Curbside Consult with Dr. Jayne 3/10/25

As a primary care physician and CMIO, I understand the importance of measuring things. We measure quality metrics, efficiency metrics, and various other factors to improve healthcare

During the early days of EHR adoption, long before the Meaningful Use years, I would encounter physicians who were against expanding the use of metrics in our physician group. We only had a small number of things we were measuring at that point – antimicrobial stewardship, appropriate testing for strep throat, patient satisfaction score, and a couple of other things. No more than five or six. However, physicians were concerned that we would start measuring a host of other things that would make their lives difficult, arguing that their patients were sicker and that having to demonstrate quality would detract from the care of those complex patients.

Fast forward a few years to the Meaningful Use days. The whole country was incentivized (or forced, depending on how you look at it) to start measuring many more elements. Fortunately, our EHR was long established and we were already delivering high quality care, so it was fairly straightforward to add a few metrics here and there to meet the regulatory requirements. We made sure as many processes were embedded in the workflows as possible and offloaded the vast majority of data capture to support staff so that our physicians didn’t become data entry clerks.

“I’ve seen the consequences when clinicians apply clinical guidelines to patients for whom they don’t make sense.. As we developed EHR training documents for upgrades and updates, I always made sure that we reinforced how clinicians can exempt patients or exclude patients from certain measures. Following the appropriate process in the EHR makes sure that providers aren’t penalized in the numbers for doing the right thing for a patient even though it sounds like it’s contrary to the guidelines. Usually, providers indicate a reason for the exclusion, which quality folks and researchers can use to understand why people aren’t being included in the measurements.

People ask how quality guidelines can be hurtful, so I’ll give an example. If you’re a patient who has had cancer, and who has had the offending body part removed, you need to be excluded from future screenings of that body part. If you no longer have a colon, you do not need a colonoscopy. I’ve been in enough patient support group meetings to hear stories that no one should ever have to hear, especially when there’s an easy way to make sure they don’t get reminder messages that add to their trauma.

This is important for organizations to understand when they are designing the reports that generate these reminders. There are ways to not only look at the exclusions, but also to look at elements of the patient’s history to reduce the risk that you’re prompting patients for services or tests they don’t need.

Guidelines that are applied too strictly can also cause patient harm in other ways. I was visiting an elderly relative today at her independent living community to drop off a prescription that was missed by her usual delivery service. She mentioned that she had been eating her meals in her apartment, which is a departure from her usual pattern of going to the main dining room in the evenings. She has had intermittent issues with social isolation since being widowed, so I wanted to find out more about what was keeping her from going to eat with her friends.

It turns out that her primary care physician doubled one of her diabetes medications, resulting in some digestive distress that’s worrisome enough to keep her in her apartment. I asked what her diabetes numbers looked like and we took a trip into her patient portal, where I confirmed that her hemoglobin A1c had indeed gone up, representing higher average blood sugar levels over the last few months.

Her last visit note, which was clearly captured using ambient documentation, noted the fact that she had consumed a three-pound jar of peanut M&Ms between Thanksgiving and Christmas, likely leading to elevated blood sugars. Bonus points to the ambient solution for capturing many of the details, as my relative is certainly a talker.

However, the note also contained what I would describe as a mini-lecture about “the importance of tight glucose control in preventing the 10-year complications of diabetes.” I thought that was funny, because this patient is just a few years shy of 100 and has had negligible complications of her diabetes, which is of fairly recent onset. She’s as healthy as a proverbial horse from a physical standpoint, but she’s at real risk for worsening depression, which has made her nearly housebound in the past.

I know her primary care physician personally, having trained him on his first EHR a decade ago, but it made me wonder a bit about what he is thinking with her care. Is he just following algorithms to drive that hemoglobin A1c to goal come hell or high water? Or does he not have a lot of experience with nearly 100-year-old patients who have different risk/benefit profiles than younger patients? Does he know that driving blood sugars too low is a much bigger risk in her age group? Does he not see depression as a risk factor in the same way that her family does? Does he see patient values and preferences as part of the decision-making process? And if they had a risk/benefit conversation and she declined to take the higher dose of medication, would he know how to adjust things in the EHR so that his paycheck won’t be impacted by her lack of tight glucose control? Having worked in the same system for years, I know how to do the exclusion, but suspect he might just be running a bit on autopilot.

My relative and I worked together to send a patient portal message to the care team outlining her symptoms and the fact that she’s been essentially isolated since the medication change. I’m glad that I’ll be able to follow along with any replies and adjustments in the portal. We joked about the situation with the peanut M&Ms, and I suggested that maybe she should fill a separate pill box with her daily ration of treats so that she can enjoy them, but not overdo it. I hope that I’m doing as well as she is if I make it to her age, but it’s important for her to be able to enjoy every day since the next one isn’t always promised.

If you make it into your 90s, what food would you use to treat yourself regularly? Leave a comment or email me.

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