EPtalk by Dr. Jayne 5/26/22

Plenty of clinicians and health organizations are less enthusiastic about wearables than you might think. They’re still worried about the sheer volume of data that can be generated by patient-owned devices and how that needs to be managed with respect to electronic health records and who should own the follow up for any abnormal data. As wearable devices begin to identify more physiologic phenomena, this continues to come up in conversations. A recent JAMIA article looks at whether the ability of Apple devices to identify abnormal heart rhythms could potentially prevent strokes. The authors considered how they might identify high-risk patients in whom device data could lead to a diagnosis of atrial fibrillation and whether those patients would benefit from treatment with blood thinners.

The study used data from over 1,800 patients at Cedars-Sinai Medical Center and looked at both EHR and Apple Watch data collected between April 2015 and November 2018. They estimated the number of high-risk patients using three different methods: medical history, Apple Watch wear patterns, and atrial fibrillation risk determined by an existing validated clinical model. The authors concluded that using clinical and demographic data from the EHR might be helpful to identify patients who would benefit from device monitoring. They noted that “a randomized controlled trial to study the benefit of consumer-directed heart rate monitoring devices in preventing strokes would require either a massive sample size or an enriched sample of patients very likely to experience stroke” due to atrial fibrillation. They noted that Apple Watch users tend to skew towards young healthy, which might not be the best demographic for identifying those at high-risk for stroke. I’m sure there’s more to come because clinicians will continue to question how to best use patient-generated data.

Last week, the American College of Obstetricians and Gynecologists dropped New Orleans as the site of its 2023 annual conference, citing concerns about Louisiana’s restrictive stance on abortion. The group’s official statement noted: “Holding the nation’s largest gathering of obstetrician-gynecologists in a location where the provision of evidence-based care is banned or subject to criminal or other penalties is directly at odds with our mission and values.” There’s been quite a bit of discussion whether other groups will move their conferences as well. It’s a difficult decision as contracts and venues are typically negotiated years in advance.

Other groups are at least talking about it, though. The American Medical Informatics Association published a set of “guiding ethical principles” for selecting venues for AMIA events and conferences. The authors specifically note abortion and voting rights as issues that have led members to question where meetings are held. The document was created with input from AMIA’s Ethical, Legal, and Social Issues Working Group as well as its Ethics Committee and was approved by the AMIA Board of Directors in April 2022. Among the principles are commitments to:

• Right to benefit from science.
• Right to safety and security.
• Freedom to travel.
• Freedom of speech.
• Right to nondiscrimination and civil discourse.
• Human rights.
• Access to professional development.
• Transparency and veracity.

AMIA notes that it does not have a list of excluded or boycotted locations, but that the document will allow those who hope to host an AMIA meeting to evaluate their eligibility and the likelihood of a successful bid.

Speaking of organizations selecting interesting locations, University of Pittsburgh Medical Center has opened a cancer center in Sicily, with clinicians receiving support from those at the Pittsburgh location. They’ll be offering medical oncology services that build on the hospital’s surgical focus areas including gastrointestinal and cardiothoracic cancers. In addition to this program, UPMC also has cancer center offerings for radiotherapy in Roma and Campania. I’m sure there are a fair number of clinicians who might be looking forward to rotating at the new site, depending on their love of cuisine and beautiful landscapes.

I’ve been doing a fair amount of work in telehealth, and there are still plenty of barriers to audio-only telehealth visits. Recently, the US Department of Health and Human Services held its first National Telehealth Conference and audio-only telehealth was discussed as a key strategy for health equity. Voice visits can be done without a smartphone or internet connection and can be useful for managing chronic conditions as well as many acute problems. In my urgent care telehealth practice, it’s usually the patient’s story that most leads me to the assessment and plan rather than the cues I might get from a video exam. Of course, certain conditions necessitate a video visit or at minimum a photograph, but often the value of the visit lies in the physician’s advice and counsel rather than with the exam.

Many of the telehealth patients I see are just looking for reassurance that they can wait for an in-person appointment in the morning. Others might not have tried any over-the-counter remedies and are looking for advice in that regard. Some have a self-limited problem that really doesn’t need a visit at all, but the patient’s employer is demanding a work note, resulting in unnecessary healthcare expenditures. There are still barriers to audio-only visits, including payer requirements for initial and/or ongoing in-person visits that aren’t an option for physicians like me who don’t have a brick-and-mortar location. If I couldn’t practice telehealth, I’d be out of direct patient care entirely, which doesn’t seem like the right answer for a nation with a primary care physician shortage.

Audio-only visits are important for rural patients who often have less access to telehealth services compared to their urban counterparts. A recent article notes a gap not only in telehealth service offerings, but in marketing them to rural patients. In rural areas, there are approximately 40 primary care physicians per 100,000 population compared to 53 in urban communities, and as rural areas struggle to recruit, this is not likely to improve. Of the patients I’ve seen in the last month or so, I’d estimate that 80% of them are from outside major metropolitan areas. I always find it interesting to see exactly where people are located as I confirm their pharmacy information or ask questions about their exposures as related to outdoor activities. (It’s tick bite season, in case you’re wondering, so please remember to wear long pants, long sleeves, and some insect repellent.) I’m glad that I can be a resource for those patients, but look forward to solutions where they have their own primary physicians who can coordinate care.

Have you had a telehealth visit in the last year? Was it audio, video, or asynchronous? What did you think? Leave a comment or email me.

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