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Curbside Consult with Dr. Jayne 11/27/23

November 27, 2023 Dr. Jayne 3 Comments


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.

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Currently there are "3 comments" on this Article:

  1. I feel for your elderly family member who could not easily get the RSV vaccine. I take care of my 88-year-old mother, and for ease, I’ve been getting all her vaccines at our local Walgreens. They do require an appointment, so I use their website; my 88-year-old mom could not navigate that on her own. She recently got Flu, RSV, and COVID at a single appointment, and instead of a pharmacist injecting, they now have a full-time RN for this purpose. No Rx was necessary for any of those 3 vaccines for her age group. This should not have been so difficult for the local pharmacy to help your family member make an appointment. Our local Walgreens pharmacy is severely understaffed, so even though we had a scheduled/confirmed appt, we were seen 40 mins later.

  2. I understand and sympathize with your elderly family member story. I don’t agree with your solution though. Why are you not solving the problem at the source? If the PCP or other docs are not keeping up with latest stuff, why should they be allowed to practice? Isn’t it their job and they get paid several times more than median US income?

    EHRs can help but that shouldn’t take away the responsibility of a doctor.

  3. I think the points I took from your elderly family member is a demonstration of the disfunction of healthcare today. I would argue that all three of her attempts were unacceptable outcomes.

    Why is there a need to have the medical director add a vaccine to the ‘administrable’ list? Why has the CDC not designated some vaccines as administrable by any pharmacy with a licensed pharmacist? If there are specific concerns about who should receive specific vaccines then that guidance could be provided.

    The clinician not keeping up with the literature, maybe a subscription to UpToDate? I don’t envy clinicians’ need to keep their knowledge relevant — especially given the number of facilities that have been bought by PE firms — with the corresponding requirement to ‘make more money with less’. I know it is more than that, but it seems like that PE firms are not helpful to medicine, anymore than legislative actions are.

    About the EHR administrators — I can only speak about a half dozen EHR vendors — but, those vendors do not do enough to ensure their users have the best use of their system’s. The vendors should be releasing specific content that addresses the latest knowledge. That should include updates to Syndromic Surveillance, Vaccines, DUR, and general configurations to streamline their workflows. They should also be monitoring the clinic’s data creation to help them understand how the clinic’s entries impact the system and/or payments. The vendors should be more partners than they are today.

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