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EPtalk by Dr. Jayne 7/18/19

July 18, 2019 Dr. Jayne No Comments

I took a little break from work and writing this week due to an unexpected illness in the family. As much as hospitals focus on their subspecialty capabilities, imaging, and technology, the one thing that stood out during our stay was the importance of compassion and high-quality nursing care. The care provided by both regular floor nurses and the hospice team contributed more to our patient and family experience than anything else the facility had to offer.

I’m glad we were at a community hospital with a patient-centric focus. The staff was kind enough to allow us to spill over into a conference room for take-out meals after the cafeteria closed and kept us fortified with drinks and snacks. I think we were the only hospice family on the nursing unit and it’s a fairly low-census time of the year for many facilities, but it was good to know they were looking out for ways to make us comfortable.

Being “the doctor in the family” puts you in a unique position. I was grateful that the nurses were willing to let me eyeball the orders so I could help put the rest of the family at ease about the plan of care. It was also an opportunity to think back on the patients in similar situations that I’ve cared for over the years and whether my efforts matched up to their families’ needs. Hospice care delivered in-hospital has come a long way from having the on-call intern make it up as they go along.

I appreciate the work done in the field to ensure patients have maximum comfort and that families have the support they need, especially when things don’t quite go as anticipated. I also appreciate the role of social media in the modern grief process. Although it’s easy to make fun of memes and the silliness we see out there, nothing beats being able to contact dozens of people quickly without having to call each one. Memories can be shared collectively rather than individually and overall it impacted positively on the experience.

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Now I’m back home and back to the healthcare IT grindstone. A reader sent me this article about a skill for Amazon Alexa that allows patients in the UK to receive answers based on information vetted by the National Health Service. The NHS hopes this will reduce backlogs for patients who need advice on uncomplicated conditions. I spent some time learning about care in the NHS firsthand and enjoy the British commentary on issues. The author notes that “maybe, just maybe, this could also save some from going down an online rabbit hole into rubbish health forums.” I had forgotten how much I love the word “rubbish,” especially in that context, and will look for ways to use it going forward.

As expected, privacy and civil liberties groups are against it despite Amazon’s assurances that confidentiality will be maintained. The Health Service has set up a special division, NHSX, tasked with increasing the use of technologies, including electronic prescribing, artificial intelligence applications for radiology, and more. Clinicians want to make sure that research occurs to ensure the quality of the advice, and also that accessibility factors like cost are factored in for new approaches. My experience with Brits and healthcare is that they tend to be quite matter-of-fact and that is borne out in the comments on the piece: “Take paracetamol (basically Tylenol), and if you’re not better or dead in 48 hours, contact your doctor.”

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New data has been added to the Physician Compare website reflecting data for the 2017 Quality Payment Program. We didn’t participate, so I don’t have any data, but a quick glance at several colleagues who did participate shows no data for them either. I’m not sure why they’re not displaying, but it adds to concerns about data validity and whether patients are really going to use the metrics to select their physicians. Most of the Medicare patients in my area select their primary care physicians based on who is accepting new patients and whether they can even get an appointment rather than being concerned about quality data that may or may not be accurate.

Speaking of data, here’s some that might be useful. Research presented at the American Diabetes Association annual meeting looked at whether individualized text messages sent to diabetic patients with recent emergency visits can improve glucose control, medication adherence, and ED utilization. The authors identified the ED as a place where high-risk patients can be engaged when they are in crisis and might be willing to make changes to improve their health. The goal is to use texting to bridge between the urgent issue and stable long-term care. The original intervention was one way and patients received two messages daily for six months. The control group received the same information in a pamphlet. The program has now been commercialized and a second module targeting family and caregiver supports is available. Although small at 166 patients, a study on that approach will be completed later this year.

The beginning of July marks the time when newly-minted physicians begin their careers as hospital interns. Internship and residency has changed quite a bit since I was in those trenches, mostly through the implementation of work hour reforms and the addition of dedicated days off, caps on admissions, and extra layers of supervision. A new study published in BMJ shows that “exposure of physicians to work hour reforms during their residency was not associated with statistically significant differences in 30-day mortality, 30-day readmissions, or inpatient spending.” The authors compared rates during 2000-2006 and 2007-2012 to reach their conclusions. The study looked at 485,000 admissions and compared outcomes for patients cared for by physicians in their first year of independent practice vs. patients cared for by physicians in their tenth year of independent practice during the same-year cohorts. The study is somewhat limited by its observational construction and limitation to internal medicine physicians, but it’s a good start.

For those of you in the EHR implementation trenches, how is your July going? Are the new house officers “getting it” or are you ready to pull your hair out? Leave a comment or email me.

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EPtalk by Dr. Jayne 7/11/19

July 11, 2019 Dr. Jayne 3 Comments

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I’ve been snarky about some of the things coming out of the White House in the last few years, but I can get behind the newly-announced effort to reduce the impact of end-stage kidney disease over the next two decades.

For a long time, there has been a push towards center-based dialysis and all the challenges that come with the procedure – patients making multiple trips to a facility each week, ongoing disability, and generally feeling crummy in between treatments. The goal is to move patients towards in-home dialysis, which can be liberating for patients who are good candidates for home-based treatment. I’ve been on cruises where patients do their own dialysis at night and participate in activities during the day without missing a beat. Not to mention that home dialysis is cheaper. Having worked with some of the dialysis giants in the past, I’m not sad to see them lose a little market share.

Medicare spends more than $110 billion on kidney care, which represents one-fifth of all fee-for-service payments under the program. The new directive includes payment models to encourage early treatment of kidney disease and advocation for home dialysis. It also includes mechanisms to refine organ procurement and a public awareness campaign to help patients realize the benefits of early diagnosis of kidney disease.

With a well-configured EHR system, it’s fairly easy to identify patients with or at risk for chronic kidney disease and start doing outreach. However, operational and clinical structures are needed to make the disease a priority among everything else practices are doing. It will be some time before all the rules and policies are in place to support this initiative, but it’s nice to see something positive coming to the healthcare community.

Last week the US government issued a new Request for Information as part of the Patients Over Paperwork initiative. The RFI seeks additional public input on regulatory, policy, practice, and procedural changes that would reduce administrative burdens for providers, patients, and families. The comment period will be open through August 12.

It looks like the feds are dragging their feet however on the Primary Care First initiative, where an application was promised in spring 2019 for a January 2020 start. I haven’t seen the Request for Application document yet and the website still shows it as pending, which is frustrating for practices and providers who were actually interested in the program. I’m guessing CMS had a bit of a premature launch on this one, based on the lack of deliverables and their ongoing rearrangement of webinars on various topics (the one scheduled for Wednesday, July 10 has been moved to July 24). Many of us are waiting for the application, which was promised to clarify various details. If you know anything about when it’s coming, leave a comment so the rest of us can play along.

My adventures in telehealth continue, so I was excited to see this article about mothers being power users of virtual medical consultation apps. I see a ton of ads on Facebook and other media targeting my demographic, and the vendors agree that women are a major audience. My brick-and-mortar practice has considered telemedicine, but hasn’t moved forward.

It would have been a great option to have the other day, when one of my provider colleagues called me to see if she could put herself on my schedule for a rash. Even though we had a phone conversation, she sent me a picture of the rash, and we discussed a plan of care, we couldn’t bill for the visit due to limitations in the EHR. Ultimately one of our medical directors took charge of the situation and got my colleague the care she needed, but in reality we were just a few clicks away from a virtual visit.

The telehealth segment is targeted to exceed $64 billion in the next six years, so it’s not surprising they are targeting family health decision-makers. Mothers make nearly 80% of the decisions around their family’s healthcare, according to a 2017 Kaiser Family Foundation study. It seems that most of the services being offered at present time are acute / urgent in nature but the smart money is on providers that are building out the true capability for virtual primary care.

I know I don’t want to go to a physician office as a patient unless I have to. Many are still highly inefficient and can suck the wind out of your sails for an entire day. I had an exception with a recent visit to the optometrist, where my physician was running late and they proactively offered a visit with another provider to keep me on schedule. I declined because I like my optometrist and he is worth the wait, but it was a nice gesture, and if I hadn’t had the day off, I might have taken the offer.

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I still run into a fair number of providers who don’t understand the Security Risk Assessment that is required under HIPAA. There are some great (and reasonably priced) vendors out there who deliver white glove service, but practices still opt to go it alone or try to skip it entirely. ONC and the HHS Office for Civil Rights are holding a training session for their homegrown Security Risk Assessment (SRA) Tool. It is designed for small to medium-sized providers to help them conduct their internal security risk assessment. A webinar will be held July 17 for providers and staff to better understand the tool. They will also have the opportunity to ask questions and provide feedback. I haven’t seen the tool lately – a previous version hadn’t been updated in some time – so I hope it’s beneficial.

Speaking of ONC, the public comments on the Trusted Exchange Framework and Common Agreement (TEFCA) are now available. ONC received more than 100 comments from a variety of stakeholders, including professional societies, providers, health information technology vendors, hospitals, public health organizations, payers, patient advocates, and health information exchanges. Most of the comments are what you would expect, although there are some curveballs among the submissions. I’m still struggling to understand what one individual from Tashkent was trying to say and how it related to TEFCA. Patient Stuart Morgan is “very much against these efforts to make my medical records more readily accessible by other parties that I have no control over.” He goes on to mention the difficulties in trying to correct inaccurate records, including “information that is totally false, entered by a doctor or other medical worker who appears to have a grudge against me.”

What was surprising about the list is the number of vendors who didn’t submit comments. Perhaps in their opinion TEFCA is perfect the way it is? Or maybe they were unaware it was going on? As a provider, I would be concerned if my vendor didn’t send a comment.

What do you think about TEFCA? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 7/8/19

July 8, 2019 Dr. Jayne 2 Comments

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I was off the grid this week doing some volunteer work. Since I sent Mr. H my posts in advance, I failed to notice that Independence Day in the US fell on Thursday, so Happy Belated Birthday, USA.

One of my volunteer partners is a US history teacher, who asked some very pointed questions that provoked discussion on how treasonous the revolutionaries were, Not just the so-called Founding Fathers, but the Founding Mothers who stood behind them. Cokie Roberts wrote a book using their correspondence as source material. I read it a few years ago and was glad to learn of women like Deborah Read Franklin, who held things together on the home front so their husbands, sons, and brothers could help shape a nation.

After being away, the first place I stopped on the internet was of course HIStalk, where I was ecstatic to learn that Samuel Shem is at it again with “Man’s 4th Best Hospital.” I still recommend “The House of God” to all of my clinical scribes who aspire to attend medical school or physician assistant school. Although many things have changed since 1978, there are still a number that are the same.

Clinicians are still faced with rampant absurdity on a daily basis and often develop some off-the-wall coping skills in an effort to not descend into madness themselves. I thought about it yesterday when multiple patients had issues where I was forced to offer less-effective care just because of their insurance coverage. Of course, it’s always the patient’s decision to pay out of pocket for the more effective option, but seeing that choice made is a rarity. I can’t wait to see his treatment of the topic of electronic health records and the crazy world in which we are forced to operate.

I’m glad Mr. H mentioned it. Even as a HIStalk insider, I still marvel at his ability to distill the news of the day and help us keep up even after we’ve deliberately avoided the internet.

As is usual after I’ve been away, my inbox was full of messages clamoring for my attention. It’s increasingly difficult to sort the wheat from the chaff. Although I have all kinds of rules in operation, I still struggle to find the important items at times.

An educational activity on “Managing Common Summer Health Conditions” from the American Medical Association caught my attention, although I was somewhat surprised that they grouped tick-borne illnesses and sexually transmitted syphilis in the same educational session. I was shaking my head, but then I came up with a couple of snarky “Summer of Love” jokes, so maybe they do indeed belong together.

I’m working with a client right now who is trying to optimize their EHR to help them improve a variety of clinical quality metrics. Despite efforts for federal organizations to corral these measures into a meaningful cohort that is supported across multiple groups of payers, they are tracking subtly different metrics for different audiences. They’ve worked with various payer medical directors and others trying to find a resolution, but everyone seems entrenched in their own specific benchmarks. They use the excuse that they need to keep the metrics the same across all their providers, but since most of the providers in this particular metropolitan statistical area are contracted with the same payers, it just means that everyone has to suffer with a hodgepodge of requirements.

I understand where the subtle differences come from. Perhaps they see particular trends in their patient populations, or perhaps they’re chasing outcomes noted in recent literature. If it’s the latter, I was excited to see a recent article in the Journal of Internal Medicine that looks at one of the healthcare cost kings – diabetes – and how it develops in older adults, which are going to be a large segment of our patients moving forward. The Swedish National Study on Aging and Care looked at nearly 5,000 patients, following them for 12 years. Most of the older adults with pre-diabetes either remained stable or returned to a normal blood sugar range, with blood pressure and weight management contributing to the latter.

It’s unclear whether these results from Swedish patients can be translated to other populations and racial / ethnic groups. If they can, it may support a change in how we think about these patients. If the results aren’t generalizable to different populations, it may argue for a more precision approach to disease management that current EHRs haven’t even thought of. I’m pretty sure that the addition of clinical guidelines that are based on sub-populations would make many physicians’ heads explode. On the other hand, that’s right where we’re headed with precision medicine, although we don’t yet have all the systems and financial support in place to support that type of approach.

As a physician, I’d like nothing more than to be able to input factors about my patient, their family history, their genetic makeup, etc. into my EHR and have it tell me exactly what screenings they need and when they need them. As issues arise, it could also advise on whether they need aggressive treatment or conservative treatment. Right now we spend money treating some diseases that from a statistical standpoint aren’t necessarily fatal and/or don’t cause a lot of disability; but since they’re there, we feel obligated to beat them into submission. What if we could pick and choose the patients who would most benefit from treatment?

Delivering those kinds of recommendations requires a tremendous amount of data. I’m not apologizing for the patient safety issues or workflow horrors found in many EHRs. However, it does improve one’s mood to remember the reasons (other than facilitating billing and keeping up with government regulations) why EHRs might be a good thing. I’m looking forward to the day I can have a system capture my spoken office visit through a console on the wall (come on, Nuance, refine that technology for primary care already) and adaptively learn what I’m going to recommend for a patient based on my past practices. I’m eager for the arrival of seamless data interchange so that clinicians can have all of a patient’s data at their fingertips. Until then, I’ll keep plugging away with the EHR and working from the sidelines to make the technology better for providers.

What benefits of technology are most exciting to you? Leave a comment or email me.

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EPtalk by Dr. Jayne 7/4/19

July 4, 2019 Dr. Jayne No Comments

It’s that time of year when CMS releases updates to ICD-10 codes for the coming fiscal year. The files are now available and go into effect starting October 1. For those of you used to receiving a General Equivalence Mapping update along with your new codes, you’re out of luck. CMS previously announced that they would only update the GEMs files for three years after the implementation of ICD-10. It’s hard to believe it’s been that long since we kissed ICD-9 goodbye. I wonder how many clinicians are hoping they’ll be long-retired before ICD-11 comes around? Most World Health Organization member states are slated to start using it in 2022, but I’m betting it will be a long time before it makes it to the US.

Kaiser Health News reports some interesting data from the Food and Drug Administration database containing medical device malfunctions and injuries. Manufacturers sent data to this “hidden” database via Alternative Summary Reports rather than to the public FDA database used by researchers and patients. Top tidbits include: blood glucose meters had more incident reports (2.4 million) than any other device, with the majority of them being manufactured by a former subsidiary of Johnson & Johnson; dental implants comprised 2.1 million reports; 176 deaths were reported through the non-public workflow, including those related to insulin pumps, pacemakers, and ventilators; surgical stapler malfunctions numbered 66,000 in the hidden database vs. 84 in the public database; and breast implants accounted for nearly half a million reports. Despite the visibility of this issue, the FDA has replaced the alternative “hidden” reporting process with a new Voluntary Summary Reporting Program that may be just as hard to track as the previous Alternative Summary reports.

In the Virtual Assistant arms race, CNBC reports that Google Assistant does a better job than Alexa or Siri in helping patients with medications, although studies still indicate that voice assistants aren’t ready for prime time where health or medical data is at stake. The study looked at queries regarding the 50 most commonly prescribed medications and whether users received accurate information when asking a device to “Tell me about” a particular drug. Google Assistant identified 92% of brand name drugs and 84% of generics, with Siri scoring 58% and 51%, respectively. Alexa trailed at 55% and 46%.

It’s time to cut the cat videos. Nearly all of us have fallen down the rabbit hole that is YouTube and found ourselves minutes (or hours) later having watched video after video. (My personal favorite begins with the “Nope Ropes, Sneks, & Danger Noodles” offering  from Lucidchart and devolves from there.) New data shows that the number of people spending two hours a day or more watching TV or videos is high – 62% of children, 59% of teens, 59% of non-retired adults, and 84% of seniors. This inactivity places us at risk for obesity, chronic disease, and overall mortality. I made a pact with myself to only watch Netflix while I’m on the treadmill, so thanks to “Halt and Catch Fire” for helping me meet this month’s fitness goals.

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I literally could not contain my excitement when I stumbled across this option in Office 365 that allows me to display a third time zone. I’ve been wishing for that enhancement for a long time and it will make my life so much easier. Not that I don’t know how to figure out time zones, but it’s a nice check and balance to be able to confirm it on the screen. We’ve all been the victim of wrong time zone meetings and I certainly don’t want to be a perpetrator. Now if they could just come up with a calendar widget for scheduling recurring meetings on different days of the week (a la GroupWise circa 2011) my scheduling desires would be complete.

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A recent Journal of the American Medical Association article introduces the concept of a TACo, or Targeted Automatic e-Consultation. The TACo aims to bridge the gap between traditional sub-specialist consultations, which are time-consuming, and so-called “curbside” or informal consultations. Traditional consults are problematic because they require analysis of the chart, examination of the patient, and detailed documentation; subspecialists who are in short supply at some facilities can run themselves ragged trying to complete all their consultations. Curbsides are informal and might be limited by the information available along with lack of an examination; usually the recommendations aren’t documented in the chart because there isn’t a physician-patient relationship. Unlike other consultations which require a physician or care team member to initiate the consult, the TACo would be automatically triggered by certain laboratory or examination findings as they are documented in the chart. The receiving subspecialist would have access to a “customized view of the pertinent information” for virtual review and could then suggest focused advice, a formal consultation, or neither.

The approach is under evaluation by the diabetes service at the University of California San Francisco. The EHR identifies patients meeting certain criteria and presents key chart elements to the diabetes sub-specialist. Management suggestions are documented and most reviews take less than five minutes. The team published data showing improvement in diabetes management through reduction in both high and low glucose events. The outcomes have allowed the organization to provide continued funding to support the time spent in review by the subspecialists. They plan to expand the TACo concept to other services including hematology, metabolic diseases, and infectious diseases with an eye to common conditions that may be managed incorrectly and can be triggered by objective data mined from the EHR. The authors note that “if TACos prove to be beneficial, a convincing argument could be made for payers to reimburse them, just as care coordination and telemedicine ultimately became eligible for reimbursement.” Even if they were billable, organizations would still need to expend resources in managing the technology required to support the approach.

Is your organization considering something along the lines of a TACo, or is it just lunch food? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 7/1/19

July 1, 2019 Dr. Jayne 1 Comment

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One of the challenges we have in healthcare IT is figuring out whether different technologies bring an adequate return on investment. This can be particularly challenging when the expenditure falls to one team’s budget (such as information technology) but the cost savings occurs elsewhere (such as the central scheduling department).

Organizations use a variety of cost transfer mechanisms to try to sort this out, but often the calculations fail to fully represent the true work needed to deploy a new solution, especially on the part of the end users. This becomes even more complicated when the solution is a combination of technical tools and operational changes, such as might be required for a practice to advance through recognition as a Patient-Centered Medical Home.

As we move into value-based care, it will be more important for practices to understand the costs and benefits of new models of care. To be honest, many independent practices are not well equipped to try to figure this out. I was excited to see that NCQA has engaged with Milliman’s actuarial team to offer guidance on how practices can calculate return on investment for that type of clinical transformation project.

The NCQA white paper is publicly available, and even if you’re not knee-deep in one of these projects, it provides background for greater understanding of what it takes to re-engineer a practice. The hypothetic practice in the paper represents a 10-physician primary care practice with approximately 20,000 commercially-insured patients. The model concluded that there would be an increase in revenue, although it varied from 2% to 20% depending on payment models.

Although 2% still represents a positive return on investment, I’m not sure how many practices would be willing to embark on wholesale modification of how they do business for that small of a gain. Many practices pursuing Patient-Centered Medical Home recognition do so for other reasons, including the belief that it’s the right thing to do and/or that they will be able to provide better or higher quality care for their patients.

As with any calculation of this kind, NCQA points out that this is a hypothetical practice and our mileage may vary based on the actual characteristics of our practices. To further the effort, Milliman helped develop guidance for practices to develop a pro forma to calculate their own return on investment data. The guidance is clear on the fact that the numbers will vary based on:

  • Practice size and location.
  • Payer mix and payer models.
  • Medical complexity of the patient population.
  • Degree of change needed to practice processes, procedures, and reporting to align with PCMH.
  • Ability of the practice to meet quality targets.
  • PCMH program rules.

I frequently work with practices that are considering whether they will pursue recognition as a Patient-Centered Medical Home. Often, they jump straight to trying to figure out whether their EHR supports PCMH or whether their technology vendor has programs that will make it easier. Some vendors support a subset of PCMH standards but not others – a host of organizations have developed recognition programs, including HCQA, The Joint Commission, the Accreditation Association for Ambulatory Health Care, and the Utilization Review Accreditation Committee, not to mention other homegrown programs developed by practice networks, health systems, and payers. I find that educating practices on the differences between the different programs is a good first step beyond asking whether the EHR can support it. Often the burdens of a particular program will be a deal-breaker for a practice.

Practices must next consider whether they have the capacity to change, which often translates to whether the physicians have the capacity to change. If physicians are employed, this might be mandated by the organization, but in physician partnerships, it can be daunting if some partners want to move forward but others don’t. It doesn’t matter what the return on investment might be if you can’t get everyone on board. I’ve worked with physicians who aren’t able to delegate and don’t trust their support staff, so that makes the idea of team-based care a non-starter.

The white paper does a nice job listing out the costs during both the investment phase,  when it is figuring out how to manage the transformation, and during the maintenance phase, when they’re trying to sustain the change. They include the amount attributable to lost physician visits for the clinical champion along with time spent by a PCMH manager, other clinicians who lose time to huddles and quality improvement activities, care coordinators, etc.

In reality, many practices don’t allocate dedicated time for physicians to work on PCMH or other initiatives. Instead, they expect the team to perform these tasks on top of their usual workload, under the guise of “other duties as assigned.” I suppose under that model the return on investment becomes even greater from a purely monetary standpoint, although the job satisfaction element may be on the decline.

It goes on to note that contractual requirements for PCMH recognition are the strongest ways to drive provider behavior. The authors discuss the issue of multiple contracts with differing payers and the need to try to align those requirements in order to work efficiently and to not have to meet multiple PCMH standards. It provides a good list of questions for CEOs and CFOs to consider when contemplating a move to one of these care models.

Overall, I think the white paper provides an excellent tutorial for practices considering a change. There are definitions of key terms and explanations of the process along with the actual guidance for doing the calculations. Whether you’re on the tech side or the patient-facing side, it’s a nice primer to better understand what your organization might be getting into when they start talking about Patient-Centered Medical Home or other care models such as Comprehensive Primary Care Plus (CPC+) or Primary Care First, which are based on PCMH. Knowledge is power and I will definitely be using this tool as a conversation starter when working with practices who want to embark upon clinical transformation.

Has your organization found success under the Patient-Centered Medical Home Model? Leave a comment or email me.

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EPtalk by Dr. Jayne 6/27/19

June 27, 2019 Dr. Jayne 1 Comment

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There’s been good uptake on the new Medicare cards since they began rolling out last year. Nearly 75% of claims are being submitted with the new Medicare Beneficiary Identifier as of last week. Both institutional and professional claims are at the top end of the range, with durable medical equipment vendors lagging around 64%. Our office staff has a number of word tracks they’re using to counsel patients on the need to get the new numbers on file and most of the patients seem to be aware of the transition.

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I’ve got an Echo Dot on my desk. Although I use it mostly for alarms, reminders, and shopping lists, I haven’t really explored many of Alexa’s skills or other abilities. I was curious about an article that discussed a tool to detect cardiac arrest by monitoring so-called “agonal respirations.”

This gasping-type breathing pattern is fairly common after cardiac arrest. Half of cardiac arrests occur outside the hospital and more than 90% of them die unless someone calls 911 or starts CPR. Researchers at the University of Washington School of Medicine reviewed 911 recordings from confirmed cardiac arrests and trained a machine learning model to identify appropriate respiratory patterns using Alexa, the iPhone 5s, and the Samsung Galaxy S4. The tool identified 97% of agonal breathing events from six meters away. They also used audio recordings from sleep labs and private residences to train the model on the normal range of sleep noises, resulting in a false-positive rate of 0.2%. The authors hope to use other 911 databases to further hone the tool, which might be useful not only in homes, but in elder care facilities and on hospital units that might not have intensive monitoring capabilities.

Fortune recently reported on record venture capital funding for digital health companies. The all-time record of $14.6 billion in 2018 is up from a mere $1.1 billion in 2011. I think I’m most excited about devices that will help in the virtual visit space, including home-use cameras to look at ear drums or to capture good photos of the back of a patient’s throat. I’m less excited about home EKGs, knowing that even in the office it’s sometimes difficult to obtain a good tracing. Healthcare continues to appear to many investors as a bottomless pit of money and demand even as payers try to ratchet down the expenditures. One thing is for sure, the next couple of years will not be dull.

Speaking of telehealth, reader Randy Bak had some questions about my recent experiences: “On your telemedicine foray, please update when you accumulate a run of data. My big hesitation: how much expectation is there for unnecessary prescribing (particularly of antibiotics) from patients, and more importantly, from management? Also curious how the telemedicine doctor is equipped to follow a case for a couple of days when needed, for clinical, liability, and professional satisfaction purposes.”

Since I’m relatively new to telehealth and am only a sample of one, I reached out to several colleagues who provide telehealth services to get their opinions.

The first colleague I spoke with is part of a telehealth pilot program through her employer, which is the outpatient physician organization for a large integrated health system. Their telehealth offering really doesn’t have any clinical guidelines, and since the providers are delivering services to their own practice’s panel of patients, there aren’t any specific requirements for prescribing or not prescribing. It sounds like the physicians are basically doing the work that used to be done by their triage nurses, but are charging for it as a virtual visit rather than giving it away for free.  Antibiotic usage data becomes part of their overall practice data, although she reports that patient expectations for prescriptions are high. Follow up is easy since they’re document the visits in the EHR and can always task their clinical support staff to contact the patient, or reach out to the patient directly.

The second colleague I reached out to works as an independent contractor for a nationwide telehealth group, but in a specialist capacity as a dermatologist. He spends most of his telehealth time doing virtual visits, where the patient is in the office with their primary care provider, often at a rural health clinic. It’s more of a second opinion consultation service rather than a direct-to-consumer model. Being specialized, the expectations are different than what you bring up in your question. He doesn’t believe his group is doing very much with data and doesn’t receive any clinical scorecards. Even though that’s not the flavor of telehealth you were asking about, I figured it was worth finding out. He said there isn’t much follow up.

The third person I spoke with works for a large organization that primarily markets their services to employers as an employee benefit and to payers as a way to reduce emergency department expenditures. As expected when a payer is footing the bill, the focus is on delivering the right level of care and keeping a tight leash on scope of practice issues. He receives regular clinical scorecards that include metrics such as patient satisfaction and timeliness of visits, but also on antibiotic stewardship and appropriate referrals to a higher level of care.

In hearing about some of the specific grading, I was truly impressed. The providers are coached on how to have those difficult conversations about the fact that they’re not going to give everyone a Z-pack, and it frankly sounds like they are keeping a tighter leash on inappropriate prescribing than my brick-and-mortar practice is doing. Management sounds supportive and provides clinical guidelines summarizing the evidence. Providers who want to follow up with patients have some messaging capabilities through a patient portal, but it sounds like it might not be too widely used as most of their virtual visits are for self-limited illnesses.

My personal experience is more along the lines of the latter, with encouragement to practice good evidence-based care and not to wildly prescribe antibiotics just because patients ask for them. My favorite chief complaint from my brick-and-mortar urgent care is, “I’ve got 20 people coming for Thanksgiving, I can’t possibly be sick, and Dr. X always gives me a Z-pack.” Needless to say, Dr. X was no longer employed at my organization and I wasn’t going to give antibiotics to a patient whose only symptom was a feared complaint, so I wasn’t very popular that day.

Now that there is parity in reimbursement for telehealth and face-to-face services in many states, I suspect the payers will be active in forcing telehealth providers to gather data and demonstrate their quality, or at least prove that they’re not being capricious. With many players in the market, vendors are going to be looking for ways to differentiate themselves. Additionally, as my small sample showed, there are many different varieties of telemedicine out there and direct-to-consumer is just one piece of the pie.

Have you ever badgered a physician into giving antibiotics even though you knew they didn’t want to? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 6/24/19

June 24, 2019 Dr. Jayne 2 Comments

I wrote last month about my experience with a dysfunctional registration process for imaging at Big Medical Center. I was sharing the story recently with a colleague who uses Epic at another institution and was gratified to learn that they have a much more seamless process. My Epic Jedi set up a demo for me, showing me all the bells and whistles on the system at his early adopter facility.

Like other vendors, Epic is working hard to get its clients up on the latest and greatest code. It’s certainly easier for support to have fewer versions live in the field. Several vendors are also starting to ship their upgrades with new functionality enabled, under the premise that clients won’t bother to turn the features off. Compared to what I saw with my Jedi, it sounds like Big Medical Center is either on an older version of Epic that doesn’t have some of the nice features for online check-in or has somehow failed to enable them.

My colleague and I discussed our shared belief that patients take more time when completing pre-visit activities at home. This might be because they can look up information they don’t know for sure, or call a family member, or because they’re not flustered because there is a clipboard standing in the way between them and their doctor.

We also talked about the release of results. My study results came by mail in 10 days, which was the same interval for their appearance on the patient portal. The results had been signed off by the physician within 24 hours of the study, so I’m not sure why the organization chooses to embargo them for another week when it’s a test that patients are allowed to have without a physician order. The old attitudes about protecting patients from their own results need to go by the wayside. He did show me some nice functionality for trending of patient-generated data that might be encouraging for physicians who are worried about incorporating that data into the chart.

The majority of my urgent care patients seem to be using MyChart, so we talked about some available features where patients can email their continuity of care documents to other providers via Direct. It seemed like it would be more nearly seamless than the “break the glass” functionality offered by Share Everywhere, with the added benefit of being able to actually consume and utilize the data not just view it.

We also talked about Epic’s Happy Together functionality that allows patients to see aggregated data across multiple instances of the system. For patients in my area where there are multiple competing health systems, it should be useful. It was a great conversation and gave me some ideas to help patients better manage their data when I see them in the urgent care.

Patients are embracing technology and are using apps during the office visit, whether it’s to look up a medication at the pharmacy or to show me lab results. According to recent data, more than half of all physicians are offering patients mobile apps for processes like appointment scheduling or retrieval of lab results. I know I would much rather interact with my providers’ offices through my phone or a laptop rather than have to call them and get stuck in the land of voicemail.

That assumes that the practice has an efficient online process as well, unlike the five days it took my ophthalmologist to respond to my appointment request through the patient portal. I can’t fault them too much, though. Just having an online appointment request is light years ahead of what some practices are offering or what they decide to “allow” patients to use. Plenty of clients decide not to embrace new features, which is why vendors are now in the position of having to “force” clients to use new features. I’m sure they’re tired of getting a black eye from patients and users when the real fault is in the client’s decision-making layer.

Vendors are getting better at serving up smaller, more frequent upgrades and updates that don’t overwhelm users or bring down the system for days at a time (with a few notable exceptions). This seems to make client leaders more comfortable with the process. In theory, as long as quality remains stable and the new features deliver what they promised, clients will be more willing to apply and use new code.

On the other hand, if an upgrade package is a dud (or worse, if it breaks any existing workflows) the vendor will have to work hard to regain its credibility. I’ve been on the losing end of a bad upgrade before and it wasn’t pretty, although it did lead to lifelong friendships made with the developers who spent weeks onsite keeping us in business. Without those relationships, it’s sometimes hard for customers to trust their vendors, which might be one reason that clients don’t like to enable new functionality that they don’t consider critical. Another issue is the fact that organizations are trying to deliver many initiatives at the same time, and when push comes to shove, something just has to be cut from the implementation and training schedule.

Hopefully over time vendors and their clients will be able to perfect that balance between delivering frequent releases of high quality while avoiding upgrade fatigue. We’re in a relative lull from a regulatory requirement standpoint, so it’s certainly a good time to catch up on new releases.

As a physician in a practice that seems a bit laggard, I have to confess I’m often jealous of early adopter sites that are embracing the bells and whistles. My organization is focused on expansion of new sites and growth of practice volumes, so it’s not surprising that they don’t want to spend a lot of time on technology projects. We’re also onboarding dozens of new staffers and a handful of new providers, so at the moment, stability seems to be the watchword.

How often does your organization take upgrades? Do you find them frictionless or irritating? Leave a comment or email me.

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EPtalk by Dr. Jayne 6/20/19

June 20, 2019 Dr. Jayne 2 Comments

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There is hope: The US House of Representatives voted last week to lift the ban that keeps the Department of Health and Human Services from funding efforts for a national patient identifier. The ban began in 1999 and blocks HHS from participating in private sector initiatives involving a unique identifier. HIMSS, CHIME, and other organizations have been lobbying for two decades to have the ban overturned in hopes of improved patient matching. The language was added as an amendment to the 2020 HHS appropriations bill and was introduced by both a Democrat and a Republican. Getting appropriations bills passed and signed into law can be tricky, so I won’t be holding my breath waiting for it to continue its journey on the hill.

Telehealth provider American Well has partnered with Cisco for a solution which enables virtual visits through television technology. Participating patients would use a set-top device that integrates with American Well. The solution is targeted to patients with chronic medical conditions as well as to older patients who might need regular visits. Many baby boomers are perfectly happy using smartphones and laptops and I’m not sure having one more device is necessary. People assume the older generations are “digitally dark,” but they are more savvy than you think. My own mother has a cooler, newer phone than I have. Years ago when I finally gave in to joining Facebook, the first friend suggestion I received was my then 87-year-old grandmother.

Lots of chatter in the physician lounge recently about media reports on the inclusion of “burnout” as a diagnosis in ICD-11. The World Health Organization says that media have it all wrong, that it hasn’t been recognized officially as a medical condition. ICD-11 includes burnout under “factors influencing health status or contact with health services” The chapter also includes indicators such as “contact with health services for reasons associated with reproduction” and “presence of device, implants, or grafts.” The American Psychiatric Association also states that burnout is not a medical diagnosis or a disease. Either way, being able to categorize burnout with a standardized code will allow for data gathering and better analytics. You can’t manage what you’re not measuring, but it will be a long time before we see ICD-11 in the US, so I’m not going to get too excited.

Speaking of mental health, clinicians in California are testing an app that tracks everything users do on their phones. The goal is to identify when a user is about to experience an emotional crisis. Various cities and counties are involved in the project, which is being tested on patients using the Los Angeles County public mental health network. It looks at historical use data to determine whether behaviors are changing and sends a message to the user. About half of initial pilot users dropped, citing technical issues or lack of interest. It’s an interesting concept, but one which would have to balance the loss of privacy with the potential benefit to users. For those with significant health conditions or risk for self-harm, it might be worth it, but for others it might be too invasive.

My practice has both x-ray and CT scan capabilities. Although the CTs are read immediately by a radiologist, we’re responsible for the primary reads on our plain films and often the radiology over-read doesn’t happen until our shift is over. Especially in that context, I’m excited about using AI to help interpret radiology studies, and frankly for some of our films, it can’t come fast enough. Although some films are grossly abnormal, other findings are subtle. Sometimes the quality of the studies is limited by the physical size and bulk of the patient. It would be great to have some support for those of us that are reading films in the field. Needless to say, I was excited to hear about the FDA approval of Zebra Medical Vision’s product that assists with CT studies that are looking for brain bleeds. The solution can reduce turnaround time, which is always good for the front lines. Zebra already has FDA approval for a chest x-ray product that specifically looks for pneumothorax. Maybe sometime before I retire I’ll have a virtual radiology assistant that pre-reads my films.

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Like many of my peers, I enjoy learning about the history of medicine. I crossed an item off my bucket list a couple of years ago when I visited the Mutter Museum and admired Albert Einstein’s brain along with the Hyrtl Skull Collection. I’m also a fan of literature, so I couldn’t contain my excitement when I learned about a treasure trove of clinical notes from 400 years ago. The collection contains handwritten notes on more than 80,000 patients in early 17th-century England, kept by two healers who were known to cure their patients by using cues from astrology. The notes include treatments with tobacco and horse manure and cover conditions from depression to gonorrhea. Researchers at the University of Cambridge have put transcriptions of more than 500 cases online and its been great entertainment to learn about a patient whose “spleen was not sound,” as diagnosed by the presence of “black stuff that comes from by his excrements.” Another patient complained of “fretting & choleric & melancholy.” Other hot topics include childbirth, infertility, and witchcraft. My favorite treatment apparently involves avian slippers with “a pigon slitt & applied to the sole of each foote.”

Telehealth is officially the fastest growing place of service, growing 53% from 2016 to 2017 in comparison to 14% for urgent care centers and 7% for retail health clinics. Emergency departments experienced a 2% decline. This data comes from New York non-profit Fair Health, which hosts a claims database. Their annual white paper on place of service trends shows that organizations that are not thinking about how to incorporate telehealth might be missing out. Telehealth is still a small portion of all claims – 0.11% in 2017 data compared to 2.6% at emergency departments and 1.2% at urgent care clinics. This will only grow now that payment parity has arrived and telehealth or virtual visits are covered similarly to in-person visits.

I recently joined the ranks of telehealth providers and was surprised by how satisfying it can be. The patients are genuinely grateful that you’re there to take their call at 11 p.m. even if it just results in self-care recommendations. My previous proposal for being a dedicated after-hours telehealth provider for one of our local health systems was met with lack of interest and I still think they’re missing a major opportunity. I care for plenty of their patients in person at my urgent care, so we’ll have to see how long it takes for one of them to turn up in my online queue.

Have you ever used telehealth services for yourself or a loved one? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 6/17/19

June 17, 2019 Dr. Jayne 2 Comments

I wrote recently about a less than optimal shift where we had multiple intermittent issues with our EHR that impacted electronic prescribing and several other key functionalities. Although the issue was fairly serious, it turns out that a good portion of the lack of communication our users experienced was the fault of our practice leadership rather than the vendor. In trying to “protect” the clinicians from what they felt would be distracting, they erred in providing too little information. It turns out the vendor was communicating pretty well, but they weren’t passing on the information to those of us on the front lines.

This is a challenge for any healthcare organization – figuring out the right way to communicate about serious issues and knowing how often to provide updates, even if the update is “no update.” In organizations where clinical leaders work closely with the IT team, there can be good conversations around a service disruption and how to handle it. There can be discussions about user culture – whether they would benefit from more information or less and whether the disruption is more of an annoyance or a disaster. When clinical and technology leaders don’t work together, there’s an increased risk of erring too far in one direction or another.

I still encounter organizations that don’t believe it’s important to have dedicated clinician support for health information technology systems. When I put on my consulting hat, one of my tasks is to try to convince these practices that they can’t afford not to have clinician leadership where EHRs and other systems are concerned.

I recently pitched to a convenient care practice that has almost 100 providers. They have one nurse who spends a couple of hours each week working with the EHR, mostly responding to specific end user questions rather than working on global strategy. I spent a few days in the practice to identify potential opportunities for workflow improvement as well as long-term strategies.

The first thing I identified while watching physicians document was that none of the physicians were using medication favorites. Apparently they aren’t allowed to build their own favorites because the organization is concerned about upkeep. Instead, there are some global favorites that everyone can use, but that might not be aligned with current treatment guidelines. Providers can delete the global favorites, but can’t put anything in their place, leading to the opportunity for errors when physicians try to use the global favorites and edit them as they go.

There were some order sets available, but they weren’t very complete, and many common diagnoses didn’t have associated order sets. As a result of providers not being able to build their own order sets, I observed several clinicians using Word documents that contained their most common patient instructions that they would copy and paste into the free-text plan field. Some of these makeshift order sets didn’t seem terribly evidence-based and they varied dramatically from person to person. The diagnosis screens were cluttered with diagnoses that didn’t seem to be commonly used, while providers were having to search for conditions that they treated several times each day.

When I perform a practice analysis, I also dig into how the practice handles upgrades and changes to payer requirements or federal programs. It turns out that that when it’s time for an upgrade, the physician CEO and the EHR nurse evaluate the release notes and decide which features they will implement and how the end users will be trained. They don’t seek input from any of the users or even the physician group’s medical directors. The two of them personally deliver most of the training in a one-on-one fashion, which means that some users might get trained as much as six weeks prior to the upgrade. Others might just receive a PDF that they are supposed to review before launching into the new workflows. There’s not a lot of satisfaction around that process.

Understanding that process explained some of the issues I saw in the system, including a workflow for in-office medications that borders on dangerous. There are fewer than two dozen medications available in the office, many of which are in specific unit doses. Rather than configuring an order screen with those medications and defaulting in their strength, form, and administration instructions, providers are required to individually select every parameter for every order. Some medications can be ordered multiple ways.

For example, one drug can be ordered either as 3 ml or 2.5 mg. Since the medication is 2.5 mg/3 ml, either order is appropriate, but I saw several physicians click for 3 mg or 2.5 ml, neither of which were correct. The system didn’t flag these, but instead the clinical support staff was responsible for changing the orders. Incorrectly ordering albuterol at that scale isn’t going to cause significant harm, but for other drugs, those types of mistakes are far more serious. Beyond the safety issue, there’s the matter of the numerous clicks required to even order a single drug.

I identified all kinds of operational issues in the practice as well. Although they have a time clock system for both clinical and business office staff, they don’t have hourly providers use it. Instead, providers have to email their “stop time” every night and it takes a manual process to document the time in both the payroll system and the scheduling system. For the latter, they use one system for providers to request their schedules and another system to actually publish the schedules. They’ve switched payroll systems three times in five years, which makes me wonder whether it was really a software issue or something much more challenging to fix.

There were plenty of other issues to tackle, enough to keep several consultants busy for many weeks. I knew there were some internal disagreements on whether to bring in outside help, so I prepared a conservative proposal in multiple phases to allow them to get used to the idea of letting someone help them. The return on investment was easy to demonstrate, but as I presented to their leadership I could tell they weren’t interested. It was clear that the CEO believes his way is not only the best way but the only way to do things.

Although many of their technology struggles could be made better through the application of skilled assistance, they’re not ready for change. Given the challenges that will be upon them as healthcare continues to evolve, it will be interesting to see where they are in three to five years.

What’s the scariest CPOE system you’ve seen? Leave a comment or email me.

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EPtalk by Dr. Jayne 6/13/19

June 13, 2019 Dr. Jayne 1 Comment

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I’m an avid reader and was very excited to hear about “Code Blue” by Mike Magee. The author is a physician and chronicles decades of bad behavior by what he calls the “Medical Industrial Complex” of self-interested parties that drive our healthcare non-system.

Magee skewers physicians, hospitals, payers, pharmacies, drug makers, legislators, and other special interests. He notes that healthcare reform as been needed for decades, going back to a speech by President Nixon in 1972: “We need to work out a system that includes a greater emphasis on preventive care, sufficient public funding for health insurance for those who cannot afford it in the private sector, competition among both health care providers and health care insurance providers to keep down the costs of both, and decoupling the cost of health care from the cost of adding workers to the payroll.” It’s been a long time since we’ve seen a Republican call for greater public funding of health coverage for the poor.

Magee also calls out healthcare executives, physicians, and the American Medical Association. The worst criticism, however, is saved for pharmaceutical giants (it should be noted that Magee was a VP at Pfizer) who use profitability to determine which drugs will come to market. I highly recommend it, especially for newbies in the industry. It’s a steal at $16 on Amazon.

Road warriors take heart: London’s Heathrow Airport is installing new carry-on baggage scanners that can screen liquids and computers while they are still in your bags. Although some of us get a pass on the great unpacking routine in the US if we have TSA Pre-Check, perhaps this will clear the way to going back to a pre-2006 workflow at many more screening checkpoints. The story points out that it’s also an environmentally friendly option, helping cut plastic use since people won’t be using as many ziplocks. The technology, which is similar to CT scanners, has been in trials at Heathrow for two years and is also in use at several sites in the US, including ATL, ORD, and IAD although authorities still require us to pull out our baggies at those sites. I miss my road warrior ways, particularly since my airline status will likely sunset this year.

Speaking of road warriors, those of you on the clinical side might be interested in this Journal of the American Medical Association article on in-flight medical emergencies. I found it fascinating reading and learned a few things:

  • Emergencies occur in approximately one per 604 flights.
  • FAA-required contents of the emergency medical kit are rudimentary.
  • The most common issues are syncope / fainting, gastrointestinal issues, respiratory issues, and cardiovascular symptoms.
  • One-fourth of emergencies are handled by the flight crew alone,  half by physicians, and the remainder by nurses and other emergency personnel.
  • Diversion to a different destination happens in only 4% of inflight emergencies.
  • When flight crew request emergency medical services to meet the plane, only one-third of passengers are actually transported to a hospital and only one-third of those transported are admitted.

I’m a big fan of online medical journals, and this week I came across a JAMA Viewpoint piece explaining why we should consider eliminating or modifying the requirement for a Review of Systems (ROS) during patient visits. Although asking a variety of questions about body systems as part of the ROS has been part of the history-taking process for years, it became an annoyance a couple of decades ago when the number of systems reviewed was tied to the coding and billing process.

There hasn’t been much academic work looking at the validity of the ROS, although one study found that it only identified new diagnoses in 5% of cases. Other studies have noted that only a small percentage of issues identified during the ROS are even addressed.

The authors of the viewpoint article took into account that EHRs make the entry of ROS findings easy, especially if they are self-reported through a portal or kiosk, and wondered whether those findings that aren’t identified by the physician would be followed up even less. The authors go on to discuss “the fact that a complete ROS may be required by billing guidelines at times when it is clinically unhelpful.” They call for clinicians to “claim ownership of the determination of what clinical information is required for appropriate care in which setting.” Very few clinicians would argue this point. We’re tired of generating notes full of irrelevant information and we’re tired of reading it when we see it. Changing documentation requirements would certainly help with the “note bloat” we’re all subject to.

In that same train of thought, CMS is calling for additional input on its Patients Over Paperwork Initiative. The announcement claims that “since launching in the fall of 2017, Patients over Paperwork has streamlined regulations to significantly cut the ‘red tape’ that weighs down our healthcare system and takes clinicians away from their primary mission.” I spend at least half my time in the clinical trenches these days and haven’t noticed any significant change in paperwork or red tape during that time. I’m not sure where their purported 40 million hours and forecast $5.7 billion savings is happening, but it’s not on the average physician’s timecard.

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It’s that time of year. Hotel registrations for HIMSS20 are open, and even though it’s barely June, my preferred hotel is already booked for my preferred dates. The HIMSS Call for Proposals is also open through July 15. No word on keynote speakers and actual event registration doesn’t start until August. HIMSS is in Orlando again this year, and I never thought I’d say it, but I’m actually looking forward to going back to Las Vegas.

Due to some unexpected scheduling issues, I’ve had to spend more time in the clinic than I normally do. This week was punctuated by an entire day of EHR malfunctions, including failure of the system to talk to the pharmacy search API, which meant that we couldn’t do anything but print prescriptions if patients didn’t want them from our in-house dispensing system. Over the last decade, patients have gotten used to us sending their scripts to the pharmacy directly, whether electronically or by fax. The idea of printed prescriptions led to many requests for us to phone in the scripts and I rapidly discovered that not a single person on my staff that day had ever called in a prescription. Needless to say, we had a lesson because I wasn’t going to spend all day calling Walgreens.

We also had multiple random Citrix issues, chronic slowness, and random popups about some index failing to call the SOAP note. There was even an error message that cited my email address and I have no idea why it would even be listed in the EHR. I’m seriously disappointed in my vendor and their response – no resolution within 12 hours for sure, and at one point they stopped taking customer calls altogether. My practice suspected it had outgrown our vendor and I’m hoping that this is a wakeup call that it might be time to switch.

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Curbside Consult with Dr. Jayne 6/10/19

June 10, 2019 Dr. Jayne 2 Comments

As much as clinicians complain about EHRs, they can be powerful tools for data analytics. I’ve worked with a number of organizations that have embraced the ability of the EHR and practice management systems to help them understand why their schedules are backed up and also to implement strategies to improve things. Sometimes it’s a patient panel that’s too big, or inefficient scheduling, or getting a late start in the clinic every morning.

Now there’s new data that shows that appointment scheduling isn’t just a point of frustration. It can actually impact patient care. The authors looked at screening for breast and colorectal cancers and whether the time of day the patient was seen makes a different on whether the patient actually receives a screening referral. Patients who were seen in the morning were more likely to be seen than those with afternoon appointments. The study looked at family medicine and internal medicine practices in a variety of settings in New Jersey and Pennsylvania during 2014 and 2016. Acute and sick visits were excluded, so these were times that physicians should have been managing preventive care or chronic health issues.

The authors cite factors such as lack of time (possibly due to physicians being behind schedule) and “decision fatigue” as potential causes. The latter occurs when clinicians are less likely to have screening discussions because they have already had similar discussions multiple times earlier in the day. There’s also concern that patients who decline screening earlier in the day may make it less likely for physicians to bring it up in later appointments. Additionally, patients who are seen later in the day may also be under time pressure and may not want to discuss screenings.

The authors recommend using non-physician care team members to assist in addressing screening gaps and adjusting clinic workloads so that physicians can better focus on patient care during visits. It’s tempting for physicians to have a knee-jerk reaction to these recommendations because they are used to being the primary point of contact with a patient. I continue to come across physicians that are resistant to team-based care even when they are stressed and burned out.

There are plenty of patient engagement solutions out there that can assist with encouraging patients to receive preventive services, whether they are blast messaging through an existing patient portal, email, or text system or novel apps designed specifically for patient engagement. Those reminders can reach patients when they’re not preoccupied with other discussions during an in-person visit. Of course, patients might be just as likely to blow off those asynchronous reminders, but it’s another tool for practices to use to try to better address patient needs in a way that doesn’t impact schedules.

These types of issues are also part of what primary care transformation programs are trying to address. Initiatives such as Comprehensive Primary Care Plus (CPC+) are designed to provide additional care management payments that would include coverage for these interactions. Other programs such as Primary Care First are designed to reduce administrative burdens and make payments more streamlined which theoretically should increase the capacity for practices to deliver patient-centric services.

Of course it will take time to gather data on these programs. The CPC+ program has been live for a little over a year and initial reports on the program indicate that it’s really too early to determine what kind of impact the program might have on overall spending related to clinical outcomes.

It’s not just screening services that are impacted by the duration of the workday. The study notes that other investigations “have found higher rates of inappropriate antibiotic prescribing and opioid prescribing later in the day. In each of these studies, behaviors improved slightly after lunch (a short break for most clinicians).”

Organizations that want to tackle issues like time pressure and decision fatigue need to be careful in how they address this with their providers. One author recommended that physicians set aside time for breaks throughout the day to address the problem. This is easier said than done in office settings where providers often don’t have time to take a break to eat a meal, use the restroom, or interact socially with staff because they’re just trying to grind their way through the day. Offering those kinds of suggestions without fully understanding the problem can come off as patronizing or antagonistic. Personally, the last time I ate food during a 12-hour shift that did not involve nibbling while charting was never.

Physicians are also becoming increasingly resistant to the idea that they are responsible for changing patients’ behaviors. Physicians are supposed to motivate patients who appear tired or uninterested in a conversation about screening. The study’s author commented that patients need to be convinced that their decisions have an impact and that physicians need to think about how to best organize discussions around patients’ health.

I know I’m not alone when I admit that I’m tired of trying to persuade patients who don’t give a damn about their health that they need to take charge of, or at least get involved in, their own health. There’s a dearth of personal responsibility in our society compared to what I’ve experienced in healthcare in other parts of the world. It feels like we are no longer practitioners of the art of medicine but cheerleaders, salespeople, and at times parent-substitutes for grown adults who should be able to at least participate in their own well-being.

I think this is a major part of why we see primary care providers defecting to the urgent care or emergency department care environments. They are not expected to manage anything beyond the acute issue in front of them. Providers who gravitate to direct primary care or concierge practices are at least being paid better for their time and effort, so there is higher satisfaction among my colleagues who have made that jump.

In the mean time, the study is important to illustrate that many variables affect patient care and we can identify ways to address some of them. There are plenty of relatively simple solutions out there that practices are still resistant to implement.

I was in an office the other day where the entire staff walked in two minutes to opening time. They were waiting outside because they’re not allowed to clock in before 7:57 a.m. There is no way that any of them were prepared for patients arriving at 8 a.m., but such was the office policy. Until we begin to tackle those obvious issues, addressing the more subtle ones will remain out of reach.

What do you think about decision fatigue, appointment schedules, and personal responsibility? Leave a comment or email me.

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EPtalk by Dr. Jayne 6/6/19

June 6, 2019 Dr. Jayne No Comments

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The American Board of Family Medicine takes a step towards interoperable encounters of the professional kind by becoming the first American Board of Medical Specialties member Board to implement automated licensure updates for US licensees. Instead of Diplomates having to log in and update their state licenses annually, ABFM will receive the data directly from the Federation of State Medical Boards. Licensure details will automatically update monthly and providers will receive notification when updates occur so that they can confirm accuracy. It’s a small thing, but can be a big issue for physicians who fail to update. Automation makes it one fewer thing to worry about.

I truly enjoy working in the realm of informatics, but would miss patient care if I didn’t get to do it as well. Being in a patient-centric practice environment helps since we’re all working together to ensure our patients have a great experience. Even when it’s a difficult day, it’s still better than a lot of the days I have had with other employers.

Today I celebrated the best chief complaint ever and made sure to memorialize it in the chart: “Patient states: We were walking out of Starbucks and saw you open over here, so we decided to come in.” I probably wouldn’t have heard that one a decade ago, but it underscores that patients sometimes value convenience and accessibility more than other variables. The flip side of this was the patient who arrived at the front desk at 5:30 p.m. and wanted to be sure she could be out of the office by 5:50 since she had plans to meet someone for dinner at 6:00. We get 90% of our patients out in under an hour, but trying to squeeze it under the 20-minute mark is pushing it when there is only a single provider on duty and other patients are awaiting care.

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Device of the week: Researchers conclude that the home use of video goggles that measure eye movements can provide an early and accurate diagnosis of vertigo. Patients were instructed to use the goggles to record eye movements that can help confirm which specific type of vertigo is occurring so that providers can determine the best course of action. Since vertigo symptoms can wax and wane, this would be a benefit to patients whose symptoms might be gone before they make it to a provider, or who have issues limiting travel to see a clinician. I’ve had vertigo that forced me to crawl through the house because I couldn’t stand, so I can’t imagine the frustration of patients who have symptoms frequently but may not have a definitive diagnosis.

Speaking of devices, it might be time to fire up those Fitbits. An article recently published in JAMA Internal Medicine and presented at the American College of Sports Medicine 2019 Annual Meeting shows that the risk for all-cause mortality fell among older women who walked at least 4,400 steps per day. As the number of steps increased, the risks continued to fall, leveling off at 7,500 steps per day. This is great news for individuals who might not be able to meet the oft-touted but poorly-researched 10,000 steps per day.

The authors note that current US Health and Human Services physical activity guidelines recommend a weekly time goal for exercise, but that counting steps may be more easily translated into real-world practice given the widespread nature of step-counting devices. The mean age of women in the study was 72 and they were followed for a mean of 4.3 years. The study adjusted for other risk factors including age, smoking status, alcohol use, general health, and 10 other factors related to risk for cancer or cardiovascular disease. As with many studies, there were some limitations – participants were predominantly Caucasian and of high socioeconomic status, which may have made them more active than the general population, so the results may not apply to different demographics or to men.

Telehealth continues to be a hot topic, and Epic recently added the American Well telehealth app to the App Orchard. The app is supposed to add one-click virtual consult functionality within the EHR workflow. It includes control of remote cameras and digital collaboration for non-Epic sites.

I have a couple of colleagues who use Epic and are trying to get into the business of virtual consults, but their organizations haven’t committed to allowing providers to block time to handle the requests. It is becoming just “one more thing” that causes time pressures in the office. It’s disheartening to see that administrators think they can just add these programs without a thought since that’s a recipe for employee dissatisfaction. One of my former employers tried to add evening appointments and it was a bust – patients didn’t take advantage of the appointments as much as was hoped and providers felt they were losing even more time away from family.

A reader sent me this article about health skills for the Amazon Alexa platform. Functionalities include diabetes management tracking, virtual physical therapy, and general health management.

Although I don’t doubt that personal assistant-based technology can be a benefit, especially for patients who have access issues or who otherwise wouldn’t go to a brick-and-mortar healthcare facility, I would caution people about changing to this manner of care without data that shows it’s at least equivalent. The virtual physical therapy in particular makes me nervous. I have several friends who are PTs and understand how difficult it is to get patients to do exercises correctly even when they’re present in face-to-face encounters. Doing PT incorrectly can not only lead to stalled progress, but it can actually cause harm.

The author notes one of the major consumer concerns about telehealth, that “my doctors have long answered my questions and dispensed phone and email advice for free.” It’s difficult for patients to accept that physicians are not only tired of doing this for free, but that the constant ratcheting down of healthcare payments and the addition of administrative burdens have made it untenable. You wouldn’t call your lawyer for free advice and even my auto mechanic won’t talk about my car without a diagnostic visit (which isn’t free).

She notes that her OB offered great advice, but probably doesn’t realize that OB care for a pregnancy is part of a global fee that the OB is paid for the entire episode of care. Virtually no one outside the industry understands those nuances of healthcare finance. She complains about a $235 bill for a virtual visit, but never says what the accepted amount or the actual payment was. I bet it wasn’t $235.

What do you think of the rise of personal assistants in healthcare? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 6/3/19

June 3, 2019 Dr. Jayne 1 Comment

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Maybe I am becoming less tolerant as I get older, but I seem to be very easily tired by people in this industry who talk a good game, but are unable to get any of their ideas to fruition. It’s especially tiresome when these folks are hired by major organizations at high salaries and they can’t seem to solve the basic problems that plague clinical technology projects.

I worked with one of these folks a year or so ago when he was hired by one of my clients as a senior vice president for clinical transformation. I had been doing clinical transformation work for them for almost a year, so I was excited that they were finally putting some leadership and visibility behind the effort other than just third-party consultants. What I immediately found, however, was that he had no experience with physician adoption or creating workable timelines. His only healthcare experience was in the finance realm, and he immediately alienated nearly everyone on the project who had been working hard for incremental change.

A lot of us asked ourselves how he was hired and came to the conclusion that the organization was looking for a social media wunderkind, someone who was an “influencer.” But it turned out he was only an influencer in his own mind. He curried favor with the physicians by agreeing with their (largely unfounded) complaints about the EHR and by offering to throw the entire project out and get the group moved over to Epic per their request.

This was during his first 30 days of employment. He didn’t bother to do the due diligence to find out that the EHR project was suffering because providers had contracts that financially rewarded them for bad behavior and refusal to use the EHR. He didn’t find out that the rest of leadership had no stomach for either changing the contracts or doing something else to change the behavior, but instead took the easiest route in condemning the vendor.

The organization is now in the throes of a significant software spend. They still have no governance, no change control, and no plan. But by golly, they’re going to be on Epic, so all their problems will be solved.

I continue to watch this individual on Twitter and am surprised he doesn’t have tendonitis in his shoulder from patting his own back so much. I still have some consulting work going on with the client, although thankfully outside of his area, and it’s been hard to watch the carnage. I wonder at times whether anyone above him has read the story about the emperor having no clothes. Most of the workers under and around him see through it, and I feel for them.

I was having flashbacks this week when I met someone at a conference who reminded me of him. He was full of great ideas about how his organization was going to use data to drive outcomes and change clinical behavior. It sounded great until it took a dark turn towards volume-based incentives. I watched others in the roundtable session nodding their heads and listening attentively and I wondered if they were missing the fact that he was talking about incentivizing providers for ordering more tests, medications, and procedures.

His independent provider organization is somewhat boutique-y and has a large population of young and middle-aged patients who value convenience. Due to their relatively low Medicare population, they’re not part of an Accountable Care Organization and they’re not worried about readmission rates. They offer a significant spectrum of cosmetic services along with all kinds of wellness testing that isn’t typically covered by insurance.

Essentially, his organization has come up with what I would consider bogus metrics, a “compassion index” that uses interventions as a proxy for good clinical care. Using point-of-care tests rather than medical knowledge or those pesky clinical decision rules raises a provider’s index. Prescribing multiple medications to treat patient symptoms also raises that index (however, over-the-counter medications that the patient might already be taking do not). He (and I assume the rest of the leadership of the organization, since the presentation was clearly bragging on their outcomes) has latched onto a word-track that “patients know we care by how much we do for them.”

I wondered for a minute if the presentation was straight out of The Onion. Certainly no one in the current healthcare environment would be talking about running up charges? As a former primary care provider, I always thought patients knew we cared by the fact that we sat down and talked with them, counseled them through their issues, and made sure they had follow-up.

I hid in the tall grass and waited for the opportunity to ask a question about what most of us would consider “real” metrics, such as antimicrobial stewardship or appropriate use criteria for advanced imaging. I asked it nicely, and it was fun to watch him blow it off saying that they don’t find those types of metrics to be relevant to their practice. You could see the light bulbs come on over a couple of the attendees’ heads because those types of actual clinical quality metrics have been so drilled into our heads, why would someone not use them?

He went on to describe some of their other metrics, which sounded more like defensive medicine than anything else. He explained their push for imaging as “patients feel better when they know beyond a doubt that nothing serious is going on,” which I immediately translated to “our accountant feels better when we radiate people.”

Nothing in medicine is “beyond a doubt” because there is great variability in patients and how their bodies react to various biological challenges. Medicine throws me curve balls all the time, including the patient last week who was very, very anticoagulated but still had a new deep venous blood clot form in his leg. Trying to use shotgun-style testing as a substitute for clinical intuition, experience, and evidence-based care is a dangerous construct.

He went on to talk about their interventions to drive clinician behavior and raise the “compassion index” alongside patient satisfaction scores. It sounds like they look for outlier physicians and sit them down and use peer pressure to try to raise the volume of order interventions. It didn’t sound like they overtly bonused physicians based on ordering volume, but instead use emotional hooks to try to keep clinicians on track. They do bonus physicians on throughput, which makes it easier for people to just order tests rather than sit down and explain a decision process to patients, since education and shared decision-making take time.

I found their bogus metric even more bogus when he explained that they judge the usage of interventions based on the documented chief complaint, not on the diagnosis. At this particular facility, the chief complaint is self-selected by the patient on a kiosk at check-in, so judging whether providers order testing based on that is particularly obnoxious. I’ve had patients who say their complaint is “throat pain” that is really poison ivy on the neck, so if a provider is going to be dinged for not ordering a strep test for throat pain that’s actually a neck rash, they’re fighting an uphill battle.

I can’t imagine working at a place like that. He did note that they have some issues with provider turnover. I’ve found that when people talk about their turnover issues, it’s kind of like talking about how much alcohol they drink – it’s likely to be underestimated.

I’m not sure how long payers are going to put up with this, or how long patients will keep coming back if they have to shoulder the bills for over-testing. Not to mention that over-testing is not a harmless intervention. Sometimes you find things that lead you to additional interventions when it would have been better if you hadn’t done the test in the first place. It falls into the “do no harm” piece of what we trained for as physicians.

I’m curious if this is a new trend or if this guy is as much on the fringe as I think. Have you seen anything like the compassion index in your area? Leave a comment or email me.

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EPtalk by Dr. Jayne 5/30/19

May 30, 2019 Dr. Jayne 1 Comment

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I’ve been following Diasyst for some time and was happy to see their recent win at the Webit.Foundation Founders Games in Sofia, Bulgaria. Diasyst was recognized as a finalist and was selected by Microsoft for Startups for $120K in awards to support growth, including assistance with investments and partnership development. Diasyst has an elegant solution that assists clinicians with diabetes management and currently partners with Emory University, the US Department of Veterans Affairs, and Georgia Tech.

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The state of Missouri closed its legislative session last week and remains the lone holdout in the US without a statewide prescription drug monitoring program. St. Louis County provides the leading workaround with its federally-funded voluntary PDMP; more than 70 additional jurisdictions including Illinois, Kansas, and Oklahoma share data with the system and it now covers 84% of the state’s population. Missouri legislators continue to cite privacy concerns as preventing Missouri from enacting PDMP legislations despite the support of new governor Mike Parsons. A Kaiser Health News piece covering the issue is worth reading. One of the main legislators who had opposed a statewide PDMP is a family physician, although he was finally term-limited. PDMP legislation has also been inexplicably tied up with gun rights issues. It should be noted that Missouri was also last to implement a statewide immunization registry. My favorite quote of the piece: “But if 49 other legislatures are saying ‘This is important, we need to save lives,’ I don’t understand why Missouri can’t find a way to compromise and do what’s best for its citizens.”

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It’s already been mentioned in HIStalk, but I’m intrigued by Amazon’s foray into wearables that can read the emotion of the wearer. It’s a step up from a mood ring, but I wonder how well Amazon is really doing with understanding user emotions and experiences at present. The company needs to do a better job selling its data in a way that I don’t keep seeing ads for products I’ve already bought. The device would supposedly analyze user voice patterns to determine their emotional state. I’m just trying to get my Echo to recognize my commands when I’m moving across the room or when there is background noise.

Artificial intelligence continues to be a headliner for buzzword bingo and the US government continues to expand spending. Early adopter agencies such as the Defense Department, the General Services Administration, NASA, and the Department of Health and Human Services are using AI to reduce backlogs or increase productivity of existing workers. Additional departments looking to leverage AI include the Departments of Agriculture and Veterans Affairs, along with the National Institute of Standards and Technology. Additionally, the Patent and Trademark Office wants to use AI to screen patent applications against more than ten million patents already on the books.

A recent report on federal AI adoption highlights the need to make sure agencies have solid business cases for AI and that they’re not building solutions in search of a problem. It also notes that government needs to get “beyond the belief that AI is magic. It’s not – it’s something that’s evidence-based that uses data.” The report also calls for a unified ethics framework that addresses difficult issues around AI transparency and accountability. Previous projects involving analysis of drone footage have been controversial.

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The US Food and Drug Administration (FDA) is fast-tracking an Apple Watch app to help individuals who experience nightmares from post-traumatic stress disorder (PTSD). The NightWare app uses biometric data collected during sleep and processes them with machine learning algorithms to identify the onset of nightmares. Vibrations are triggered to interrupt the nightmare without waking the user or interrupting sleep rhythms. The FDA granted “breakthrough status,” which is typically granted for life-threatening conditions with no approved treatments. Nightmares and nightmare disorder are linked to increased risk of suicide, heart disease, diabetes, memory loss, anxiety, and depression. An estimated 5 million Americans suffer from nightmare disorder. NightWare is conducting randomized clinical trials prior to applying for FDA priority review.

I’ve noticed an increase in the number of elderly patients who don’t have family nearby. They may continue to drive past the point where it is safe because they don’t want to be dependent on taxis or ride share services. As the Baby Boomers age, self-driving cars may be an appealing way to stay independent. IBM and British startup Cera Care are taking a deeper look at using the technology off the road to help elderly patients navigate within their homes. They plan to use lidar laser sensors from self-driving cars to monitor patient movements and daily routines. A change in movement patterns may indicate physical deterioration, psychological changes, or a fall. Lidar sensors are expensive at approximately $1K per room, but developers expect costs to fall over time.

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The University of Michigan finds that the DNA of new doctors ages six times faster than normal DNA during the critical internship year. Researchers looked at segments of DNA called telomeres, which keep the ends of chromosomes intact. The interns were compared against a control group of college students. The study showed that telomeres in stressed subjects shrank in an accelerated way. The data could be applicable to other populations exposed to prolonged stress such as military trainees, new parents, and those working for startup companies.

I had the chance to connect with an old friend and industry vet this week. It was great to catch up and to commiserate about the problems we’re trying to solve out in the client community. Some of the issues we continue to run across include clients who want to do the wrong thing despite our best advice, such as failing to flag deceased patients in the system. Nothing says “patient engagement” like a family receiving a colonoscopy reminder after their loved one has died of colorectal cancer. As we use increasing amounts of information across numerous applications and data streams, the need to ask “is this the right thing for the patient” becomes more important.

Does your organization constantly keep patients at the forefront? What are your pitfalls or a-ha moments? Leave a comment or email me.

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EPtalk by Dr. Jayne 5/23/19

May 23, 2019 Dr. Jayne 2 Comments

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Tech pet peeve of the week: time zones. I am working with some folks who don’t know their EST from their EDT, let alone how to work with people in localities that don’t participate in Daylight Saving Time. I’m thinking maybe we just need to all go GMT so we can get along. Either that or Microsoft needs to give us additional time zone display options in Outlook. Two is just not enough for those of us who work coast to coast or sometimes trans-Pacific.

Non-tech pet peeve of the week: recruiters who don’t know their audience. I was contacted by a recruiter from a payer (whose name I will keep anonymous to protect the guilty) who apparently had me confused with someone in another generation. “We believe that you, as a rising star, will use your unparalleled talents… fulfill your dream.” Last time I checked, most physicians don’t dream of working for a payer (although some people are really into it) but the flowery language screamed insincerity. That’s not how I’d approach a seasoned physician exec, but it made for a fun conversation when I decided to just mess with him.

EHR pet peeve of the week: having to respond to laboratory “Ask at Order Entry Questions” that should be hard-coded. How many times have I had to free text “throat” as the source for “culture – throat” in the CPOE screens of my EHR? Seriously, folks.

Clinical pet peeve of the week: my mammogram visit at Big Medical Center. I was greeted by a volunteer, then sent to waiting room purgatory for 25 minutes despite being on time. The registrar who called me over had a coffee-stained desk (right where I was supposed to lean over and fill out paperwork) and the base of her monitor hadn’t been dusted since the Bush administration. There were rubber bands everywhere on the desk and I can’t for the life of me imagine where rubber bands would belong in the workflow. I was asked to fill out a paper clinical history, including all my demographic information, by hand, and then she peppered me with registration questions while I was trying to fill out the clinical history. Perhaps my time in the waiting room would have been a better time to fill that out?

The registration system popped up a phone number that I’ve been trying to have removed from the system for almost 15 years. She had to find someone else to find out how to try to remove it. I asked why I had to put my contact numbers on the paper history and was told “if the techs have to call you, they never look at the computers.” That’s reassuring in this age of interoperability.

The worst part was being informed that I would receive my results “by mail in 7-10 days.” Despite Big Medical Center’s high-risk breast cancer program, I think I’ll be having my next study at Independent Imaging, where I used to go and where results were real time and in person. Independent Imaging at least used their EHR to pre-populate the clinical history form and have patients just update it, which is exactly what I would have expected at Big Medical Center since they just spent half a billion dollars (literally) going up on Epic. Let’s see if they contact me after I gave them free consulting on their comment card.

That’s certainly a greater number of peeves than I should be allowed this week, so let’s talk about what went well.

I’m part of a pilot project with the American Board of Family Medicine to see if doing quarterly board exam questions can be substituted for the in-person, high-stakes exam. I did my second batch of questions and think I finally have my strategy figured out on which references to use and how to approach the questions. The system is pretty streamlined and they did make a few tweaks between the first and second quarters, so I’m looking forward to see if they make any additional enhancements for Quarter 3. Those of us who have hitched our wagons to this paradigm are likely in it for the next three to four years, so hopefully the improvements will continue.

From a mental standpoint, I definitely prefer it to the testing center, where you have to turn your pockets inside out and are practically frisked if you take your allotted breaks. Let’s hope the American Board of Preventive Medicine considers a similar approach before I have to sit for informatics recertification in 2024.

I also caught up on some of my journals, including Applied Clinical Informatics, which published a study validating what most of us already knew – that physicians don’t always document key components of a visit in the EHR. The authors looked at the documentation compared to recorded office visits and concluded that for some clinicians, EHR documentation is more challenging than paper notes. Other factors influencing curated documentation include overbooked schedules and patients with complex medical conditions. Social and emotional health issues were often left out of the EHR, and while primary care physicians may be aware of these details, there are other clinicians who would not be able to access that information in a different setting of care. These omissions may prevent hospital or consulting physicians from creating a workable care plan because they don’t know about patient-specific constraints.

The study is relatively small, looking at 10 unique patient encounters from 2016. All were from the same medical center and documented on the same EHR. Patients had an average of 14 chronic conditions and were on an average of a dozen medications. Chronic conditions were documented 90% of the time, preventive 89%, acute problems 84%, and social/emotional conditions just 30% of the time. Looking at the breakdown of the recorded visits, physicians were having the conversations real time, but just not documenting them.

This is a great place where technology could help. What if we could actually accomplish what virtual scribes are doing, but actually do it real time in the exam room? What if voice recognition was as good as we need it to be? Of course, clinicians would still need to review notes for accuracy after processing, but it would be more valuable use of a computer than we are currently doing. I know Nuance is working on the exam room of the future that would be able to collect some of this information, but last I heard, they were going to pilot it with subspecialists rather than tackle the tangled world of primary care. How long will it take until we finally make it there? Only time will tell, and perhaps it will tell us in GMT.

What is your pet peeve of the week? Leave a comment or email me.

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EPtalk by Dr. Jayne 5/16/19

May 16, 2019 Dr. Jayne No Comments

We had some struggles at my clinical office this week. Our soon-to-be fossilized PCs running Windows 7 had a bad interaction with Active Directory and Citrix. The result was that nearly half of the physicians couldn’t access the EHR. When our IT team tried to fix it, they effectively eliminated access for the remainder of the providers.

It wasn’t pretty and caused a great deal of consternation as the staff tried to figure out how to execute downtime procedures when only half of the people were down. Staff continued to document electronically, but providers were on paper, except for the lucky providers at busy locations that had scribes assigned to them. Ultimately the situation was remediated, but it underscored the need for our leadership to get rid of Windows 7 since it is reaching the end of its support cycle.

Thanks to Dr. Nick van Terheyden for his kind mention of my recent Curbside Consult regarding employment-based health insurance and its impact on efficiency and fairness. He mentions one sad consequence of our US healthcare non-system that I didn’t mention — married couples who divorce when one of the spouses becomes seriously ill so that the surviving spouse is not saddled with medical debt. Another similar scenario that I’ve seen includes divorce from a spouse with serious (but non-terminal) health issues so that the ill spouse can apply for Medicaid or try to get Medicare coverage due to disability. People shouldn’t have to try to game the system in order to get the care they need.

A recent article in the Journal of the American Medical Informatics Association covers the evolution of knowledge and competencies needed by the clinical informatics workforce. A lot has changed in the years since board certification in clinical informatics was being designed. Survey participants spent approximately a third of their clinical informatics work time on improving care delivery and outcomes, while another quarter of their time was focused on leadership activities. Other blocks of time were spent working with enterprise information systems and on data analytics and governance. AMIA plans to reassess informatics practice every five to even years to ensure that their understanding of needs in the clinical informatics domain remains current.

I struggle sometimes with the requirements of board certification in clinical informatics, particularly the maintenance of certification ones. For those of us who are not employed by a hospital or health system, finding ways to meet the “Improvement in Medical Practice” MOC Part IV requirement is difficult. I don’t own the data of my clients and they’re generally reluctant to have their information used outside of their own organizations. As a consultant, I can’t steer projects to become something I need for informatics certification – I have to keep them between the lines of the client’s engagement.

I struggled with this is a family physician as well. One of the MOC Part IV requirements was to do a hand hygiene project that involved handing out surveys to patients about whether caregivers washed their hands. Guess what? My then-employer (who was a big health system) wouldn’t let me do the project in the office because they felt it would interfere with patient perceptions. Since I don’t have continuity patients, many of the other options were off the table. I have quite a few friends who are giving up on board certification, although it’s easier for them because they don’t practice clinically.

Whether you’re a clinical person or an IT person, most of us have spent many sleepless nights running upgrades, working on projects, or taking care of patients. A study published this week looked at the metabolic changes associated with sleep deprivation and whether “sleeping in” might help mitigate some of them. Nearly a third of US adults don’t get the seven hours of sleep recommended for us, but trying to make up for that isn’t as easy as we think. Researchers engaged a cohort of healthy adults and assigned them to a control group with sufficient sleep, a restricted (five hours nightly) group, and a restricted group that was allowed unrestricted sleep on weekends. The “makeup sleep” group only slept an additional three hours on the weekend despite missing more than a dozen hours of sleep during the previous nights. Those trying to catch up also experienced disruption to their circadian rhythms resulting in trouble falling asleep at the end of the weekend.

Sleep restriction led to decreased insulin sensitivity that was worse in those engaging in recovery sleep. Restricted individuals also consumed excess calories and gained an average of three pounds over the course of the study.

Given the fact that study participants were healthy, the authors question whether the results might be even more striking in patients who were older or less healthy. Even though it leaves a number of unanswered questions, the study shows that our bodies are negatively impacted by lack of sleep and it’s not easy to try to make up for it.

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I was excited to start receiving the AMIA Daily Download, which includes a roundup of top news along with key issues in clinical informatics, bioinformatics, data science, population health, and social media highlights. They’re also including a link to HIStalk Morning Headlines, making it even easier to get your HIStalk fix.

We talk a lot about health insurance and many of us also deal with professional liability insurance, business continuity insurance, and more. I’ve seen some recent articles about data breach insurance. Most of the physicians I’ve spoken with have never heard of it. Policies typically cover expenses related to a breach as well as recovery services. We know that hackers find physician organizations to be easy targets and independent physician practices may be particularly vulnerable. I still see plenty of users writing down their passwords or using easily hacked passwords such as their children’s names. I see many practices that totally disregard the physical safeguards required under HIPAA as they leave server rooms accessible and allow users to put their own devices on the network without appropriate policies in place.

I’ve not been through the underwriting process for a data breach insurance policy, but I wonder if they look at how tuned-up your organization is to begin with. Do you they ask you if you have appropriate policies in place? Is it like auto insurance where they charge more for inexperienced drivers who are more likely to generate a claim? I’d be interested to hear from organizations that have been through the process and especially interested to hear from an organization (anonymously of course) who had to file a claim against their policy. Was it easy to get the coverage to pay out? Or did you have to fight them all the way? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 5/13/19

May 13, 2019 Dr. Jayne 4 Comments

We as CMIOs are often called upon to try to use data, information, and knowledge to try to solve complex problems that are caused by specific factors within the US healthcare system. They might be tied to low health literacy, funding barriers, or the high cost of care. I’ve worked with people to try to strategize around school-based health centers, community outreach programs, healthcare for the homeless, and more.

Since I often see situations where health insurance coverage (or lack of coverage) becomes part of the care equation, I was interested to see this piece in the Journal of the American Medical Association. It asks the question: “Does Employment-Based Insurance Make the US Medical Care System Unfair and Inefficient?”

On the surface, it seems like the answer to the question is yes. I often see people trapped in jobs they don’t like or aren’t suited for because they are afraid of losing their insurance coverage. I see people staying in dysfunctional marriages or domestic partnerships because of the insurance issue. Insurance in general adds inefficiencies to our practice, as we have to hire a fleet of people to handle claims creation, management, denials, appeals, and other billing functions. The complexity of insurance rules and differences in coverage are significant and it’s nearly impossible for the average clinician to try to make sense of it without significant assistance.

The coverage offered by employers can differ in striking ways. I was privileged to grow up in a family that had excellent coverage that was tied to my father’s membership in a union, insurance that was independent of the contractor for whom he worked and which could be continued in the event of a job loss through credits that workers could bank over time. I didn’t realize until medical school how amazing it was that my parents still had a $5 co-pay and that they didn’t need a referral to go see a specialist. (Of course that was in the bad old days when you were kicked off your insurance when you finished college, so I didn’t think the coverage was that great when I had to pay out-of-pocket to have my wisdom teeth extracted after they caused issues during my first semester.)

This was during the time when HMOs were growing in the US and many patients were having to get used to the ideas of working through a primary care gatekeeper and of being restricted to certain groups of physicians or particular hospitals. Now that we’ve seen that approach wax and wane and morph into what we’re working with now in the realm of value-based care, people are still complaining about their insurance. Employers may limit the plans available to employees due to cost. Changes in coverage can lead to frequent switching of physicians that can cause fragmented care for patients with chronic conditions.

Having heard about those factors over the years, I was interested to see an academic’s impression of the situation. The author notes that in the US, “the interests of high-income individuals dominate decisions about what medical care is offered and how it is financed. The result is a less efficient and less equitable medical care system than in other high-income countries.” He offers a review of the history of employer-based insurance, which initially started as a benefit to recruit employees during World War II. Other factors fueled its growth, including group insurance and tax advantages for employer contributions to the cost of coverage.

Employer-based coverage is cited as a contributor to rising costs when it includes wide networks, fee-for-service payments, and self-referral to specialists. The author notes other cost factors, including a focus on specialty / subspecialty care, high-cost technologies, relatively low hospital occupancy rates, and better hospital amenities, including space and privacy. He goes on to note that higher-income patients might be likely to pay for those amenities, but that “many low- and middle-income households would be better off if medical care was less costly and they had more money for other public and private goods and services.” He likens the high-cost product of the US medical system compared to other high-income countries as the difference between Whole Foods and Walmart.

He agrees with rank-and-file physicians about the high cost of administering the US system and its “mix of employment-based insurance, other private insurance, numerous government programs, including Medicaid and Medicare, each with its own eligibility rules and payment schemes and out-of-pocket payments.” Because of that hodgepodge, it’s impossible to understand the true cost of care, either to the patient or to the overall healthcare system, because of financing across patients, employers, and government entities. Ultimately in the US, patients bear the cost as employers lower wages to cover insurance premium payments and as the federal government collects money for Medicare through payroll taxes.

He notes that the US could save a significant amount of money if administration were simpler or if the healthcare “products” offered could be tailored to create a lower-cost alternative. However, government regulations would need to change for this to occur. He concludes that additional exploration is needed, although it appears that the way our system is financed causes inefficiencies and unfairness.

Trying to move from this hypothetical state to one that actually has an impact on our medical system is a tall order. People aren’t going to be lining up for narrow networks, stripped-down experiences, or a return to general ward care. Hospitals are in a veritable arms race as they compete to put heads in beds by offering in-room services that rival some of the nice hotels I’ve stayed in. However, those services don’t change the rate of handwashing or operative complications regardless of how much they appeal to patients.

We’re also addicted to technology and that raises costs. I was working with a medical student last week who trained in China. He’s seeking residency training in the US and was asking for strategies and feedback to improve his chances of being offered a training slot. We had an extensive discussion about physical diagnosis skills and how in the US we often jump to technology rather than using our ears and eyes and brains when we order CT scans and echocardiograms. I suggested that his ability to manage complex patients in a low-tech environment might be appealing to residency training programs given the alignment of those skills with what is desired in value-based care. It’s not going to change the fact that patients want an MRI, CT, X-ray, or lab test because they trust it more than physician skill, but it creates interesting food for thought.

The JAMA piece only had one comment. I would be interested to hear what readers think about the role of employer-based insurance in our complex healthcare system. Is it a blessing or a curse? Leave a comment or email me.

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