EPtalk by Dr. Jayne 9/21/23

I was back in the patient trenches this week, having needed an appointment at a practice where I’m only seen every two or three years. This time around it was less than three, which is the cutoff at which most practices consider you to still be an “established” patient, but they treated me as a new patient nevertheless.

Despite having information in the EHR that they could have printed and asked me to either update or confirm accuracy, they handed me the proverbial clipboard, with six pages of information to read and/or complete. I absolutely hate when medical office forms ask me to write in my insurance member number and group number when they’re right there on the card that the front desk staff just scanned.

I felt validated when a patient who came in shortly after me went back up to the desk and asked if they needed to complete that section, since they had already provided it in the form of the scanned card. I felt a little less validated when the staff responded back by saying yes, they needed it as a “backup to the system,” which could also have been accomplished with a photocopy rather than introduce the potential of a transcription error with a patient copying information from the card.

Across the multiple sheets, I was asked for my primary care physician’s name and phone number two times and was asked for my pharmacy address once and phone number twice. As is common in medical office situations, the documents had been photocopied so many times as to be nearly unreadable in places, which made me want to educate them on the virtues of putting the “master copy, do not use” sticky note on the last sheet in the folder to ensure a clean copy is used for future copies. Alas, I wasn’t there in the role of practice management consultant, so I refrained, although I was sorely tempted.

One of the papers I was asked to complete was essentially the SOAP note (Subjective, Objective, Assessment, and Plan for the non-clinical folks) for the office visit, including a request to complete the History of Present Illness, including the prompts that coding specialists look for when assigning billing codes. These prompts hadn’t really been translated to patient-friendly terms, and still read “location, duration, modifying factors, and associated signs/symptoms” much like you’d see in a CMS manual or a medical history-taking textbook.

I gamely played along and admit that I did enjoy the radio station playing in the waiting room, which was FM 106 coming live to us from Dublin, Ireland. I wish they had radio in the exam rooms, because I could hear in great gory detail what was going on in the room adjacent to mine. A medical assistant popped his head in the door (literally halfway in and halfway out) and asked a few more questions, then said the practitioner would be in to see me. She arrived quickly, addressed my problem, and I had no complaints about the clinical care.

Given the paper nature of the office visit thus far, I was surprised to see a link to a patient portal account before I even made it out of the parking lot. I logged on later in the day and was shocked to see the documentation – vital signs were documented including a weight that bore no resemblance to my own, even though no vital signs were taken. Exam elements that weren’t performed were recorded in great detail, alongside the procedure note, which was fortunately accurate as to what actually occurred.

If those exam elements were used to substantiate a higher level of billing, then what we have there is fraud, which is concerning. As a patient, I shouldn’t be placed in the position of having to correct my records, but apparently that’s where I am at the moment. Seems like a call to the office is in order when I get a break in my schedule.

I’m a huge devotee of evidence-based medicine, where we use science and data to help identify the best treatments for our patients. Taking a data-driven approach has also been a big part of my informatics practice, where I look at system utilization and how multiple physicians are using the system before I approve changes that might have only been requested by one user.

In the sprit of evidence-based practice, I was interested to see an announcement by the US Food and Drug Administration (FDA) about the decongestant phenylephrine, which is found in over-the-counter medications including Sudafed PE and some NyQuil products. An FDA advisory panel found unanimously that the ingredient is ineffective, and questions remain whether it will be banned or whether drug companies will be given time to reformulate their products before having to pull drugs containing the ineffective ingredient from the market.

These types of announcements are important for clinical informatics folks, including our colleagues in the pharmacy sphere, as we have to try to find these drugs in order sets and physician favorites lists and send out bulletins to let people know of the announcement if they’re a frequent user of the drug.

The change in this drug’s status is also important for those of us who have followed the methamphetamine crisis in the US, which forced pseudoephedrine behind the counter and led to increased use of phenylephrine as an alternative. It’s the law of unintended consequences, with patients caught in the middle as they try to self-treat minor illnesses. (It should also be noted that the rise in phenylephrine use was also due to another decongestant, phenylpropanolamine, being pulled from the market in part due to an elevated risk of stroke with use.) The reality is that we haven’t seen much action in the development of new drugs like these in recent years and millions of doses of a drug that isn’t much better than placebo have been used by patients generating well over a billion dollars in sales. Here’s to all the informatics folks who will be hunting down this drug in the coming weeks to months.

This week was Telehealth Awareness Week, as decreed by the American Telemedicine Association. There has been a lot of buzz about it online and plenty of people saying how much they think telehealth is improving the healthcare ecosystem, but there are still some downsides to the modality. Healthcare organizations that aren’t embracing it may unwittingly encourage their patients to have more fragmented care as they seek visits with third parties that aren’t considering the patient’s existing records or sharing back to the patient’s medical homes. Other healthcare organizations are frankly encouraging that fragmentation through third-party contracts. A fraction has found a way to make it work, either by building their own telehealth workforce or by using integrated third parties, but they’re in the minority from what I see. On the telehealth platform where I practice as a physician, I have zero access to patients’ records and it makes delivering good care much more difficult than it needs to be.

So many of my colleagues are hyper focused on research in the realm of artificial intelligence that they might be missing out on other interesting topics. I was absolutely blown away by this article in Plos Biology that looked at how music can be reconstructed from brain activity in the auditory cortex. The article’s opening line “Music is core to human experience, yet the precise neural dynamics underlying music perception remain unknown” is a powerful one. In addition to not fully understanding perception, we also don’t understand what makes one person love a particular piece of music and another perceive it like the proverbial nails on a chalkboard. The authors worked with data from 29 patients who listened to a Pink Floyd song, ultimately reconstructing something recognizable out of the neural recordings. Music perception was more dominant in the right brain and researchers localized a particular part of the brain to perceive rhythm.

The authors noted that their findings show the possibility of “paving the way for adding musical elements to brain-computer interface (BCI) applications.” I was talking to a young colleague about this, and he profoundly stated, “Because if you’re going to do trippy mind control research, Pink Floyd is the way to go.” In case you’re wondering, the specific song used in the research was “Another Brick in the Wall, Part 1” which was cited as constituting “a rich and complex auditory stimulus.” Don’t worry about volunteering to be a research subject in this area soon, since the participants all had surgically implanted electrodes due to a diagnosis of drug-resistant epilepsy.

If you could only listen to one album for the rest of your life, what would it be? Leave a comment or email me.

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