EPtalk by Dr. Jayne 6/29/23

Telehealth is here to stay, and the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act has been reintroduced in the US Senate, this time by a bipartisan group of 60 Senators. A companion bill was also introduced in the US House of Representatives. The bill was first introduced in 2016 and aims to expand coverage of telehealth services through the Medicare program. It would amend the Social Security Act and includes provisions to: expand the range of health professionals who can deliver telehealth services; remove requirements for in-person visits in tele-mental health programs; expand telehealth in rural health clinics and health centers; remove geographic restrictions on telehealth services; and require research on the impact of telehealth on quality of care.

Broadening the reach of telehealth is part of the overall solution package needed to deal with the physician shortage, disparate distribution of physicians between urban and rural areas, and lack of access for many in the US. It’s naturally complimentary to other strategies such as team-based care, nontraditional appointment times, and the ability for patients to be seen at a location that is convenient to them. In speaking with members of my community, a large number of people aren’t aware of the care options available to them, including after-hours clinics and telehealth. In addition to legislation, health systems and care delivery organizations need to do a better job informing patients of their options for care beyond the traditional doctor’s office. It seems like payers and employers are doing a better job pushing telehealth (most likely because they see it as a lower-cost alternative to in-person visits), but depending on where they’re steering patients, it might be contributing to fragmented care. We’ll have to see how this bill makes it way through Congress or if it will just sit there on Capitol Hill like so many other bills.

I’ve been following some public health informatics issues, and was surprised to see a recent write up describing the transmission of malaria in the US. A handful of cases have been detected in Florida and Texas, after being eliminated from the US in 1951. (An eight-person cluster of cases was identified in Florida in 2003 without further spread.) Although the risk of being infected with the disease is low in the US, there are plenty of other reasons to either use insect repellent or wear long pants and long sleeves during outdoor activities. Malaria is a serious medical condition and most physicians in the US don’t think about it when they’re seeing patients who haven’t traveled to areas in the world where transmission is more common. I’ve seen a couple of professional organizations issue bulletins to their members, so hopefully this will help get the word out as well. Maybe some of us in the CMIO trenches can consider clinical decision support interventions to help our clinicians think of diseases that might not yet be on their radar. Symptoms include fever, chills, headache, and fatigue. Although patients typically get sick within a few weeks, there can be a lag of up to a year after the initial infection, which adds to the difficulty in diagnosis.

In other public health news, healthcare expenditures due to pickleball are on the rise. UnitedHealth Group has detected an increase in healthcare utilization due to pickleball-related injuries. The game is increasingly popular among the senior set and may be contributing in the neighborhood of $377 million to healthcare costs for procedures such as emergency department visits, outpatient visits, knee surgeries, and hip replacements. It would be interesting to see if the increase in costs is similarly associated with paddle tennis, which is a similar concept but “not remotely the same” according to my racquet-wielding friends who can cite the differences like they’re defending a dissertation. Pickleball growth continues with estimates that the number of players will reach 22.3 million this year, with seniors accounting for nearly a third of the pickleball regulars.

Complaining about the EHR is a common activity for many physicians, especially those whose organizations haven’t taken steps to tame the inbox or provide adequate support staff to manage the rising numbers of patient-generated messages and requests. A recent study in JAMA Network Open notes that part-time primary care physicians spend more time using the EHR per hour of clinic than their full-time colleagues, and also spend more time outside scheduled appointments. Data from the University of Wisconsin-Madison looked at 11 months between May 2021 and March 2022. EHR measures were normalized per week and per eight hours of scheduled patient time. The authors found that panel size, visit volume, or message volumes didn’t explain the additional time spent by part-time physicians.

They did find that the part-timers spent more time in their inboxes but were unable to fully draw conclusions from that finding, hypothesizing that “more EHR work outside scheduled hours … may allow them to feel caught up or allocate more time for panel management work ….” The study is limited by the fact that it was done at only one center and had a relatively small number of participants. It also included non-patient-care EHR administrative work that part-timers (such as your friendly neighborhood CMIO, super user, or practice champion) might do. Understanding exactly what is going on in the EHR with various providers is the key to improving their efficiency. I continue to see physicians who refuse to take advantage of EHR features that are designed to make their lives easier, and who would rather type the same phrase 20 times each day than spend the seconds it takes to create it as a favorite for future use. It’s baffling, and I struggle to get into the user psychology that supports it, but I’ll continue to advocate to get physicians on the happy path.

On a recent trip, my inbound aircraft was carrying the remains of a fallen soldier. I was impressed by the level of respect shown by those waiting at the gate as well as the airport staff. Resources from the airport fire department and security offices were lined up on the tarmac in tribute alongside what appeared to be family members. The flight crew held all passengers on the plane while an honor guard transferred the flag-draped coffin from the aircraft to a waiting hearse. For that moment in time everything stopped – a fitting tribute to someone willing to give his or her life in service of our country. Well done, MKE, well done.

For those of you preparing for the Independence Day holiday and the potential family gatherings this weekend – be safe, enjoy the time with family, celebrate our nation’s birth, and don’t forget the insect repellent.

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