EPtalk by Dr. Jayne 12/15/22

The clinical informaticist virtual water cooler is abuzz with conversations about how to address radiology decision support, given the fact that the Centers for Medicare and Medicaid Services (CMS) announced that it is “unable to forecast when the payment penalty phase will begin” for requirements to use Appropriate Use Criteria (AUC) for certain types of diagnostic imaging. For many organizations, the indefinite delay is prompting them to question whether they should remove decision support from their clinical workflows given the burden they add and the level of burnout among clinicians.

One of my colleagues has pressed its institution’s vendors to provide return on investment data to convince her why they should continue to pay for a product that angers clinicians. Depending on where a set of clinicians were at baseline with regard to ordering the impacted tests, there may be little proof that the solutions reduced inappropriate testing or improved efficiency. For those of us looking to help our clinicians any way possible, de-installation is certainly tempting.

My protected health information was included in a data breach that occurred last year at a large health system. In the notification I received several months ago, I was invited to submit a claim for the eligible time and expenses involved in monitoring my credit, cleaning up any problems, etc. Today I received a check as part of the settlement for the data breach litigation. I’ve been part of many data breaches over the years, but this is the first one where I got any monetary compensation, and I’m always happy to have a little extra cash this time of year. Of note, the check is void after 60 days, so I hope other recipients make a beeline to the bank or take advantage of mobile deposit quickly.

One of the organizations that won’t be getting any part of my recent windfall is Aspirus Health, since the website featured on the invoice I recently received takes me to a dead link. The system’s explanation includes migration to a new site. Of all the links you would want to test and validate, I would assume that the bill pay link should have been included, or the statements should have been updated. I’m not about to spend time contacting them to let them know, so I’ll wait until I can circle up with the family member that incurred the charge. Hopefully I can make a payment on their behalf through the patient portal, but putting more work on a patient (or guarantor) trying to pay timeline is never the answer to the question of how to optimize your revenue cycle.

Since emergency departments are packed across the US as the “tripledemic” of Influenza, RSV, and COVID creates havoc, telehealth is a hot topic. Despite its broad use since 2020 and the growth in proficiency by providers and patients alike, there is concern about its quality. A recent study published in JAMA Network Open looked at whether emergency department follow-up visits that are conducted via telehealth versus an in-person office visit would lead to return visits to the ED. The authors found that in this particular situation, patients who had telehealth follow ups after ED visits were indeed more likely to return to the ED, as well as being more likely to be admitted to the hospital.

The retrospective cohort study looked at adult patients who visited one of two EDs within an academic health system between April 1, 2020 and September 30, 2021. Patients participated in a follow-up visit with a primary care physician within two weeks of their ED visit. Approximately 70% of patients followed up in person and 30% via telehealth. For those receiving in-person follow-up, 16% returned to the ED and 4% were admitted to the hospital within 30 days. For those with telehealth follow up, the figures were 18% and 5%, respectively. Additional analysis showed that telehealth follow ups were associated with more ED return visits and hospitalizations per 1,000 encounters.

Before coming to conclusions, it is important to look further at the design of the study. It controlled for how acute the patient’s condition was, their associated comorbid conditions, and sociodemographic factors. Additionally, the authors adjusted models based on age, sex, primary language, race, ethnicity, Social Vulnerability Index, insurance type, distance to the ED, billing codes for the original ED visit, and the time from ED discharge to follow up. They note the need for further evaluation of telehealth’s effectiveness in this specific scenario of continuing care after an initial ED visit for acute illness. In the discussion section of the paper, they note that the findings “need to be considered in the context of a substantial body of science demonstrating the benefits of telemedicine” and specifically call out research demonstrating the value of the modality in managing chronic diseases such as diabetes, heart failure, and more.

They go on to propose a potential mechanism for the observed phenomenon: “the inherent limitation in the ability of clinicians to examine patients, which may compel clinicians to have a lower threshold for referring patients back to the ED for an in-person evaluation if they have any ongoing symptoms.” They also mentioned that patients who had telehealth follow-up visits tended to live farther from the ED than those who had in-person follow-up, proposing that “from the patient’s perspective, the remote nature of the encounter may cause them to seek further care for questions or concerns that they were not able to address via telehealth.” They note that future research is needed to understand whether patient-side or provider-side factors are influencing the decision for telehealth follow-up.

They also note that “telehealth clinicians may not be able to communicate as well with patients, leading to an inability to fully evaluate or intervene on evolving illness and leading to deterioration in patient condition and subsequent need for hospitalization.” I was intrigued by the comment about communication and reached out to a couple of colleagues who are on faculty at different medical schools. Both of them confirmed that their programs are not teaching telehealth skills to medical students, although they did say that some level of telehealth education was included in residency training programs for primary care. It will be interesting to see if that changes over the next few years as more clinicians are expected to render telehealth visits as patient preferences shift in favor of virtual visits. In reviewing the limitations, the authors note that discrete EHR data can’t capture complex social determinants of health, how well a patient feels, or whether they have social support or other resources needed for an in person visit. Additionally, conducting the study at a single academic medical center might not result in generalizable findings.

Healthcare technology is increasingly tied to the use of smartphones. I’ve been in a lot of conversations about what age is appropriate to allow minors to access their own health records via patient portals and how practices should consent to minors corresponding with their care teams. The COVID pandemic has raised questions about children and screen time along with the role that social media plays in anxiety and depression, so I’m always interested in strategies to help families make good decisions. AT&T has teamed up with the American Academy of Pediatrics (AAP) to offer a questionnaire to help with this decision making. It’s located on the AT&T website along with other resources for online safety, digital harassment, and parental controls.

The questionnaire asks about who is initiating the conversation about a phone, whether a parent feels one is needed for the child’s safety, whether it would help with connections to family or friends the child can’t see in person, the child’s level of responsibility and rule-following with regard to media, the child’s level of judgment and impulse control, whether the child readily admits mistakes, and whether the parent is prepared to set parental controls and manage online use. Even if the result indicates that the child and parents are in the “Ready Zone,” they are presented with resources such as healthychildren.org to learn more about technology use by children. Kudos to AT&T and the AAP for taking this on.

What’s the hot technology item on your or your family’s wish list? Leave a comment or email me.

Email Dr. Jayne.