with a relative’s phone number.

The list of security questions had some interesting choices. Not only were they strange, but they’re also things that change over time for many people, which doesn’t make them a good security question. The highlight reel:

  • What did you earn your first medal or award for? Hmmm, was it swim team or horseback riding in elementary school? I have no idea.
  • What is your favorite movie quote? I’m at a point in my life where I can barely remember the things I’m supposed to remember, let alone the specific grammar and syntax of a movie quote.
  • What music album or song did you first purchase? I seriously have no clue since it was more than 40 years ago.
  • What was the first computer game you played? Truly have no idea here either, although I was tempted to put Oregon Trail due to the lack of good questions.
  • What was your grandmother’s favorite dessert? I can’t wait until I’m old enough to have a grandchild call and ask me this.
  • Where were you on New Year’s Eve in the year 2000? I think the better question for healthcare workers was where we were on New Year’s Eve in 1999, since many of us were in Y2K hell.
  • Who is your favorite book/movie character? I read more than 50 books a year, so I wasn’t touching this one.
  • Who is your favorite speaker/orator? I can’t remember the last time I saw the word “orator” and was tempted to put Abraham Lincoln, but I knew I wouldn’t remember that down the line either.
  • What is your favorite security question?

I couldn’t believe it when I got to that last one. Again, how would I ever remember the syntax if I selected that one? Maybe “what is the answer to your favorite security question” would have been a better option, since it wouldn’t involve more than a word or two. Still, the entire experience was bizarre and fortunately I was quick enough to grab a screenshot of the list of crazy questions. I sent it to one of my favorite online security experts who replied with four different kinds of eye-roll emojis and GIFs. You can’t make this up, folks. Thanks to CMS for keeping it real.

What’s the weirdest security question you’ve seen? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/11/24

January 11, 2024 Dr. Jayne 2 Comments

Masks are back on at my local hospitals. Our area is seeing a surge of COVID, influenza, and RSV patients. We’re seeing full intensive care units. Nursing exhaustion is approaching pandemic levels.

Across the US, hospitals are experiencing staffing challenges, which often cause beds to be unavailable because they aren’t staffed. This rolls downhill in the hospital, landing in the emergency department that has to board the patients until beds are available. In turn, this can back up ambulances, which leads to delays in 911 calls. For my friends working in EMS, this is starting to feel a lot like 2020, and in my community, the COVID-related hit to EMS staffing is still present.

If you’re on the healthcare IT side and the clinical staffers that you are interacting with seem frazzled and distracted, it’s because they are. One of my ICU nurse colleagues commented, “It’s like people forgot what we went through and just don’t care about healthcare workers any more.” Let’s remember to wash our hands, stay home when you’re sick (or wear a well-fitting mask if you can’t stay home), and look after each other. We’re all in this together.

I’ve started working on a project that involves an area of clinical informatics that I haven’t worked on in some time. To get up to speed with the vendor landscape, I’ve been visiting lots of websites to view white papers and customer case stories. Maybe my brain is just used to operating in an older way of working, but I find myself increasingly annoyed when companies have decided that the only way they’re going to share information on their websites is through videos. Some of us absorb more through reading actual words. Of course, others are more visual or auditory learners and might do better with that kind of content.

For me, it’s often a time issue. I can read much faster than most video presenters speak, which means that when there is only video content available, I tend to perceive the sites as not being a good use of my time. It left me wondering what happened to the good old written word and whether it’s just me or whether times have changed and I need to get used to my work taking 50% longer than planned.

A primary care colleague reached out to me today, venting that her organization has yet to configure the EHR to allow physicians to submit the G2211 billing code that went into effect on January 1. That’s an add-on code that allows physicians to submit charges for the time they spend building longitudinal relationships with patients and addressing patients’ issues over the long term. CMS describes the code as billable for “visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed healthcare services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition.”

The nature of the relationship between the patient and the physician is the factor that determines whether the code should be used. It’s worth around $16 when billed for Medicare patients, so it’s not designed to drive significant revenue, but rather to offset some of the valuable whole-person care that is provided by primary care physicians. Medicare’s documentation about the change says that the typical primary care physician who has Medicare beneficiaries in their patient panel will coordinate care with 229 physicians in 117 disparate practices. If it hasn’t yet been added to your EHR workflows, your clinicians are missing out.

The US continues to have supply and demand issues with stockpiles of personal protective equipment (PPE). A recent AP report explored the fact that states that had scarcity of supplies during the high points of the COVID pandemic are now dumping PPE at an alarming rate. Ohio has auctioned off nearly 400,000 protective gowns and has thrown away 7 million gowns along with countless masks, gloves, and other supplies. States are having to determine their go-forward strategies for supply stockpiles and preparation for potential disasters.

The amount of materials that is being shredded, recycled, or destroyed is simply staggering. Georges Benjamin, MD, executive director of the American Public Health Association, mentioned that our “bust-and-boom public health system” creates waste as well as lack of preparedness. Many states didn’t respond to the AP’s request for information, so it’s hard to know exactly how large the problem might be.

As a CMIO, I’ve worked on a number of projects around health literacy. I would bet that most people in healthcare IT don’t understand the level of understanding of the average patient. For written communications, we need to focus our writing at roughly the fifth-grade level to ensure that patients will be able to understand any instructions we provide. Organizations have also made significant efforts to provide documents for as many patient-preferred languages as possible.

I was excited to see this article that looked as the association among hospitalizations, emergency department visits, and health literacy interventions. Researchers concluded that patients who read patient education materials and summarize their understanding back to the care team are 32% less likely to be hospitalized and 14% less likely to visit the emergency department. Additionally, there was an association with overall declining health costs in patients who received the intervention. The study was performed using subjects that were part of an employee health plan, so it’s not clear if results are generalizable to all patients. Thanks to Healthwise for including this study in their blog, otherwise I would likely have missed it.

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The Consumer Electronics Show is upon us, and Garmin is finally taking a giant leap forward in the realm of wearables by introducing a women’s heart rate monitor that clips onto a sports bra and doesn’t require a separate strap. For anyone who has had to deal with a heart rate monitor strap interfering with your bra, this is a welcome addition. The HRM-Fit strap retails for $150.

What are the best and worst things you’ve seen coming out of the Consumer Electronics Show? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/8/24

January 8, 2024 Dr. Jayne 1 Comment

This weekend was all about playing cleanup. The new year brings a lot of things for the physician to-do list, one of which is starting my quarterly questions that are needed for me to maintain my specialty board certification.

The Maintenance of Certification (MOC) process is almost universally hated by physicians, to the point where some of them will take a high-stakes exam every 10 years rather than participate in the program. I was part of my specialty’s pilot program for MOC and much prefer the quarterly questions to an all-day exam, especially since I haven’t practiced full-spectrum primary care in quite a while. Unfortunately, my specialty still thinks we should be able to manage all the conditions we used to manage during our residency training programs, so I have no choice but to play along.

The quarterly MOC questions are open book, so that’s something, and usually if I don’t know the answer, I can find it using a combination of UpToDate, the online version of my specialty’s flagship journal, and the website of the US Preventive Services Task Force.

Arriving in the New Year also means paying an annual fee to the board, which I had forgotten about. Many of my colleagues who are in purely informatics roles have to pay these expenses out of pocket, which is burdensome. The boards assume that physicians are either self-employed and can take their board fees as a business expense, or that they are employed and receive reimbursement from their practice, hospital, or health system.

There’s a lot of chatter in the physician world right now about the value of MOC, with oncologists and cardiologists being among the most recent to launch challenges. Usually, physicians have to maintain particular board certifications approved by the American Board of Medical Specialties in order to be granted hospital privileges and to join insurance plans. However, there’s a movement towards supporting an alternate organization, the National Board of Physicians and Surgeons. Although it’s gaining traction, NBPAS isn’t accepted in my area, so I haven’t pursued it.

Some clinical informaticists see MOC as an opportunity where AI tools might help physicians trim the time-consuming process. Rather than having to search three or four websites, one could query a generative AI system to provide the information that is needed to answer the questions. Physicians could also perhaps ask a virtual assistant to search the rules and regulations for their specialty and create calendar appointments for all the deadlines that are required to maintain certification. For those of us who have multiple board certifications, that might help a lot, especially since each board has its own timeline and requirements that differ depending on where you are in your certification cycle. The questions I did this weekend didn’t have any disclaimer that you couldn’t count AI tools as some of the online resources used in answering the questions, but I’ll have to keep my eye out for such prohibitions in the future.

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Also on my list for the weekend was setting up a new laptop that was sent by a client I recently started working with. This is the first time I’ve had Microsoft balk at my use of a password that doesn’t contain words. I’m not sure how someone would guess a 10-character password that contains two numbers, three lowercase letters, three uppercase letters, and two symbols or why Microsoft would have seen my particular combination of characters “too many times.” I certainly don’t use the same password on all of my accounts, so this just seemed like a weird error. I had to try three versions of what I wanted to use before it finally gave up and let me set my password.

I also caught up on some reading, which put me to sleep the first time I tried to get through it. ONC is scheduled to publish its “Health Data, Technology, and Interoperability: Certification Program Updates, Algorithm Transparency, and Information Sharing” final rule this week. The rule implements pieces of the 21st Century Cures Act through the creation of new requirements for health IT developers under the Health IT Certification Program. The rule includes provisions for developers to report metrics that give insight into how organizations are using certified IT products, updated criteria for decision support interventions, and updates to patient demographics and electronic case reporting. It also requires developers to move to the United States Core Data for Interoperability (USCDI) Version 3 standard no later than January 1, 2026. This will help organizations better share data that will promote health equity, reduce healthcare disparities, and improve the interoperability that is needed for public health efforts.

Of course, no ONC final rule would be complete without a mention of information blocking, and I can assure you that’s in there, at least in the current unpublished version that’s available on the Federal Register website. Its 804 pages of double-spaced delight isn’t much of a beach read, but it contains other hot topics, including a C-CDA Companion Guide update, a Synchronized Clocks Standard, information on a patient’s Right to Request a Restriction on Use or Disclosure, and more. The rule will become effective 30 days after it is published in the Federal Register.

The final cleanup activity of the weekend was catching up on a New Year’s Resolution on which I had already fallen behind. This year, I’m aiming to read two scholarly articles each week that cover an area of medicine or clinical informatics that isn’t part of my usual practice. One of my articles this week was “Effect of an Intensive Food-as-Medicine Program on Health and Health Care Use.” The article, which was published in JAMA Internal Medicine, covers a randomized clinical trial designed to see if a program for patients with diabetes that provides healthy groceries, dietician consultations, education, and health coaching would improve blood sugar control in compared to the usual care they would otherwise receive. The study had over 400 participants. Although the authors didn’t find an improvement in blood sugar control, they did find improved patient engagement in preventive health care interventions. They recommend that additional studies be performed to find optimal “food  as medicine” interventions to improve patient health.

Since this resolution was designed to stimulate my curiosity, I wandered around the internet a bit to learn more about food-based medical interventions. I was intrigued by The Goldring Center for Culinary Medicine at Tulane University. The Center has been around for more than a decade and was designed as a teaching kitchen to educate future physicians “to understand and apply nutrition principles in a practical way” and to better work with patients on diet and lifestyle modifications. The Center also provides cooking classes for the community. I was glad to see that they offer continuing education classes for practicing physicians since many of my medical classmates subsisted for anywhere from seven to 10 years on a diet of ramen, sandwiches, drug rep-provided lunches, leftover patient meals, and a stash of graham crackers and apple juice that was liberated from nursing unit stockrooms.

New Orleans is a great city. Anyone up for a HIStalk continuing education field trip? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/4/24

January 4, 2024 Dr. Jayne 1 Comment

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I didn’t ring in the new year in Auckland, but since I visited there earlier in the year, I could at least visualize more accurately what it must be like to celebrate in one of the first major cities that greeted 2024.

I spent the evening in my Midwest neighborhood, where the fireworks started at 6:35 p.m. courtesy of some folks who I suppose either wanted to get a head start or were celebrating with small children before they sent them off to bed. The random gunfire held off until midnight. at least, and fortunately was short lived. Maybe I’ll plan a trip to greet 2025 in a more spectacular locale.

I always like reading various year-end review articles and Google shared the top 10 health-related searches of 2023. The list was wide ranging and showed that even post-pandemic, infectious diseases are still top of mind for many:

  1. How long is strep contagious
  2. How contagious is strep
  3. How to lower cholesterol
  4. What helps with bloating
  5. What causes low blood pressure
  6. What causes warts
  7. Why do I feel nauseous
  8. What causes preeclampsia
  9. How to stop snoring
  10. How long does food poisoning last

I have to admit I was a little surprised by #8, which is a pregnancy-related complication. However, a quick Google search of my own revealed that the condition affects over 200,000 pregnant patients in the US each year and the rate of the condition in the US has increased 25% in the last two decades. It’s good to know that people are seeking additional education about the condition, which is a leading cause of maternal and infant morbidity and mortality.

I also got a chuckle out of #7, since it’s decidedly first-person in comparison with the other queries. I doubt Google knows whether the person asking the question recently consumed Flamin’ Hot Cheetos and a Mountain Dew or whether they just returned home from a wild night at the local dance club, so maybe a more refined search is in order.

I spent a few hours on New Years Day catching up on my inbox, which has been overrun the last couple of weeks. One message advertised an upcoming webinar for automated fax processing, which made me chuckle. I’ve had a situation for over a year where a particular pharmacy chain is sending refill requests to my practice fax line for patients (and providers) who have no affiliation with my clinical practice. I thought it had been resolved, but it started up again, leading me to believe that the pharmacy chain somehow downloaded an outdated prescriber database.

I sent a formal notification to their corporate entity, but it hasn’t been corrected yet and they haven’t even responded to my message. If you work for a pharmacy company, please make sure you have updated provider profiles, because this kind of thing keeps patients from receiving their refills in a timely manner.

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Also on New Year’s Day, I spotted this ad for Amazon’s clinical care options. I appreciate the sentiment that they are trying to express, namely that they are available for various clinical situations, but nasal foreign body removal isn’t listed as in scope for their in-person offices and it’s definitely not a problem that can be resolved during a virtual visit.

I’ve fished plenty of items out of kids’ noses and ears in my career, and while it might be helpful to talk to a medical professional for advice on whether to go to an urgent care (older kids with certain foreign bodies) or whether to go to the emergency department (pointed objects, young children who might need sedation), waiting for a consultation might lead to a delay before a child gets appropriate care, which can make extraction more difficult due to swelling. Here’s to all the parents who have survived the trauma and drama of this happening and the process that is needed to reverse it.

The US Government Accountability Office has appointed five new members to serve on the Health Information Technology Advisory Committee (HITAC). The group advises the federal government on implementing healthcare IT and has been around since 2016. Four of the new appointees are physicians and one is a nurse. Their experience includes quality standards, innovation, health plans, applied clinical informatics, AI models, and having personally been a caregiver for someone with a serious health condition. Personally, I think the latter element is one of the most important. If we had more healthcare consumers making decisions about healthcare strategy, we might see a different health system than we have today. Each will serve a three-year term with the potential for reappointment.

I’m continually amazed by the number of physicians that don’t understand some of the basics of clinical informatics. This wasn’t such a big deal a decade ago, but now that nearly everyone is using EHRs, there is a minimum level of knowledge that one needs for survival. The first thing to understand is that most EHR installs have significant differences, even if they’re from the same vendor.

I lurk in some unofficial user forums, and people working at different hospitals seem baffled that there aren’t magical pixies that move their favorites and defaults from hospital A to hospital B even though “it’s all Epic.” They’re also confused about the governance of IT systems, that one hospital might tightly lock down their EHR against customizations where another is permissive, and that the EHR vendor isn’t responsible for hospitals that make bad decisions about EHR configuration.

I was glad to see a recent article in the Applied Clinical Informatics journal that calls for the support of informatics curricula in US-based residency training programs. Graduate medical education bodies are focusing on telehealth competencies, clinical quality, and documentation, but I’m not seeing education that helps physicians understand why their systems are the way they are and what they can do to help.

I’d be happy to go back to my medical school or residency program and deliver the same governance lecture that I delivered to countless healthcare executives and physician leaders during my time as a field consultant. I’ve found that helping people manage expectations can lead to happier end users, especially when users are educated on which pieces of the EHR can be customized or configured, which ones can’t, and who makes the decisions. One physician colleague who was recently griping about his EHR was shocked to learn that his practice partner sits on the EHR steering committee. The look on his face when I explained it to him was priceless.

Do your physicians and end users understand that your organization has made the majority of decisions around how your EHR is structured, or do they just assume the vendor is responsible for the things they don’t like? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/28/23

December 28, 2023 Dr. Jayne No Comments

As we expected, coming out of the Thanksgiving holiday and moving towards Christmas, emergency department and hospital visits for respiratory viruses were on the rise. According to data from the Centers for Disease Control and Prevention, the most recent numbers show a 21% increase from the previous week, with influenza accounting for the majority of visits.

While seeing patients, I’m hearing a lot of stories about family drama when someone attends a gathering and they’re sick. I’m also hearing a fair number of complaints about people who are staying home when sick, depriving their relatives of the chance to see them. It’s rough for patients who can’t win either way, especially when all they want to do is take a nap and feel better. Kudos to those who stay home when sick and keep their germs to themselves.

Speaking of staying home, Uber is advertising its package service as an option to help with post-holiday gift returns. Customers selecting “Return a package” can send up to five packages to a single postal carrier for $5, with the driver sending a confirmation when the drop off is complete. Packages are limited to less than 30 pounds, need to fit in the trunk of a midsize car, and must not contain any prohibited items. I perused the list of banned items for entertainment value. As expected, you can’t send illegal items, weapons, money, or alcohol. Also making the list: recreational drugs, stolen goods, obscene materials, livestock, or animal parts.

The virtual water cooler is abuzz with a recent private equity-related article that was published in the Journal of the American Medical Association. The findings suggest poorer quality care and clinical outcomes at facilities that are owned by private equity firms. The researchers were associated with heavy-hitting organizations: Massachusetts General Hospital, Harvard Medical School, Beth Israel Deaconess Medical Center, and the University of Chicago. They looked at data on millions of hospitalizations at 300 facilities, focusing on years before and after private equity transitions. They found that private equity-acquired hospitals had higher rates of hospital-acquired conditions such as falls or central line-associated bloodstream infections. Surgical site infections also rose after acquisitions. The other interesting finding was the lower-risk demographic of patients at private equity-associated hospitals, which makes the other findings all the more striking.

As expected, more research is needed, but lots of physicians are jumping on the fact that staffing looks dramatically different at PE-owned hospitals compared to other community hospitals or even academic medical centers.

In other journal publication news, this year’s Christmas edition of the BMJ provides an “Analysis of Barbie medical and science career dolls” as a descriptive quantitative study. Among the highlights: although Barbie can be a doctor, she is usually shown caring for children and rarely meets occupational safety standards. Loose hair, heels, and exposed legs are all considered workplace hazards. Science-related Barbie dolls were also short on personal protective equipment such as gloves or full-coverage lab coats. Competitor dolls were also analyzed and had a more “clinically accurate” appearance. Of note, Dr. Ken was more compliant due to his full-length pants, flat shoes, and short hair.

The article goes into gory detail on a lot of different features, but is interesting to think about given the sheer number of Barbie dolls out there. Of note, my own childhood Barbie doll had scrubs, and although they came with a pair of white sneakers, she couldn’t wear them due to her heavily molded feet. My Ken doll was a hand-me-down and had one leg that popped out of the socket any time you tried to get him dressed, so in hindsight perhaps my own Barbie should have been an orthopedic surgeon rather than whatever specialty she was.

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It was nice to take a bit of a holiday break, but my heart goes out to all the healthcare professionals who are working during the holidays. I’ve spent enough of them in the emergency department to know that it’s hard work, and the pressure just keeps increasing. One of my colleagues mentioned that the new ED mandate is “do more, do it faster, do it friendlier, with less resources, and you can never ever make one mistake.” Hospitals continue to use short staffing as an excuse for everything, and often the buck stops in the ED because they don’t turn patients away and the halls end up filling with patients who are boarding. They don’t yet have rooms elsewhere in the hospital, yet require care that is often different from what the emergency department is equipped to provide. It’s stressful for all involved, especially when there are empty beds in the hospital but not enough people to staff them.

I’m involved in an online physician support group where one of our members shared an editorial that was published this week in the Annals of Emergency Medicine. The title is certainly eye-catching: “My Suicide Blanket.” It begins with a vignette about a hospital giving out blankets to staff as part of a mental health improvement plan. It reminded me of the challenge coins and other tokens given to staff during the height of COVID and which served only to illustrate how disconnected administrators were from those who were actually delivering care on the front lines.

Emergency department physicians are often treated as if we are expendable, expected to operate under a mindset where we don’t dare call in sick because that means we’re not team players. We’re supposed to just take everything thrown at us even when we know we’re working so fast that we aren’t delivering good care. The author of the piece is a member of our group and mentioned that it had to be published anonymously due to fear of retaliation. Students have been seeing this for the last few years, and during the most recent residency program match, they ran away from the specialty of emergency medicine.

Many of your clinician colleagues are not OK. Check on them and let them know that resources are available. They can call or text 988 or visit the 988 Suicide and Crisis Lifeline for help at any time.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/21/23

December 21, 2023 Dr. Jayne 2 Comments

I’ve spent the majority of my career helping people use healthcare technology as efficiently as possible. It gets under my skin when clinicians report wildly inefficient workflows and I always want to dig in to see if I can fix them.

The grating example this week occurred in an article featured in a communication from the American Medical Association. In the piece, the AMA’s vice president of professional satisfaction, Christine Sinsky, MD, claims that workflows for immunization ordering had gone from a verbal order to “21 clicks… to order a flu shot for one patient.”

Although I understand the sentiment, I’m wondering if this isn’t a bit of an exaggeration. There are now thousands of clinical informaticists out there who have dedicated their careers to stamping out what can only be considered a horrific workflow if it actually exists. I’m wondering if she’s not referring to the entire immunization documentation process, which is more than simply placing an order and had a significant number of steps in the paper world if practices were doing it properly.

I don’t think examples like this are helpful, especially if they are inaccurate or if people are comparing apples to oranges. If your workflow for ordering (and not administering) an immunization is really 21 clicks, I encourage you to reach out. Let’s name and shame organizations where this is happening.

The AMA was busy this week, also publishing an article about EHR usability and safety challenges. The article cites a 2018 report looking at EHR safety. I’ve seen some significant improvements in the base versions of EHRs in the last few years and I don’t think it’s necessarily fair to regurgitate data from a half decade ago.

I think also when we look at EHR safety and efficiency, it’s important to note that many clients are not using their vendors’ systems out of the box. I’ve watched client after client configure perfectly good EHRs into the stuff of user nightmares. This typically occurs when those responsible for installing and implementing the EHR don’t understand clinical workflow, don’t have adequate clinical governance, and/or don’t have adequate clinical and end user participation. Usually, these deficiencies are directly related to budget, timing, and politics, a sad combination that often sabotages projects before they start.

Unfortunately, some of the concerns do still exist a half decade later. Physicians and other clinicians are doing too much non-value-added data entry, they’re encountering too many alerts that don’t improve patient care, and they’re dealing with content, including drug databases, that isn’t updated with the appropriate frequency. Couple that with inadequate training and rising expectations for patient throughput and you have a recipe for unhappiness all around.

There are also rising expectations for care quality. When you looked at physicians in practice 25 years ago, they were tracking health maintenance screenings and chronic care management elements, but they weren’t necessarily being graded (or paid) based on their outcomes. Now, insurance contracts have added bonuses and penalties for performance, and regardless of EHR use, there is simply more expected of physicians and clinicians. It’s easy to blame the EHR and to wax nostalgic about the good old days of paper charts, but there are so many more complicated factors at play. I watched two more of my family medicine colleagues retire this month and miss them already.

From ShowMe: “Re: the go-live of the Missouri Prescription Drug Monitoring Program (PDMP) last week. I was able to log in through my existing credentials with the St. Louis County PDMP, although I did have to accept new state-level terms and conditions. On the previous system, I had requests for midlevel providers to become delegates under my license that had been pending since I left a previous employer in 2017. They were still there on the new system, but I was finally able to figure out how to decline them. As expected, there were two major inconveniences: the absence of information from surrounding states, and the loss of records of past searches. It will take time for the new system to build up a history on some patients and it still feels a little like two steps forward but three steps back.” Missouri is the last to deploy a statewide solution, and I wish all the clinicians the best as they navigate the transition.

From Internet of Things: “Re: the proliferation of web-connected devices. It’s cool until it’s not. Healthcare isn’t the only single-threaded industry in which connectivity issues can bring everything to a screeching halt. The local school district has lost all internet communication and phone lines due to a fiber-optic cable being cut somewhere, although they don’t know where yet. They have learned that literally everything is tied to the internet, including the bell to start and end classes and the automatic motion-detection light switches. For two days (so far), the kids have been sitting in the intermittent dark, with administrators using an air horn to announce the beginning/end and periods at school. It’s so loud I can hear one school’s horn blow every 42 minutes. They can’t assign, grade, or update any work and it’s finals week. Did I mention that even the photocopiers are internet-based, and they can’t print out worksheets or paper tests?” I come from a long line of teachers and I bet the ones who are having to teach in that environment are losing their minds. It’s already a rough time of year, with many students dealing with end-of-semester anxiety, too much holiday excitement, or increasing levels of family dysfunction. Here’s to those courageous souls that need to make it through just a couple of more days before break starts.

The holiday season is also a time when companies occasionally behave badly. One colleague reported that his hybrid employer took all in-town employees out for lunch, but completely ignored the remote team. I guess management has never heard of sending Uber Eats or DoorDash? Holiday gifts abound, often with company logos and questionable usefulness. Among the best I have received during my career: a Total Wine gift card, small picnic cooler, a $100 bill, and jumper cables. Among the worst: a Santa hat with a company logo, a vanity-published book written by the company founder, framed pictures of the CEO, a rock with an inspirational word carved into it, and nothing.

Does your employer give holiday gifts that put them in the hall of fame? Or are they more deserving of admission to the hall of shame? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/18/23

December 18, 2023 Dr. Jayne 1 Comment

Mr. H posed a question last week about how to streamline training for PCPs and asked me to weigh in as well.

To really answer the question, we have to ask ourselves what we as a society actually expect primary care providers to do and what kinds of experience we expect them to have. The answers to those questions directly impact how we could best train people to share the primary care load.

To help mitigate my own bias as a board-certified family medicine physician with 20 years of experience, I looked to MedlinePlus (which is an official website of the US government) to define “primary care provider.”  According to the site, “A primary care provider (PCP) is a healthcare practitioner who sees people that have common medical problems. This person is most often a doctor. However, a PCP may be a physician assistant or nurse practitioner. Your PCP is often involved in your care for a long time. Therefore, it is important to choose someone with whom you will work well.”

Some lay people might read that and think “common medical problems” are things like cough and cold, urinary tract infections, rashes, sprains and strains, and the like. Although those are common, those kinds of acute problems are only a small part of what primary care providers actually see. In a traditional primary care practice, we’re also caring for lifelong medical problems like asthma, diabetes, high blood pressure, heart failure, stroke, chronic obstructive pulmonary disease / emphysema, kidney failure, vascular disease, connective tissue disorders, cancer, neurological diseases, and more. Additionally, we care for more complicated acute problems like pneumonia, bronchitis, kidney infections, unusual rashes and suspicious lesions, and clusters of symptoms that don’t have a clear cause.

The latter is where primary care physicians really shine, being able to look at a set of related or seemingly-unrelated symptoms and pulling it all together to create a plan to diagnose the patient. That kind of clinical skill is far beyond evaluating cold symptoms and running a COVID or flu test.

The other thing that happens in primary care, but was not mentioned in the MedlinePlus definition, is the delivery of preventive health services. This is the part where we talk to patients about recommendations, present the options, discuss the risks and benefits and which options might be best depending on the patients’ other medical factors, and ultimately order the services. For a patient who is reluctant to undergo a screening test, this might involve ongoing conversations over a period of months to arrive at the point where a patient accepts a test.

Other preventive services include counseling on smoking, drugs, safe sex, diet, exercise, nutrition, mental health, family dynamics, and what to expect as you age. Speaking of the aged, we also have conversations about advance care planning. On the other end of the spectrum, those of us who see pediatric patients do a lot o bnf counseling and anticipatory guidance, making sure parents know what to expect as their children grow and what might be normal or not normal. Some days, we give a lot of reassurance.

In family medicine, we’re also trained to perform office-based procedures ranging from skin biopsies and toenail removal to joint injections to flexible sigmoidoscopy to colposcopy and cervical / endometrial biopsies. In some areas of the country, we provide full-spectrum maternity care, including c-sections. Some of us are trained to perform colonoscopy, and a small subset of us who have done extra training can even perform appendectomies and other urgently-needed surgical procedures. Most of the family physicians working at that level are either part of a residency / fellowship training program or are practicing in a more rural area, but it’s something that the majority of readers are likely not aware of.

Internal medicine training is similar, but with less of a focus on procedures and no care for infants, children, or pregnancy. Pediatrics generally covers people under the age of 18, but includes a full spectrum of conditions and procedures. Geriatrics is often left out of the primary care list, but as our population ages, it is becoming increasingly important.

That broad definition of primary care falls to the wayside if you listen to many of the talking heads in the healthcare industry today. They feel that primary care can be delivered in a transactional fashion without continuity, and don’t fully understand that when a patient has a lot of different seemingly-minor problems, they can actually add up to something much more significant. These organizations are happy to hire people who aren’t even trained in primary care to deliver primary care services, as long as they’re willing to work for cheap. You don’t have to be board certified when patients are paying cash. (Generally, you do have to be board certified or at least board eligible if you’re being added to insurance panels.)

The definition also morphs a bit when primary care providers become employed by organizations that see them as little more than referral mills, sending patients to subspecialists who perform high-dollar procedures. One of my primary care colleagues who works for a hospital-affiliated group was recently scolded for not sending her diabetic patients to an endocrinologist. Guess what? Her patients have excellent glucose control, are on evidence-based regimens, and aren’t having side effects. That combination of factors means that referrals weren’t warranted. The organization tends to make more money on patients when they are referred to endocrinology, though, so they weren’t happy.

Another role of primary care providers, according to MedlinePlus, is to “assess the urgency of your medical problems and direct you to the best place for that care.” When we actually know you (which means you’re probably not getting your care from a transactional non-continuity entity) we can better assess your symptoms and determine if you can see us in the office on Monday, whether you can go to an urgent care tomorrow morning, or whether you need to go to the emergency department immediately. That’s not to say that a primary care provider who doesn’t know you can’t do that assessment, but from experience, that’s when I see the most patients sent to a higher level of care than they need, usually at a higher cost.

Many primary care providers also see patients in the hospital, although that’s becoming less common every day. Being able to manage hospitalized patients in an environment where the goal is to get the patient out of the hospital as quickly as possible becomes difficult when you’re also seeing patients in the office. That has led a large number of primary care providers to turn over the care of their hospitalized patients to “hospitalists” for inpatient management. Sometimes this results in better coordinated care, sometimes it results in more disjointed care, and I’ve seen the whole spectrum. In an ideal situation, the hospitalists have close relationships with the primary care providers and coordinate discharge and follow up, but there can be misses when the focus is on patient throughput.

Primary care physicians have a bachelor’s degree, four years of medical school for a MD or DO degree, and a minimum of three years of residency. They graduate training with around 20,000 clinical contact hours, which makes it much more likely that they will have seen rare diseases or unusual presentations of common diseases. Physician assistants have bachelor’s and master’s degrees and typically graduate their training with around 2,000 clinical contact hours. Nurse practitioners have a bachelor of nursing degree and typically graduate their training with around 500 clinical contact hours. Although in the past many nurse practitioners had extensive experience as a registered nurse prior to going to NP school, most of my colleagues who have recently entered the field have two or fewer years in practice before starting their NP program. Boiling those hours into years of post-bachelor’s training using data on the quickest paths around — physician=7, PA=2, NP=2.

Keeping that all in mind, we can turn back to the question. What is the shortest time we could train someone to work as a primary care provider? It all depends on what we want them to do. If we want them to be able to find the zebras hiding among the horses (which is how medical school professors like to describe rare diseases) we probably need people with more education. If we want people to follow algorithms and guidelines and crank out referrals and orders, we can use resources with less education.

I think there is room to streamline the path for physician trainees, or at least to allow them to focus on the areas where they might want to dig deeper. For example, I knew early on in my training that I would not be practicing in a rural area and would not be delivering maternity care. Still, I had to complete multiple months of required labor and delivery rotations that could have been better spent learning geriatrics or weight management. I also spent several months staffing the intensive care unit even though I knew that I would be moving to an area that doesn’t allow family physicians to have ICU privileges.

Mr. H asked whether med school should be more training than education given the endless access to literature and resources. I think med schools have evolved over the last decade. I have watched my alma mater make significant changes to its curriculum. For example, they’ve shifted clinical education so that it starts almost on Day One.

For people who are committed to a career path, it could be streamlined a bit, but sometimes physicians don’t find their calling until their third or fourth year of medical school. My own school penalized me for wanting me to do family medicine from the get-go, but that’s another story. As someone who chose a path to deliver comprehensive care, though, I can only think of one clinical rotation in medical school that didn’t contribute to my future specialty-specific knowledge, although it taught me an unquantifiable amount in the realm of delivering compassionate care.

Mr. H also asked how much of a mid-career PCP’s practice uses their training from decades before. I’d say that 20 years out, my family physician colleagues in traditional practice are using a fair amount of their original training, minus the obstetrics, general surgery, ICU, and some of the emergency medicine procedural skills. They’ve also learned a considerable amount as medicine has changed. For example, many of the drugs used to treat diabetes today didn’t exist when I was in medical school. For me in the emergency and urgent care space, on a routine basis, I use about 70% of my training, but when something comes in that falls into the other 30%, I’m glad I have it deep in the recesses of my brain.

Mr. H asked whether some things can be eliminated because they’ll become obsolete, and I think that’s tricky because it’s hard to predict what exactly will be obsolete. For example, we’re still treating strep throat the same way we did 20 years ago, but not diabetes.

As a seasoned attending physician who formerly precepted students and residents, I’ve seen what can happen when less-trained individuals see patients. During the training period, however, there’s the opportunity for supervisors to educate and correct these situations. When less-trained individuals are out in practice unsupervised, regardless of their degree, there’s no process for correction until the patient sees another provider or something bad happens. There is a growing body of literature that demonstrates that less-trained individuals order more referrals, which leads to more expensive care, not to mention delays in patient care and poor patient experience.

Because of that, and what I’ve seen in practice, I personally don’t believe that less training or less education is what we need. Instead, I think we need to be using the resources we have more effectively. How do we do that, you may ask?

First and foremost, unshackle the highest-trained providers (the physicians) from the work that others with less training can do. Free them from their inboxes and hire adequate staff to support them. Use highly trained support staff to manage messages and triage patients using protocols and standing orders. Put registered nurses back on the team, not just medical assistants or patient care technicians.

Second, embrace team-based care. Bring nurse practitioners and physician assistants into specific roles. For example, seeing complex diabetic patients monthly for ongoing education and fine-tuning of treatments while the physician sees them quarterly. That way, the patient can benefit from both levels of education. Encourage patients to build relationships with the team so that there’s a larger pool of people that know them and can watch for changes in their status.

Third, bring in ancillary disciplines for support – registered dieticians, clinical pharmacists, certified diabetic educators, psychologists, social workers, care coordinators, health coaches, patient navigators, and more. Those disciplines have different education than primary care providers and can help deliver more focused interventions so that others can work at an appropriate level commensurate with their training and education.

Finally, I’m going to go out on a limb and mention the rise in the number of for-profit schools as contributing to the problem. For some of them, the focus seems to be on cranking out graduates rather than producing well-educated, well-qualified graduates. As an example, the local medical schools and PA programs (which are affiliated with comprehensive universities) all provide students with lists of “approved” preceptors for rotations. They are vetted and provide documentation about their teaching style and what they’ll allow students to do. The for-profit NP program in the area (which is not affiliated with a comprehensive university) allows students to select their own preceptors, and the students have to call around and beg people to allow them to rotate. I get two or three calls a month. I can’t imagine there’s much quality control over what some of those preceptors may or may not be teaching and the process seems predatory given how much tuition the students are paying.

To make a long blog short, I think there are some ways we can streamline training programs in the US, but we still need some primary care providers to have longer, more comprehensive educational experiences. By using those with shorter training programs or those that have a narrower focus alongside those with broader training, along with other ancillary professionals, we can provide not only the best care for patients, but also the most cost-efficient care with the best outcomes. I would be remiss if I didn’t mention the biggest barrier to people becoming primary care physicians, which is that they are among the lowest-paid specialties.

What do you want in a primary care provider? Or do you just want to get your care from Amazon? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/14/23

December 14, 2023 Dr. Jayne No Comments

From Patient Satisfaction: “Re: patients navigating coverage choices during open enrollment. You are right on target. The challenge of navigating the maze between coverage and patient care is overwhelming. I sympathize with physicians and staff that have to navigate this mess. I appreciate their efforts. I am fortunate to have a great PCP and a network of specialists who care for me. I have been impressed by the coordination of care I have received in my area, even though all the practitioners are not with the same health system. They are all on Epic and share my medical information, which may account for this.” Having your records on a common EHR platform certainly makes some kinds of sharing easier. The most reliable sharing seems to be clustered around the data elements that were required as part of federal incentive programs and now have become table stakes: medications, allergies, and problem list.

Things become murkier when you’re trying to share laboratory data even among systems using a common vendor. Some require mapping of specific lab tests among all trading partners, which can be laborious. Even mapping the top 100 labs can be challenging when you’re dealing with different hospitals using different analyzers. Reference ranges and normal / abnormal flags have to be dealt with, and I’ve seen plenty of organizations just throw up their hands and avoid the problem by doing minimal mapping. Sometimes a thyroid test isn’t just a thyroid test, after all.

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For years, I’ve been a keen follower of footwear fashion, but a reader recently clued me in to advances in surgical wear. Surgeons at Mayo Clinic have partnered with Cardinal Health to create the first commercially available surgical gown  with pockets. It boasts two instrument pockets and one holster, suitable for different users, “right, left-handed; any gender of clinician; standing or sitting procedures; etc.”

Although I like the sales talking points around reducing handoffs and drops, or avoiding breaches to the sterile field, I’m less enamored of the gown’s ability to give “an extra hand to understaffed ORs” since that feels like a way for administrators to justify continued understaffing. I reached out to a couple of colleagues. The first said “heck yeah, it’s amazing,” but it sounds like he hasn’t experienced it yet. The second colleague, a 20-year veteran scrub nurse, was a bit more skeptical. She felt it may create issues with lack of standardization in how different surgeons put equipment in their pockets, creating potential confusion for surgical assistants and scrub staff that could ultimately impact patient outcomes. In a salute to the litigious folks out there, Cardinal Health warns that “sharp, hot, heavy, or long instruments should not be placed in the pockets or holster.”

CMS recently released data on National Health Expenditures for the 2022 fiscal year. Here are some of the highlights:

  • Healthcare spending grew by 4.1% to reach $4.5 trillion.
  • The percentage of insured persons in the US reached 92%.
  • The share of Gross Domestic Product devoted to healthcare is 17.3%.
  • Hospital care is responsible for 30% of spending, followed by physician / clinical services at 20%, and retail prescription drugs at 9%.
  • Private health insurance pays 29% of the bills, followed by Medicare at 21% and Medicaid at 18%. Patients paid out-of-pocket for 11% of care delivered.

It’s important to keep in mind that although the percentage of insured persons has reached a historic high, that figure doesn’t say anything about the comprehensiveness of their insurance coverage, whether it’s affordable, or whether it’s delivering high-quality care.

The Association of Health Care Journalists has released a tip sheet educating reporters on how to spot and report on deepfakes, following concerns about cybercriminals trying to impersonate health system executives. Informatics guru Dean Sittig, PhD and professor of biomedical informatics at the University of Texas Health Science Center at Houston contributed to the document. Potential scenarios include using the technique to get employees to engage in activities that would allow criminals to gain access to technology, creating media that impacts an institution’s reputation, or creating media for use in blackmail efforts. The article also includes guidance from the Department of Homeland Security on how to spot faked images and videos and things to listen for in faked audio recordings.

From Renee’s Friend: “Re: lawsuit award. As a nurse, I’m always interested in stories about whistleblowers that address quality issues. This one about a Kaiser nurse who was awarded $41.49 million has me scratching my head a bit – check out the part about the isolette.” Apparently the nurse claimed retaliation and wrongful termination following her quality and safety complaints. However, the article notes that “In their court papers, Kaiser attorneys maintained that the 30-year employee admitted that in 2019 she took off her shoes and socks and placed her bare feet on an isolette, a medical device that holds sick or premature newborn babies. The defense attorneys included a photo of Gatchalian doing so in their court papers.” This seems truly bizarre and I can only imagine the events leading up to its occurrence. If anyone has more details, do share.

Axios reports on a recent survey that found patients are concerned about how their physicians may be using AI. The article noes that four out of five patients are concerned with the use of AI in making diagnoses or determining treatment plans, with the majority voicing concerns that they don’t know where the information feeding the AI tools is coming from or whether it should be trusted. Half are concerned about the creation of false information, while eight in 10 were concerned about AI using information from internet searches. That number fell to 63% when patients were told the tool was from a reputable healthcare source.

Even as a clinical informaticist who understands how various organizations are creating their AI-powered solutions, I am concerned about the frequency with which they engage clinical resources during the development process and the level of scrutiny present when engineering teams are determined whether a solution is ready for deployment.

An article published last week in the Journal of the American Medical Informatics Association looked at another angle to this issue – ethical perspectives on the development of algorithms used in healthcare. The authors identified areas where greater attention to ethics may be needed, along with technical challenges that influence clinical usefulness, and how solutions support the key ethical concepts of beneficence and justice. We are indeed living in interesting times.

What do you think about the role of ethicists in the development of AI solutions? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/11/23

December 11, 2023 Dr. Jayne 4 Comments

I’ve been doing some locum tenens work in a traditional family medicine practice. I can attest that the negative feelings that primary care physicians have towards performing uncompensated work are real.

I was brought in to provide coverage for a physician who is on family leave. I was impressed that the practice would go through the work effort to bring in a locum tenens physician. Many practices just expect the rest of the staff in the practice to absorb the excess work, which often causes resentment when there are partners who take more frequent family leave and others who feel that physicians should “power through.”

That was an interesting dynamic that played out during my interview process with the practice. The partners who were making comments about why they didn’t think my assistance was needed were generally older and/or male, and those who voiced support for having a locum were generally younger and/or female. However, there were some exceptions to the rule.

I hadn’t been told what kind of family leave the physician I’d be filling in for was taking, but was surprised at how willing some of the partners were to share another physician’s private information. One told me, “I worked every day during MY chemo, so I’m not sure why she thinks she needs to be out for her chemo.” On the surface, it’s an unprofessional comment, but it also clued me in to the potential for burnout in this practice since burnout is often associated with lack of empathy.

Another physician told me how glad he was that there would be locum coverage because he was tired of covering his partners because “so many of them have been popping out babies.” He mentioned that he didn’t ever feel the need to take paternity leave and his kids turned out OK. It was good to be clued in about the fact that I would be taking a trip to the cultural 1970s in this wayback machine of a practice, but I agreed to take the job anyway.

Although I have deep experience with the EHR the practice uses, I went through all the onboarding steps, which was good because I got to know the practice’s in-house trainers and super-users well. Fortunately, the practice’s use of technology didn’t mirror their attitudes, and I was impressed by how much delegation and automation they had in place for patients who had medical needs in between their office visits – things like refills, questions about lab tests, etc. Most of those were handled by appropriately trained staff members using standing orders and clinical protocols, which were also built into the EHR for efficiency. I’d give them an A-minus grade for overall efficiency compared to other practices I’ve seen, so I was surprised to hear some of the physicians complaining bitterly about their inboxes.

After getting my feet under me for a bit, I was able to explore what was really going on with patient messages since I was getting a lot of them. It’s been a while since I’ve been in an ambulatory practice during the typical open enrollment period for health insurance, and it turns out that questions about insurance plans, medications, coverage, and the like were making up a high volume of patient questions. Not only were employed patients sending in questions, but plenty of retirees had questions, too, thanks to some recent marketing campaigns on TV that tout the benefits of Medicare Advantage plans. It sounded like many patients were facing dramatic premium hikes and were trying to figure out how to get what they needed in the most economical way possible, but like most patients in the US, they lacked the context to be able to formulate the right questions.

For example, one question was, “Is Cigna better than BCBS for my medicines?” Since this question wasn’t addressed by any of the existing triage protocols, it came to the physician to address. No physician, care coordinator, or health navigator can answer the question with the facts provided. What kind of Cigna or Blue Cross Blue Shield plan are we talking about, HMO, PPO, or something else? Is it a commercial Cigna plan, or one that’s for a self-insured employer that just uses the Cigna network? Are there carve-outs for religious exemptions for employers in this predominantly red state? Is the patient using mail order or retail coverage? Are they stable on their medications or do they have new conditions that are being optimized? Patients were asking their primary care physicians because they felt they had nowhere else to turn to try to figure out what to do for their families.

One of my colleagues mentioned that he saw an article “where someone fed the plan data into AI and then asked it to make comparisons,” but noted that it would be nearly impossible unless you had all the plan details for the various options. Another mentioned that he just tells patients to call their employers and see if they have someone who can help. One noted that he had done that in the past, but found that employers were telling patients to call the office since they didn’t have any idea what the patient’s medicines were to determine the level of coverage. All of this together just goes to illustrate some of the key failings of our healthcare non-system in the US.

The idea that patients should be seen as consumers is part of the problem. Historically, consumer education in the US relies around people being able to make comparisons around price, looking at products with features that they generally understand. It’s one thing to compare the per-ounce price of two brands of pasta sauce, but things get more complicated when you’re trying to compare major appliances like washers. It’s another thing entirely to compare interest rates and mortgage terms to figure out which loan is the best option for a new home purchase. Looking at even more complex consumer comparisons, such as the purchase of an electric versus gas-powered vehicle, it’s different for people to assess because that decision also injects somewhat less-tangible values and feelings about renewable energy, tax policy, and more.

Now, take it to the highest level. Trying to perform comparisons of health insurance coverage is more like graduate-level consumer education. Given the levels of health literacy in the US, it’s no wonder that patients often have little understanding of their coverage.

Recent efforts to make price transparency data available to the public aren’t helpful for the majority of patients. A lot of healthcare is unplanned, and those are the costs that typically push people over the edge. Data from 2022 shows that nearly 40% of people in the US couldn’t cover an unexpected $400 expense. When someone’s child gets bounced off the trampoline and breaks their arm, parents aren’t going to head into the house and price-shop the internet to find the best deals on x-rays and orthopedic consultations. If they’re savvy, they’ll call the number on the back of their insurance card, make sure the emergency visit is authorized, and go to the facility they’re directed to. But a good number of patients are just going to hop in the car and go to the nearest hospital.

At the other end of the spectrum, when you’re diagnosed with a life-changing condition like cancer, what patient has any idea of all the healthcare charges they’re about to get hit with? How are you supposed to shop that around?

For patients with longstanding primary care relationships  — which are becoming fewer in this transactional healthcare landscape that is riddled with third parties trying to pick off the easiest and most profitable patients — these questions roll downhill to the primary care physicians, who are barely better equipped to answer them than the patients themselves. I took the issue to the office manager, who hadn’t previously been made aware of the volume of inquiries the practice was receiving. I’m glad I brought it up because it turns out that the practice’s affiliated health system has volunteers within their patient advocacy department who are tasked with helping answer those questions.

The practice was able to quickly throw together a protocol, including the creation of some quick phrases in the EHR to respond to patient questions and get them headed in the right direction. For those skeptical about having a locum in the practice, I guess I provided a little value-add that day. Now that open enrollment is largely over, those new workflows will be dormant for a while, but it’s nice to know that they’ll be ready for next year. 

As I thought through the whole process, it made me think about the use of AI to make this easier. All of the data needed to make true meaty comparisons lives in the EHR and its corresponding practice management or revenue cycle management system. You have all the medication data, including patient compliance and stability of the treatment regimen. You know what pharmacy the patient uses. You have the data on the different insurance plans such as contracts that at least give an idea about allowable charges and expected adjustments. You also have the data on other physicians the patient sees and their past history.

Certainly some smart people could figure out a way to pull that together along with the data from the insurance plans’ Summary Plan Descriptions, the employer and employee costs, and cost data from the local market. I’d pay money for something like that to help me make the hard decisions and I’m betting I’m not the only one.

What’s the solution to the chaotic problem of choosing your insurance coverage for the year? Is AI the answer? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/7/23

December 7, 2023 Dr. Jayne 10 Comments

Researchers at Brigham and Women’s Hospital, Massachusetts Institute of Technology, Celero Systems, and West Virginia University have created a new ingestible device that can monitor vital signs such as respiratory rate and heart rate. The so-called Vitals Monitoring Pill uses an accelerometer to pick up small movements in the digestive system that occur each time the patient’s heart beats or they take a breath.

The device was initially validated in an animal model, then used for humans as part of a sleep study trial. Although the study was small with only 10 patients, researchers found that the data the device collected was comparable to that collected using standardized monitoring equipment. The study was also limited by the fact that participants were either sleeping or resting in a bed and the authors note there is the need to evaluate it in a more natural environment.

Researchers plan to focus on modifications that could keep the device in the digestive system for up to a week and to develop systems that could release medication in response to certain readings. They propose to be able to use it to detect opioid overdoses and treat them without external intervention.

From ShowMe: “Re: the state of Missouri. The last one in the nation to get on board with a prescription drug monitoring program (PDMP). For several years, in the absence of a state solution, the St. Louis County PDMP has been the de facto solution and other counties participated. Missouri is finally rolling out their solution next week, but users have been warned that they’ll have less functionality with the new solution. Way to go, technology.” I reviewed the materials forwarded by ShowMe and it looks like providers will lose the interstate sharing options they previously had through St. Louis County’s PDMP. Instead, they’ll have to separately register for access to neighboring states and use those individual state PDMPs to perform queries. Illinois requires that registrants of their PDMP have an Illinois controlled substance license, which many Missouri physicians may not have, so drug-seeking patients may be able to exploit the data gap. Additionally, not all counties have agreed to transfer their historical data from the St. Louis County solution to the state solution, so gaps will exist there as well. Physicians have been asked to “please keep this in mind when making clinical decisions. As a result, co-prescribing of naloxone with opioid prescriptions is recommended.” Technology is supposed to support clinicians rather than cause new issues, but I guess it’s to be expected when a state is dead last at doing the right thing. Missouri was one of the last states to bring up an immunization registry, if I recall correctly.

From Jimmy the Greek: “Re: return to office. My organization’s leadership has asked us to ‘practice’ working in the office. Having spent more than half of my career in an office, the idea that I need to practice coming to the office before I do it for real is insulting.” Jimmy’s screenshots made my head spin. Although I appreciate the company’s sentiment, there are ways to offer the same information without being patronizing. Despite this being a team of IT professionals, they were encouraged to come to the office for a “dry run” to test the wi-fi, headsets, and desks as well as to experience the parking arrangements and practice booking a conference room and eating in the company cafeteria. Additionally, employees were told to test their commute to evaluate travel time and traffic considerations, but gave no mention of the fact that hundreds of employees returning to the office are going to totally change the traffic patterns around the facility. As someone who has been a people manager in both remote and in-person situations, I’d like to think that managers know their people well enough to know who has worked in an office setting before and who might be at risk for issues or might require extra support. At a minimum, the organization could have offered a free meal to help entice employees back.

The Joint Commission has unveiled a new certification which will become available starting January 1. The Responsible Use of Health Data certification will evaluate hospitals across key areas including deidentification, data controls, data use, algorithm validation, patient transparency regarding deidentified data, and oversight structure for use of deidentified data. It will be interesting to see how organizations prepare their employees for this certification and whether clinicians will discover that there is so much more to using health data than they realize. I recently was in a spirited discussion with a clinician who had been ignoring a patient’s request for an amendment to their medical record. When the chair of the compliance committee and I informed the clinician that this was a violation under HIPAA, she said we were “full of crap, because no patient information was shared.” It had never occurred to her that HIPAA covers much more than information sharing, because the organization’s training had a narrow focus. A follow up survey to other clinicians revealed that 90% of them didn’t know patients had a right to request an amendment and 12% thought it was acceptable to just ignore patient portal messages. It looks like this organization has some work to do, not only in education, but also in fostering professionalism.

NorthShore-Edward-Elmhurst Health has rebranded itself as Endeavor Health as a follow up to the $5.3 billion merger that was responsible for its creation. The transition effort will include new names for its hospitals as well as updated employee uniforms, websites, and of course a social media campaign. Statements from leadership were around the “inspirational and aspirational” nature of the name, but when I hear it, I only think of the similarly named PBS program. I wonder how the cost of a health system rebrand compares with filming a gritty period drama, but suspect the latter has a better return on investment.

After considerable good-natured cajoling by younger colleagues, this blog marks my first attempt at trying to stop using two spaces after a period. As someone who is in my fourth decade of touch typing and who learned on the venerable IBM Selectric, I can attest that it’s hard to learn new tricks. Objectively, the process change added frustration and reduced my typing speed significantly, but I found the mental overhead to be the worst. I think I’ll go back to the old ways that will die with me, along with the use of handwritten thank you notes, formal invitations, and knowing how to set a table to accommodate a five-course meal.

One space or two? Is it worth it to try to eliminate the extraneous keystroke? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/4/23

December 4, 2023 Dr. Jayne 2 Comments

I was invited to yet another retirement party this week. It was again for a primary care physician who is leaving medicine at an age that is decidedly less than the oft-discussed 65.

Burnout played a role in every retirement gathering I’ve attended over the last couple of years. It’s sad to see so much knowledge and experience leaving the field. More than half of these physicians would have been interested in continuing to practice part time, but it sounds like their corporate employers weren’t terribly interested in trying to make that happen. The practices they left continue to be slammed and have wait lists for new patient appointments that are several months long.

Most of my local primary care physician peers are a number of years away from being able to retire. I struggle to think of one colleague who isn’t suffering from some degree of burnout.

When asked what might help the dumpster fire that is healthcare in the US, quite a few cite artificial intelligence as the answer. Just use ChatGPT to write your prior auth letters! Or insurance appeals! Or letters for emotional support animals, educational modifications for school-aged patients, Family and Medical Leave Act documents, and more! The enthusiasm that people voice about these solutions seems to be contagious, but it’s rare that those who are using it fully understand the risks of feeding protected health information into different solutions, or that they can be liable if they’re allowing staff to use AI solutions for patient management but aren’t doing 100% review of the output.

With this in mind, I was excited to read a special communication in last week’s Journal of the American Medical Association titled “Will Generative Artificial Intelligence Deliver on Its Promise in Health Care?” If the title alone wasn’t enough to catch my attention, seeing Dr. Robert Wachter listed as the first author definitely helped.

Wachter and his co-author Erik Brynjolfsson note that historically, it usually takes many years for technologies to deliver promised benefits. Because healthcare is such a complex environment, this can make the incorporation of new technologies even more challenging. They go on to say that generative AI is different, though, and has “unique properties that may shorten the usual lag between implementation and productivity and/or quality gains in health care.” They also note that not only are health organizations more receptive to the technology, but that many “are poised to implement the complementary innovations in culture, leadership, workforce, and workflow often needed for digital innovations to flourish.”

The latter is an interesting point, especially since I’m often working with organizations that struggle to implement “innovations” that are more than a decade old. These solutions may not be heavy on technology, but are often fairly straightforward people and process adjustments that have the potential to improve patient care, reduce staff and clinician frustration, and create more efficient interactions in the healthcare system. Often they are relatively inexpensive to implement, but require the sometimes elusive stakeholder alignment in order to bring them to fruition.

Given all the buzz around AI-related solutions, I’m starting to wonder whether we can slap a label on them that says “AI-driven” and use that as a way to convince people to take some steps towards making their organizations run more efficiently.

Turning back to the JAMA article, some interesting facts jump out. First, nearly one-third of the $4.3 trillion that is spent in the US each year adds little to no value. I’ve seen that first hand in the urgent care trenches, where patient demand for testing and imaging studies often overshadows the physician’s judgment, particularly when an organization places a high value on patient satisfaction scores. Clinicians are trained to use a variety of clinical decision support rules to determine whether someone needs an x-ray after injuring their ankle, or whether a child needs an imaging study when they fall off their bed. However, insistent patients or parents may push or escalate, resulting in thousands of dollars in healthcare spending that could have been avoided.

It feels like we’re rarely able to make clinical diagnoses anymore, relying on the history, exam, and our education and training. Instead, we have to perform laboratories to prove ourselves sometimes, even when the answer is very straightforward. One organization I worked at pushed clinicians to order unneeded medications that could even be harmful, in the guise of “patient satisfaction.” Needless to say, I frequently wound up on the wrong side of that organization’s quality reports, but at least I had my integrity.

Second, preventable harms are still a major problem in the US, with tens of thousands of deaths happening each year due to situations that could have been mitigated. These range from simple medical errors that might be prevented with the application of basic technology (such as allergy warnings that appear when medications are prescribed) or complex errors that result from multiple failures along the way. Those can be particularly hard to work through as a clinician, since there are often many steps where the problem could have been prevented, but the system failed regardless. Electronic health records were initially seen as a solution to these difficult situations, but some days it feels like they have created two new problems for every one that they solved.

The article goes in depth to describe “the productivity paradox of information technology,” where technologies fail to deliver value. One main reason for this is the flawed nature of many early versions of technologies and the need to have multiple iterations before a successful tool is achieved. The second reason, which the authors view as more important, revolves around “the processes, structure, and culture of the workplace.” I felt validated when reading that sentence since I’ve lived it so often while trying to help organizations with their clinical transformation initiatives. The authors note the need to often have multiple complimentary innovations to overcome the productivity paradox. It’s another way of saying that no silver bullet exists for solving a difficult problem.

They go on to explain some of the “particular challenges” of implementing technology in healthcare. These are the factors that so many companies fail to understand as they promise to fix healthcare or revolutionize the patient experience. These challenges include the highly regulated nature of healthcare, differing opinions on data ownership, the need to protect patient privacy, and the fact that all these factors at times interfere with each other.

They go on to list other challenges, including the fact that the EHR market is highly concentrated with only a few major players left. In contrast, parts of healthcare have a plethora of players, including clinicians, care delivery organizations, payers, employers, pharma, device vendors, government, and more. As such, new technologies are likely to progress when they can make improvements for multiple stakeholders rather than for just one subset of players in the industry.

Other challenges that they list include the fact that healthcare data can be messy depending on where it comes from (billing, clinical documentation, compliance) and that healthcare is constantly evolving, often through research and changes in practice. As such, AI tools that are based on historical patient data may not be applicable in the present and in fact might be dangerous.

Last, they note that healthcare is high stakes, with the very real impact on patients making it potentially harmful to do the “fail fast and iterate” approach that happens in other technology environments. We’ve all seen innovations that harm patients, whether it’s an inadequately studied drug, a faulty medical device, or an improperly implemented clinical decision support tool.

Despite the fact that previous AI technologies haven’t delivered, (IBM Watson, anyone?) the authors see several factors that may lead to improved solutions this time around. They cite the relative ease of use of generative AI as a positive, along with the fact that the technology can be delivered to users easily through devices they’re already using. The ability to interact with new solutions via application programming interfaces (APIs) is also a plus, as is the speed of evolution of the generative AI solutions themselves.

The authors believe that healthcare leaders are better prepared to consider workflow redesign than their predecessors, in part due to the presence of clinical informaticists (yay!) and those with experience in user-centered design. They feel that leaders have learned from past failures as well. They mention the irony that many of the problems that were created by prior digital innovations – such as documentation burden and the EHR inbox – may be addressed by new generative AI powered tools, which would be a lovely thing for all of us.

It will be interesting to revisit the premises of this article after we’re six months or a year down the road. Maybe by the time generative AI reaches its second birthday, we’ll be living in a world of smoother patient care, streamlined communications, and improved clinical quality, all thanks to the wonders of artificial intelligence. It’s more likely, though, that major improvements will still take years, but at least that will be faster than the decades of inertia we’ve all been living in.

The authors call on AI developers to address elements such as bias, safety, cost, and hallucinations. They note that regulators need to develop standards that promote innovation as well as safety. They state that most important is for healthcare leaders to “prioritize the areas where genAI can create the greatest benefits for their organizations, paying close attention to those complementary innovations that remain necessary and striving to mitigate the known problems with genAI and any unanticipated consequences that emerge.”

What do you think about the role of generative AI in coming years? Are we on the cusp of greatness, or heading down the road to ruin? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/30/23

November 30, 2023 Dr. Jayne 1 Comment

We’ve made it past some of the early fall holidays, and those of us on the front lines are waiting to see if they will cause a spike in respiratory illnesses.

Heading into Thanksgiving, many parts of the US were feeling the pressure already. Respiratory Syncytial Virus (RSV), COVID, and influenza are leading the pack. At one point, all of the pediatric hospital beds in the Dallas-Fort Worth area were full, which should ring alarm bells for those who care about children.

My colleagues at Cook Children’s in Fort Worth mentioned that they were seeing up to 500 patients daily in the emergency department and were boarding critically ill patients in the emergency department because there were no ICU beds. New vaccines for RSV are in short supply in some regions, which will likely add to the problem later in the season.

This week, I ran across a couple of articles that talked about the fact that ChatGPT has only been around for a year or so. Headlines included phrases such as “ChatGPT scared the heck out of us,” and there was a lot of retrospective thought about whether its launch opened as big of a Pandora’s box as everyone thought it might.

Generative AI has certainly matured over the last year. There’s still a lot of hype about how it’s going to transform the way people work. One suggested that managers use AI to help define ambitious deadlines for projects that are underway, or that they can use it to create motivating speeches for their teams. It went on to say that AI could help identify ways to make the workplace more exciting.

Another gave the idea that AI could be used to create employee satisfaction surveys and to process results to determine how employees want to be incentivized. I kind of like this one since I’ve worked for several employers that totally disregarded employee sentiments. Maybe because AI is such a darling, they’ll pay attention to those results just because they were processed using a tool versus a basic employee survey. One article brought up an interesting tidbit about OpenAI’s GPT-4, namely that certain restrictions can be bypassed by using less-common languages such as Gaelic or Zulu. That’s definitely interesting, and you can bet I’ll be playing around with that idea.

Just a few days prior to the Veterans Day holiday in the US, the Department of Veterans Affairs (VA) met its goal of enrolling one million veterans in its genetic database, aptly named the Million Veteran Program. The database is unique because it links genetic information with electronic health records and also includes information on diet and environmental exposures. Researchers have been working for 12 years to reach the goal. Compared to other genetic databases in Europe, this one represents a more diverse population. The data is only available to physicians and scientists at VA facilities. Veterans can continue to enroll either through the link above or by calling 866.441.6075 to make an appointment at a VA facility.

Although the VA’s EHR project certainly gets a lot of press, there is so much more that the organization is doing to support veterans. It’s a vast organization, with locations from coast to coast. This year, the Veterans Health Administration delivered 116 million patient appointments at 1,300 facilities, beating the previous record by 3 million. It’s not only a care provider, but manages benefits applications and compensation programs, which necessitates maintaining a different staffing profile than other healthcare organizations. It’s also responsible for delivering services around those parts of its business. To give you an idea of scale, its Health and Benefits App reached 1 million downloads this year.

The VA is also actively investing in the artificial intelligence space, working on tools to reduce employee burnout. It plans to launch an AI-related contest that features $1 million in prize money for teams that create the best solutions in speech-to-text for medical appointments and in document processing as non-VA medical records are added to the patient’s VA chart.

Several of the physician groups that I follow on Facebook have had an overwhelming number of posts about cybersecurity incidents. Since organizations tend to take their entire network down when there is an incident, that means that physicians have no access to downtime solutions such as disaster recovery servers or third-party information archives. Although the health systems in question typically put out press releases that state that patient care is being delivered safely and effectively, comments from the trenches seem to reflect an environment that is anything but:

  • No ability to look up labs.
  • No way to access history and physical forms for surgical procedures.
  • Hand writing operative reports.
  • Clinicians who are relatively new grads have never charted on paper.
  • Systems haven’t practiced for downtime events, resulting in mass chaos.

One clinician whose system recently went through a cybersecurity event but is back online noted that she recommends keeping copies of all handwritten notes. Apparently, many were lost during the event and were not scanned or otherwise added to the system, resulting in requests for her to redo documentation weeks after the event. Another reported that his hospital was down for over a month, which as a clinician, I can’t even imagine. Hackers are a reality and organizations that think it couldn’t happen to them are mistaken. I challenge all the CIOs and CMIOs out there to ensure their organizations have adequate supports in place and that they’re practicing for a potential event.

I dropped by my primary care office this week to get a vaccine booster. Despite having just had my photo ID scanned at another office in the same system last week, I had to again present photo ID to be scanned as opposed to just being verified. I could see the previous scan of my photo ID on the receptionist’s screen, since there was no privacy filter on the monitor. I could also see my photo on my patient chart, which matched the already-scanned ID. I understand she was likely just following an office policy, but this is where I challenge people to make sure that the policies in place make sense and/or provide value or whether they’re just process for process sake.

I was also greeted with a 2020-esque COVID interrogation, including being asked if I had traveled internationally in the last six months (yes), whether I had been around sick people (yes), whether I had traveled internationally in the last 30 days (yes), and whether I had any respiratory symptoms (no). There were no follow-up questions to any of the positive responses.

As I sat waiting to be called back, another couple came in, and when asked the question about sick people, they asked, “What do you mean by sick?” It was clarified to be “measles, mumps, or chicken pox.” I suppose I should have been a “no” on that one then. They weren’t asked the question about symptoms. The couple was already wearing medical masks, so I’m guessing the receptionist made an assumption if the intent of the questioning was to determine if patients should have masks. Respiratory season is upon us and it will be interesting to see if the questionnaires morph as the season progresses.

The good thing that came out of that visit is that they pointed out that I had an open order for follow-up testing, which was interesting because the test had been allegedly scheduled during the in-person visit at another office last week. Apparently it hadn’t been scheduled properly, and had I not gone for that vaccine, I wouldn’t have had a clue. Four phone calls later, I finally had it scheduled, and I must say the patient experience component of the entire process has been lacking. At no point during any of the conversations did anyone apologize for the dropped ball, not even a lukewarm “I’m sorry you’re feeling frustrated by this.” It’s not an experience I want for my patients either, which is making me rethink my referral patterns. Where’s a patient satisfaction survey when you need one?

Does your organization actively work to stamp out non-value-added processes, or is it content with simply doing things the way they’ve always been done? Have they shifted processes to put more of the burden on the patient? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/27/23

November 27, 2023 Dr. Jayne 3 Comments

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We’ve made it past the Thanksgiving holiday, and hopefully people were able to spend time with their loved ones and then have a little time on their own to de-stress before heading back to work.

Historically, this time of year brings out all kinds of family drama. Looking at the data from one of the practices I work with, over the past couple of years there have been upticks in the number of visits for anxiety and depression between mid-November and mid-January.

Although I avoided dinner time conversations about Medicare, one family gathering involved a conversation about hospital-affiliated primary care practices that are charging facility fees. Another covered the move of private equity organizations into the local care ecosystem, leading to decreased access as they cut providers from their rosters following acquisition. US healthcare is certainly in a dark spot, and patients are paying the price as they find it more difficult and more expensive to get the care they need.

Local pharmacies have been eager to step into this gap. However, one elderly relative discovered that it wasn’t as easy to get appropriate care as it should have been. She’s in her 80s and has multiple risk factors for severe disease from RSV infection, so she tried to make an appointment for the recently approved vaccine. She walked into a location of a nationwide retail pharmacy chain and was told she couldn’t get the vaccine without an appointment. However, per her recollection of the story, they wouldn’t make an appointment for her, instead telling her to call for one. She called and wound up in a phone tree system, which kept prompting her to choose a location despite the fact that she was standing in one. When she selected the prompt to speak to a representative, it continued to ring, but no one answered.

She went to another location, which refused to administer the vaccine because she didn’t have a prescription. I’m not sure if this was because the pharmacy didn’t have the appropriate standing order in place from their medical director, or if it was some kind of insurance issue, or if they didn’t want to do the counseling since the vaccine isn’t strictly recommended based on age but rather as a part of a shared clinical decision-making process.

Either way, she left without her vaccine and instead spoke to her primary care physician. It sounds like the primary physician isn’t keeping up with the literature, because he told her she didn’t need the vaccine because she “isn’t around babies,” which has nothing to do with the indications for the vaccine. It’s designed to reduce the burden for a disease that hospitalizes more than 60,000 older adults each year and results in up to 10,000 deaths among retirement-age adults each year.

I’m hoping that the EHR team at her primary care physician’s office ensures that the vaccine is added to health maintenance dashboards so that physicians who aren’t keeping current might be prompted to address the condition with their patients. Hopefully that hospital-affiliated organization will also be providing continuing education to ensure physicians are aware of current recommendations, since it’s foolish to assume that technology alone can solve a clinician knowledge gap.

But in the mean time, thinking about my family members, I was tempted to dig out a prescription pad and just write the order myself. I don’t practice medicine like that, though, so I provided some coaching to hopefully help the patient have a better conversation with her physician. In the mean time, I’ll be calling a couple of pharmacies to see if they have standing orders in place that would allow her to get the vaccine.

Is this a place where telehealth-only organizations might help patients that can’t get what they need? Probably not, since many of them won’t allow their clinicians to order injectable medications even if they are low risk, like vaccinations. At one telehealth organization where I worked during the height of the COVID pandemic, we weren’t even allowed to write letters that would have explained that patients were high risk and could receive priority vaccinations. Even though providers on those networks are usually independent contractors, they’re often constrained by group policies that prevent them from doing things that might otherwise be straightforward in a traditional medical practice.

Speaking of telehealth, a recent article in JAMA Network Open looked at how patients complete tests and referrals when those services are ordered as part of a telehealth visit compared to those ordered during in-person visits. The telehealth visits were delivered by providers at a large hospital-affiliated primary care practice and community health center in Boston during the time period between March 1, 2020 and December 31, 2021. The authors looked at colonoscopy orders, dermatology referrals for suspicious skin findings, and cardiac stress tests. They found that only 43% of orders placed during a telehealth visit were likely to be completed, compared to 58% of orders placed during in-person visits. Interestingly, 57% percent of orders placed without a visit (perhaps as a result of a non-visit telephone call, or a patient portal message) were completed.

The authors suspect that one reason for the discrepancy might be the absence of schedulers or medical assistants to help patients during telehealth visits, or the lack of follow up communications encouraging patients to close the loop on their orders. That doesn’t explain why the non-visit orders were completed as frequently as they were, however, unless schedulers were assisting those patients. I would be curious to look at completion rates for orders from third-party telehealth organizations. Some of them won’t even generate orders for patients because they have no way to get those orders to a performing facility near the patient. Others limit their orders to those that can be done as part of an employer wellness program, such as diabetes screening tests or cholesterol testing. Third parties are often worried about liability, and given the transactional nature of many visits, there isn’t a mechanism to follow up on abnormal test results or to easily communicate follow up instructions to patients.

As someone who has done a lot of process engineering work, these are the “people” and “process” parts of the equation, but I continue to see organizations that try to solve them with “technology” alone. I’d love to see more organizations put their money towards solving people and process problems, whether it’s integrating a checkout person or scheduler into a telehealth workflow or making it easier for patients to self-schedule certain tests and procedures or doing a better job of reminding patients of orders that aren’t completed. Certainly, technology is part of all of those solutions, but it’s not the only answer.

How is your organization making it easier for engaged patients to receive the services they need? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/20/23

November 20, 2023 Dr. Jayne 1 Comment

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The Centers for Disease Control and Prevention (CDC) has launched an initiative to tackle burnout in healthcare. The Impact Wellbeing initiative falls under the auspices of the National Institute for Occupational Safety and Health (NIOSH). According to the tagline on its website, it’s designed for “building a system where healthcare workers thrive.” It will provide “evidence-informed solutions” and resources to hospital leaders on avoiding burnout and promoting wellbeing for workers.

I was pleased to see that the website encourages hospitals to use materials from the Dr. Lorna Breen Heroes’ Foundation to address how hospitals can help staff address mental health needs without being penalized. Many hospitals and healthcare organizations still have questions on their employment and credentialing applications that stigmatize mental health conditions rather than supporting those that live with them.

As an example, one job for which I applied asked, “Have you ever been treated for a mental health condition?” with boxes to check yes or no, but no way to provide explanatory information. A better way to approach this is to ask whether the applicant has any current impairment that will prevent them from performing the duties of the position. There are plenty of mental health conditions that are episodic, and asking about past conditions that may be resolved hasn’t been shown to do anything but prevent people from honestly answering the questions.

In looking at some of the other materials on the site, as well as interviews with NIOSH staff that appeared in the media at the time of the announcement, it feels like the organization’s leadership understands that talking about resiliency or offering wellness programs doesn’t scratch the surface where employee mistreatment is concerned. Healthcare workers encounter bullying, harassment, and moral injury on a daily basis and those elements need to be addressed as part of an overall solution.

The initiative also encourages the leadership of healthcare delivery organizations to involve those affected in the process of defining the issues and solving them. I don’t know when it became a revolutionary idea to talk to people in order to understand their needs, but I’m happy to see recognition of the idea featuring prominently in the campaign. Organizers can use the NIOSH Worker Well-Bring Questionnaire to better understand where their workers are across domains that include policies, culture, environment, personal health, and home/community factors.

Although I appreciate that the focus of the campaign is on hospitals since they’re such a critical part of our healthcare infrastructure, I’d like to see these elements addressed in other care delivery sites, such as urgent care centers. There are 14,000 urgent care centers in the US, and according to data provided by the Urgent Care Association, more than 25% of adults visited an urgent care center in the last year.

Unfortunately, the level of regulation for those facilities varies from state to state, and in talking to physician colleagues, abuses are becoming more common as private equity companies expand in the industry. For a while, we saw a lot of emergency department physicians leave those environments to go to the relatively slower pace of urgent care. However, as the complexity of patients presenting to urgent care rises, and the number of patients physicians are expected to see each hour increases, we’re seeing physicians leave those environments as well.

Given the reliance by hospitals on nurses to deliver patient care, there’s a lot of push by nursing organizations to improve things. Since urgent cares use many more non-nurse caregivers — such as medical assistants, emergency medical technicians, and unlicensed patient care technicians — to deliver care at a lower cost, there aren’t many advocacy organizations looking out for those workers.

Quite a few urgent care centers are physician owned and operate more under a private practice model than an emergency care model, so that adds another element to the problem. In my area, a local multi-site urgent care center recently closed after the physician owner was arrested, leaving staff and patients in the lurch. Other organizations have struggled to absorb those visit volumes in the face of their own staffing shortages, and it’s been a bit of a mess.

Meanwhile, capable physicians sit on the sidelines because they’re not willing to go back to abusive environments. At my former clinical employer, nearly all the physician employees left when the private equity company that acquired it started tightening the screws to squeeze out more profit. I know at least six of us who would return from our early retirements if the working conditions were less atrocious.

In speaking with colleagues across the country, this experience is in no way unique. One local urgent care chain classifies its physicians as hourly employees, but pays a “shift rate” that requires them to stay until all patients have left without additional pay for the additional time. I’m not sure how that’s legal under state labor laws, but they’ve gotten away with it for a number of years. On the other hand, it might be one explanation for why they have locations that are mothballed because they can’t staff them.

I admit I didn’t read every single word on the CDC website for the program and didn’t follow every link, but I didn’t see any mention of how organizations need to do more to believe workers when they complain or how to take action when issues are reported. There is still a culture at many organizations of just saying “it is what it is” or “suck it up” when employees report exploitive practices. People are suffering from compassion fatigue, which can lead to lack of empathy and may contribute to workplace bullying if left unchecked.

At one local hospital, nurses scheduled for 12-hour overnight shifts routinely have to stay for 14 or 15 hours due to staffing issues. I guarantee that situation is not doing much for morale or burnout prevention. Even among healthcare workers, I hear comments like “you chose healthcare, what did you expect?” which doesn’t help solve the issue. I have a handful of non-medical friends who understand what we go through, but when medical folks can’t even support each other, how can we expect outsiders to understand what we’re going through?

It will be interesting to follow the progress of the initiative over time and to see how many organizations are using the tools and trying to drive positive change vs. just paying lip service to the idea.

If you’re a care delivery organization leader, had you heard of the initiative before today? What steps are you taking to drive change? Leave a comment or email me.

Email Dr. Jayne.

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