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Curbside Consult with Dr. Jayne 3/1/21

March 1, 2021 Dr. Jayne No Comments

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My calendar made me smile today with an appointment reminder that had 2020 been a normal year, I would be in Las Vegas attending HIMSS21 and drinking martinis with all of my healthcare IT friends. Alas, it was not meant to be. Instead, I’m ever-present in my home office digesting a constant stream of email, press releases, and journal articles.

The theme of the week seems to be telehealth, with different companies in the news. MDLive, which was thought to be setting up for an IPO, was instead acquired by Cigna’s Evernorth subsidiary. At the same time, Mercy and Humana teamed up to expand access to telehealth services for Humana Medicare Advantage members. The latter agreement is particularly interesting because it specifically called out a value-based care component of the relationship. Once the US healthcare system begins to fully process the burden of COVID-related care, I suspect there will be a greater drive towards value-based care.

Due to the fragmented testing strategies across the country, many patients are receiving high-cost testing at urgent care centers that require a physician visit to justify the testing. A better strategy would have been to enable public health-based testing, where patients could have been tested under standing orders from local public health authorities, reducing the overall burden on the system. The nation has been walking a tightrope, balancing the need to ensure access to testing with the potential for out-of-control testing costs.

I see this in my urgent care practice, which is one of the organizations requiring a provider visit prior to testing. Patients are seen and examined, then the most appropriate test is determined, ordered, and obtained. Over the last few weeks, we’ve seen a shift in testing behavior. Previously, the majority of our tests were done on symptomatic or exposed patients, with rare testing for travel. Now we’re seeing a boom in pre-travel testing, and doing that kind of testing in an urgent care setting is a significant waste of resources. We are also seeing people just coming in to be tested weekly because they can, and because they don’t have any financial skin in the game. They’re going about their lives unmasked and practicing unsafe behaviors and the rest of us are picking up the tab.

Out of necessity, we don’t want to create barriers to testing, and as a physician, I totally get that. Recent executive orders and subsequent guidance from federal agencies make it clear that patients must be tested with no cost sharing or utilization management oversight. As someone watching the costs mount, especially in states that didn’t bother to prioritize low-cost testing options, it’s anxiety-provoking.

Fast-forward then to a new world where payers are going to be looking to make up for all of those expenditures. Premiums are certainly going to rise, and they’re going to crack down on payments for other services. I predict that use of low-cost telehealth services will be pushed to the forefront. That’s good for patients who are technology-savvy and value the convenience. It’s not so good for patients who don’t have access to technology or aren’t skilled with it, or for whom an in-person visit would be better. Telehealth may become an additional layer of triage that helps control which patients receive more expensive in-person services, and this is most certain to happen if payment parity for telehealth services does not continue.

Practicing in a telehealth environment doesn’t come naturally to physicians, and few schools taught telehealth skills prior to the pandemic. I enjoyed reading a recent article in the American Family Physician journal which explained how to do high-quality management of musculoskeletal issues through a telehealth encounter. That’s the kind of practical retraining that many physicians are going to need if they’re going to be expected to practice in that world. They shouldn’t be expected to just figure it out on their own, as most have had to do.

But if they are going to be held to the same value-based care metrics and standards that they are held to in the brick-and-mortar world, they’re also going to need adequate telehealth infrastructure to deliver it. This means being able to coordinate visits with ancillary providers such as registered dieticians or certified diabetic educators and being able to leverage high-quality remote patient monitoring services. Although these are great concepts, we’re not remotely close to delivering that level of care to most of the US.

I’ll be watching the recent telehealth acquisitions, agreements, and expansions closely to see who is hitting the mark and who starts drifting off course. Many organizations will be forced to migrate from make-do virtual visit platforms to robust telehealth solutions that integrate with the EHR. Physician groups will have to determine how they figure telehealth into evolving physician compensation strategies. Much like groups might pay physicians less when they stop taking overnight call, will they pay physicians less if they elect not to come into the office? Will they create different kinds of practice-share arrangements for teams of virtual and in-person physicians to partner together? Will telehealth be part of a continuum of care, or will it continue to be a bit siloed?

I’ll also be watching lab and other ancillary businesses. Will the big lab vendors start performing COVID testing in person, so that a patient could receive a telehealth-driven order for testing and go to a lab patient service center to have it collected, just like they might go for a blood draw or a urine culture? Or will local public health agencies step up to fill that void, especially since those states that had mass testing centers are starting to close them down? Will we see COVID testing booths on street corners like you might see in other countries? The devil will be in the details as far as how we try to contain costs and deliver the medical services that provide the most value to our patients without breaking the bank.

Looking in your crystal ball, what do you think are the next steps for telehealth in the US and around the world? Will we see massive shifts in utilization? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/25/21

February 25, 2021 Dr. Jayne 4 Comments

Today’s web-based entertainment was courtesy of Nuance and its Dragon Ambient eXperience product. I’ve been keeping an eye on it since seeing it at HIMSS19.

Their demo at the time involved an orthopedic visit, which tends to be a lot more straightforward than most of the visits we have in primary care. I was hoping they would show a truly complicated visit and how the system could handle it. It was encouraging the host said they would be doing an “unscripted” demo based on attendee input through a Zoom poll with randomly generated options.

However, it quickly turned into the same old orthopedic visit that they typically show. They asked the audience to have input via poll on past medical history elements, but many of what we were given to choose from were just standard conditions like hypertension or an ACL repair.

I have yet to see a demo where the system can manage the real-world things we see in practice. Where is the history of “heart surgery” where the patient has no idea what was done or what the underlying diagnosis might have been? What about the problems that were more complex than injuring your ankle while walking your dog Lucky, which was the demo they actually showed? They showed the voice recognition streaming during the demo, and there were a number of elements where it wasn’t capturing exactly, so I was curious to see what the process would be to resolve those.

The command “Hey, Dragon, show me the x-ray” brought up an x-ray example with no patient identifiers, which failed my realism test. The physician also interpreted the x-ray before examining the patient, which is a no-no for many of us. The physician used a fair number of medical words, but didn’t really explain to the patient what those meant, including the anatomical names for the affected areas.

I wasn’t impressed by their simulated assessment and plan, which didn’t entirely follow the standard of care in that the patient was given a scheduled controlled substance for her ankle sprain, which most of us wouldn’t do until the patient failed other pain management strategies such as anti-inflammatories or acetaminophen, neither of which she said she had taken.

I know I tend to be critical since I’m a practicing physician, but it’s all part of credibility. It’s hard to find the messaging to be credible when they missed the clinical mark. Was it intentional, or did they not find it important to be clinically credible? Interestingly during the interview, the clinician ordered tramadol, but when the host reviewed the medication orders, the canned display on the back wall showed Tylenol, which maybe was an indicator that it was a little more unscripted than they planned. The final note did mention both Tylenol and tramadol, however.

They cut away to videos from physicians, including family physicians and orthopedic physicians, but they didn’t really show what this would look like in family medicine. I asked a pointed question via the Q&A chat about how the system would manage vague elements like I mentioned above. Not surprisingly, it was skipped. They did mention that they have a four-hour service level agreement for note turnaround, although they noted it can be shorter in the real world. As a physician who likes to have my notes done when I walk out of the room, that would take some getting used to. They did demonstrate how the system could filter out the conversational parts of the visit in order to create a concise note, which is promising. Still, I’d love to see how it handles a complex primary care visit.

Today’s patient-side entertainment was courtesy of my local hospital, which continued to underwhelm. I’m living the nightmare shared by a number of female healthcare providers who received the early rounds of the COVID-19 vaccines. Since it’s been two months, and statistics do what statistics do, one-sixth of us over a certain age have been due for an annual mammogram since receiving their vaccines. Both of the current vaccines tend to cause swollen lymph nodes, usually in the neck or underarm, and sometimes those nodes turn up on a mammogram. It’s a widespread enough issue that mammography centers are adding questions to their intake forms asking about vaccine status and which arm was used for the administration. The Society of Breast Imaging sees this as a big enough issue that it has recommended women delay screening mammograms until at least 4-6 weeks after receiving their last vaccination. However, for those of us who were due for screening prior to the recommendation, we are now chasing down rogue lymph nodes that could be due to the vaccine or to something more sinister, such as breast cancer or lymphoma.

I had a difficult enough time scheduling my follow-up ultrasound due to my clinical schedule and the limited appointment slots. Today’s actual appointment could have served as a case study of what not to do from a technology, operational, and clinical standpoint.

It started with patients reporting 15 minutes before their appointments as instructed, only to find that they had a single registrar who was taking names and instructing people to be seated until called. The problem: six patients and five chairs in a waiting room that had been stripped of furniture for social distancing. Patients were slowly called to the desk, where they were forced to fill out the usual clinical history form (completely from scratch, once again not pre-populated from the Epic system as it could have been) standing there in front of the registrar. This delayed additional check-ins and I’m sure was frustrating to patients.

Despite arriving early, I wasn’t called back until 10 minutes after my appointment time, where I was taken to a changing room that fed a sub-waiting room with an additional four patients (although there were five chairs, but this time we got to sit around with each other in flimsy gowns). Plus, instead of watching HGTV in the main waiting room, we were treated to a screen displaying a version of the imaging center’s tracking board, showing all the patients and their appointments and how backlogged they were. Although the names were truncated like we were flying standby, it felt like an invasion of privacy since we could see all the procedures scheduled for the day. There was a Windows popup on the screen that looked like an error or alert message, and although I couldn’t see the details, I wondered if we were really supposed to be seeing it.

After finally reaching the exam room, I was treated to a brusque sonographer who acted like I hadn’t followed appropriate prep instructions (despite having received none). I felt like reminding her that even though she does this a dozen times a day, each patient was enduring the harrowing experience of wondering if they have cancer or not, so they don’t need her attitude. It was clear she was having trouble getting the images she wanted, but she finally went to review them with the radiologist while leaving me draped on the table.

When the radiologist came in, she started spouting medical terminology and I’m hoping it was because somewhere my chart was flagged as a physician because as a “regular” patient I would have had no idea what she was talking about. I guess I’m also more sensitive to the patient’s comfort than she was, because I rarely have conversations with patients while they are draped and lying on the table. At a minimum, it would have been nice to sit up and have a conversation at eye level.

I don’t think I have unreasonably high expectations. They have been shaped by the way I was trained and how I’ve seen medicine practiced for the last two decades. But it seems they’ve substantially diverged from the post-COVID reality of healthcare in my city. Patient advocacy and patient empowerment are supposed to be major factors influencing how healthcare organizations operate, but apparently for some they’re little more than buzzwords.

The perfect cap on the day was when the sonographer walked me back to the changing room, where she told me to “enjoy the rest of your day.” As I looked at the faces of the other women in the sub-waiting room, knowing that their lives might be changed dramatically today, it didn’t seem like what patients might want to hear, especially knowing that some of them would go home to sit and wait for results. Perhaps “take care and thank you for choosing us as your healthcare team” might have been a better option.

Have you experienced a decline in patient services in the COVID era? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/22/21

February 22, 2021 Dr. Jayne 1 Comment

I’m not sure if I’ve ever met Nordic Chief Medical Officer Craig Joseph, MD in person, but he’s definitely on my list of “people I’d like to have a cocktail with” at some point. His Twitter posts @CraigJoseph always have interesting tidbits, such as a recent white paper from ECRI’s Partnership for Health IT Patient Safety. He notes, “Lots of smart people with clinical and EHR vendor chops outline specific actions to consider.”

I checked out the paper, titled “Optimizing Health IT for Safe Integration of Behavioral Health and Primary Care.” It resonated with me because this is an issue I’ve had to deal with for years – navigating the intersection of those two disciplines while trying to coordinate care while maintaining privacy. Many organizations, including some of my current clients, choose to keep primary care and behavioral health records siloed. This results in fragmentation of care and lack of understanding around whole-person factors that drive both physical and mental health.

It lays out clear reasons why primary care and behavioral health need to be integrated:

  • 80% of behavioral health patients will visit a primary care provider (PCP) at least annually.
  • 50% of behavioral health disorders are treated in primary care settings.
  • 48% of appointments for psychotropic medications are with non-psychiatrist PCPs.
  • 67% of people with behavioral health disorders don’t get behavioral health treatment.
  • 30-50% of patients referred from PCPs to outpatient behavioral health don’t keep their first appointment.
  • Two-thirds of PCPs report being unable to access outpatient behavioral healthcare for their patients.

Additional barriers for mental healthcare access include provider shortages, health plan barriers, and coverage issues. In my major metropolitan area, we recently opened a dedicated mental health emergency department unit that is staffed full time by specialist providers. The community accepted it readily because we know we don’t do the best job for patients needing non-medical services who present to other care venues, such as the emergency department or urgent care facilities.

Even for health systems or provider-side organizations that want to try to integrate the behavioral health and primary care realms, EHRs aren’t always supportive. Psychiatry notes, therapy notes, and documentation from social workers are often kept under separate access where the primary medical team can’t see them. Especially when we’re dealing with medical conditions that can have significant behavioral components, it would be useful to be able to see all the information about the patient. The white paper does a nice job explaining different levels of integration, from “coordinated” care to that which is “co-located” to fully “integrated” care. Right now, many primary care practices are struggling to deliver even minimally coordinated care.

One of the major participants in the creation of the paper was the HIMSS Electronic Health Record Association (EHRA). I have some experience with EHRA from a past life and know many of the members of the project’s working group to be knowledgeable individuals with a deep understanding of EHRs and care delivery. EHRA has a code of conduct for EHR and health IT developers that addresses the need for collaboration described in the paper.

However, working as someone outside of an EHR vendor, I’ve found it nearly impossible to access the materials that we relied on when I was on the vendor side. This forces those of us who work on homegrown or in-house systems to re-invent the wheel trying to determine best practice as we develop our technology. Since this is a partnership with ECRI and this paper exists, I take that as positive signs. Still, non-commercial developers are going to have to do a lot of figuring out on their own unless there are maneuvers to standardize at the federal or payer levels.

The paper talks about standardizing screening and documentation tools so that data is consistent across an enterprise. Although this would be good, many patients may receive their care across multiple organizations. I cared for a patient the other day who receives medical care primarily through a county health clinic because she doesn’t have health insurance, but receives a telehealth benefit from her employer, so she’s using that for urgent care services and psychotherapy. She came to our urgent care because she needed stitches and we have an affordable self-pay program. Given the vast differences in the systems used by those entities coupled with the relative immaturity of our state’s HIE, there’s no way there will be coordination any time soon.

There are also legal barriers to sharing of data under both HIPAA and 42 CFR Part 2, especially around sensitive health information. Many organizations find these restrictions daunting and either don’t have the wherewithal or the manpower to try to tackle them, especially while simultaneously coping with a pandemic and the generalized dysfunction of healthcare delivery in the US. Patients also struggle to understand the protections and restrictions and become frustrated when we try to explain why we have to ask the patient to summarize their care because we can’t access the information that we need without recreating the proverbial wheel.

The document has some great appendices, including a literature review and tables of evidence used during its creation. The summaries of EHR challenges and existing workarounds were fascinating case studies in dysfunction: lack of integration between the EHR and tablet devices used for patient-completed screeners and surveys; copy and paste to add the same note to the PCP and behavioral health EHRs; printing and scanning of medication lists from the behavioral health EHR to the medical one; and more. My favorite is “Reliance on patient or clinical recall for inaccessible clinical information – providers describe this as ‘flying blind.’”

Due to my employer’s lack of integration with our state HIE or nearby health systems, I’ve been flying blind for the last six years, except for when patients use their phones to access MyChart and then hand them over. That’s been useful in a number of medical situations, but I have to admit I’ve never seen psychiatry notes or therapy notes in any of those encounters, and I usually can’t see a full medication list history to know what’s been tried in the past — only current medications are typically displayed.

The paper also contains pages of recommendation tables, some of which push back on ONC, CMS, and other agencies to provide easily accessible standards for developers to use when creating documentation. It also calls on ONC to drive adoption and implementation guidance for APIs to improve integration. There is also a bid for the federal government to incentivize patient care organizations to implement standardized tools. There’s a great swim-lane diagram of an ideal IT-enabled workflow for safe integration. It will be interesting to look back at this paper in a couple of years and see how far we’ve come or whether we’re still living in the land of siloed documentation.

Has your organization done work to support integration of primary care and behavioral health? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/18/21

February 18, 2021 Dr. Jayne 6 Comments

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I had a moment of excitement in my pre-HIMSS planning when a friend clued me in to reasonable rates at The Palazzo. I’m happy to be rebooked somewhere that is attached to the meeting facility so I don’t have to melt in the August heat on the way to the show. The HIMSS room reservation system shows that the resort fees are optional this year,  which is great for those of us who never get to experience the “resort” component since we’re frantically trying to see everything possible then write it up before collapsing every night. I also had a thrill when I came across this ad featuring a vintage booth babe. I’m a sucker for opera length gloves and a dramatic up-do, so it certainly got my attention.

People always ask what kinds of things I’m interested in looking at when I attend HIMSS. Smart glasses are back on my radar. It’s been years since Google Glass came and went, but I’ve seen two articles in the past week that featured some variation on smart glasses. Specific use cases include helping a remote clinician better visualize a patient during a telehealth consultation or using the glasses to deliver diagnostic information from AI-powered clinical support systems.

One of the articles noted the potential for patient-side wearables to capture clinical information for later review by the care team. There’s always a lot of talk about wearables, but I haven’t seen a tremendous body of evidence that they can significantly drive clinical outcomes. We’ll have to see what companies bring to the table come August.

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The American Medical Informatics Association issues a call for proposals for the AMIA 2021 Annual Symposium, to be held October 30-November 3 in San Diego. A quick scan of the website showed they are currently planning for a live event “with a limited component of live streaming.” It goes on to note that the AMIA board will make a decision in June if this needs to change. For those interested in presenting, submissions are due March 10.

Although I read a number of journals regularly, I enjoy JAMIA because of its focus on informatics issues. One recent submission looks at gender representation in US biomedical informatics leadership and recognition within the biomedical informatics community. The authors assessed data on AMIA members, academic program directors, clinical informatics fellowships, AMIA leaders, and AMIA awardees. Not surprisingly, men were more often in leadership positions, including 75% of academic informatics programs, 83% of clinical informatics fellowships, and 57% of AMIA leadership roles. Men also received 64% of awards.

I’ve worked with a number of informatics organizations and have seen significant differences in how they approach the creation of a diverse workforce. While some hope it will happen by chance, others work quite intentionally to provide opportunities for groups that are traditionally underrepresented in technical fields. I recently met with a group of women informatics leaders and learned about their strategies for recruiting diverse teams. We certainly can benefit from broader perspectives.I look forward to seeing what those numbers look like in five or 10 years.

JAMIA publishes a study that examines the impact of after-work EHR use and clerical work on burnout among clinical faculty. Specifically, they looked at faculty across Mount Sinai Health System, with 43% of eligible faculty members participating. They concluded that spending more than 90 minutes on EHR work outside the workday and performing more than one hour of clerical work per day are associated with burnout. The findings were independent of demographic characteristics and clinical work hours.

I’ve spent a good chunk of my career trying to help organizations improve their workflows and am always gratified to see an organization that cares about how technology is impacting workers. Unfortunately, many groups don’t see this as a priority or are happy to watch their clinicians absorb increasing amounts of non-clinical work.

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Challenges with personal protective equipment are once again in the news, as healthcare organizations have been saddled with millions of counterfeit N95 respirators. Impacted organizations include Cleveland Clinic, the Washington State Hospital Association, Jersey Shore University Medical Center, and Hennepin County Medical Center in Minneapolis.

I was discussing this article on a local physician forum and ended up talking with a local academic faculty member who couldn’t believe that community hospitals and private organizations are still struggling to provide adequate PPE. My clinical employer provides a limited number of N95 respirators to our team and makes their use inconvenient by only stocking them at a single location, requiring people to travel on their days off to pick up a new supply and to rotate that supply over an extended number of days. Some of us are providing our own respirators to avoid reuse, but the counterfeit issue is still a concern. Co-workers who don’t go through the steps are still being diagnosed with COVID-19 despite vaccination.

I have friends who are nurses at community hospitals that sometimes receive N95s only once a week since they’re not on dedicated COVID units. Others have to beg supervisors to replace their PPE when straps break, or they become wet from wear. It’s a tragedy that we are still dealing with this a year into the pandemic. I can’t help but think that if the Centers for Disease Control made N95s mandatory for patient care encounters that we would stop seeing healthcare workers being infected. Employers would be forced to raise their game and to support those employees who want the highest level of protection. But as long as they say that surgical masks are an OK alternative, we’ll continue to see cases.

Fortunately, I have enough masks to make it through the end of my current clinical situation, since I’ve officially tendered my resignation. The fact that I made the right choice was confirmed a few days later when the organization announced some fundamental changes that will significantly alter how the business operates. It will be interesting to see how many people jump ship. I was asked not to reveal my resignation to staff until a couple of weeks before I actually leave, so for all I know, there could be others in the same position. It should make for an interesting couple of months. In the mean time, I’m looking forward to having a break from work-related COVID while I figure out my next move.

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The Washington Post reports that Europe’s oldest person, a 117-year-old French nun, has survived COVID-19. Lucile Randon, who took the name of Sister Andre in 1944, was diagnosed on January 16. She was born on February 11, 1904, which means she also lived through the 1918 pandemic. Her birthday celebration was slated to include foie gras, capon with mushrooms, and red wine. Best wishes to Sister Andre for an uneventful 2021.

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Curbside Consult with Dr. Jayne 2/15/21

February 15, 2021 Dr. Jayne No Comments

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Like many parts of the US, my city has spent the weekend heading deeper into the polar vortex. I’m not a big fan of sub-zero temperatures, let alone wind chills in the negative double digits. We’re expecting snow throughout the night and into the morning, which will make for less-than-fun conditions driving to work in the morning. While some of my physician colleagues were scrambling to move their in-person patients to virtual visits, I reminded them that some of us have to work in person regardless of the weather.

I’m a bit tired of being an all-purpose clinical safety net for practices that don’t want to or otherwise can’t see patients in person, and especially having to see those patients without any supporting medical information. That’s one of the pitfalls of being part of an independent organization. We don’t have access to anyone’s broader medical records, unless you count patients who log into MyChart and hand you their phone. Our state charges exorbitant rates for independent physicians to participate in its health information exchange, so we don’t have that data, either.

Back when I was a community-based family physician, I used to call ahead when I referred patients to urgent care or to the emergency department to let them know what I was thinking and why I was sending the patient. It doesn’t seem like anyone does that any more. Half the time when I try to call a patient’s personal physician to discuss their case, either I don’t get a call back or they act bothered that I even called in the first place. I’ve had a total of two physicians thank me for calling them about their patients in the last six months. One of them was an orthopedic surgeon who not only gave me advice on how to handle the patient’s unique problem, but made the patient an appointment for first thing in the morning while she and I were on the phone discussing the case.

I try to keep positive situations like this one at the top of my thoughts when I’m dreading tomorrow’s bone-chilling and potentially dangerous trek. Due to the pandemic, plenty of people are out of practice driving in poor conditions, so who knows what it will look like. I’d much rather be at home working on technology projects. I have some interesting ones in the works. One takes me into a world where I haven’t had a lot of experience outside the clinical realm, and that’s the perioperative services arena. I’ve been contracted by a health system that is trying to be proactive about the significant number of surgeries that patients have delayed during the pandemic. As COVID-19 numbers begin to fall across the region, they are looking at the best ways to bring those patients back into care.

As you can imagine, a number of the cases are orthopedic in nature – hip and knee replacements, shoulder reconstructions, and the like. For those patients whose procedures were on the books at one time and were rescheduled or canceled during the pandemic, outreach is fairly straightforward. The challenge is identifying the patients who never made it to the surgical scheduling team. Perhaps the procedure had been discussed with a surgeon, some of whom are employed by the health system, so we have access to medical records and can begin to identify those patients depending on how the visits were documented and whether the procedure recommendations were captured in discrete data. Others had surgeries recommended by community-based physicians who are on staff at the system’s hospitals, and identifying those patients is more challenging.

Beyond identifying the patients and their respective procedures, there are several other related projects that I’m being pulled into. They look at various details including surgical scheduling, staffing for perioperative personnel, equipment management, sterilization and central supply processes, and more. One sub-project looks at the surgical instrument preferences for various procedures across surgeons and how they might be standardized. That’s where it gets exciting for me, because I get to try to look at relationships between surgical outcomes and a number of factors, including level of standardization, number of cases performed at the different facilities, staffing, and how those factors might influence each other.

Right now, I’m overseeing the gathering of the data from various sources and its aggregation into a central database. We’re designing the questions we need to ask and looking at known pain points in the processes, from scheduling to day of surgery to follow up. This is where it’s fun to be the outsider, because I don’t know any of the people or the personalities and I’m eager to let the data speak for itself.

I don’t know that Dr. X has been on staff for 30 years and that people tolerate his quirkiness because he’s considered the elder statesman of his subspecialty. I am not swayed by people’s claims that their patients require special equipment different than that used by all their peers. I don’t know any of the stories about why one hospital has been allowed to operate outside the system’s standards or why everyone else is in alignment. I’m eager to see what stories emerge as the data begins to tell its tale. I can also look at data that overarches the procedures and surgeons, such as operating room turnover time, housekeeping data, central supply factors, length of stay data, surgical complications, readmissions data, and more.

The other element that excites me about this project is having support staff to work with who know the system from the inside. It’s not the usual “let’s outsource this” type of project of which I am usually on the receiving end. I get to work with people across the health system who possess deep experience in quality improvement projects and clinical transformation work and are similarly motivated to try to find ways to improve the process as well as patient experiences and outcomes.

I knew this was going to be an interesting project, but now that I’m really involved, I feel like a kid in a candy store. What projects are you most looking forward to this year? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/11/21

February 11, 2021 Dr. Jayne No Comments

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Even with all the turmoil the US has gone through in the last several months, the institutions of government are still going strong, and the folks at CMS have not missed a beat. They did, however, extend the deadline for submission of 2020 data for the Medicare Promoting Interoperability Program. You now have until April 1, 2021 at 11:59 p.m. ET to attest through the QualityNet portal.

New Hampshire lawmakers have introduced HB 602, which aims to eliminate existing provisions protecting telehealth coverage. It would eliminate coverage entirely for audio-only services, which may have the unintended consequence of reducing access for those either not able to access the internet or who aren’t technically savvy enough to manage audio/video links. Surprisingly, one of the bill’s sponsors, Representative Jess Edwards, was one of the co-sponsors of the 2020 law that created payment parity for telehealth coverage.

As a telehealth physician, audio-only visits can be high quality interactions. In addition to the limitations above, some patients are just not comfortable on video due to their living environment or other factors. We’ll have to see whether this bill makes it through the process or not.

The ongoing usefulness of telehealth is discussed in this recent Journal of the American Medical Association editorial. The authors note that both patients and clinicians may want to continue virtual visits and that those visits could be as effective as in-person visits or used in conjunction with in-person visits as a hybrid model. Concerns about use of telehealth in the absence of hands-on examinations are valid, particularly when considering the overuse of expensive tests in lieu of physical diagnostic skills. Still, some conditions don’t require extensive physical examinations, but do require a physician’s cognitive effort.

For example, I was diagnosed with a food allergy a few years ago and I now doubt that diagnosis. I’m trying to get a second opinion from an allergist. The next available appointment that meshes with my work schedule is two and a half months away. No physical exam elements are part of this evaluation, and I recently had a full physical exam with the findings available in the shared EHR. Essentially, I need a learned expert to perform a review of my existing records and have a discussion with me about the risks/benefits of testing to determine whether it’s worth trying to proceed.

I’m willing to pay for the physician’s knowledge, experience, and time, but the construct in which we operate requires me to drive halfway across town to do it instead of being able to teleconference with the provider in the open slot that she has on Friday that would work with my schedule except for the drive time.

Of course, not every visit is suitable to a non-visit approach, but it’s time we think outside the box and focus on patient access, delivering high-value care in ways that are win-win for everyone involved. Real concerns also exist about fraud, abuse, and low-quality care. I would argue, however, that telehealth can be an important adjunct to whole-person care and for scenarios where a physical exam isn’t necessary or a recent exam is well documented. It could save a substantial amount of time and money for all parties involved.

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I’m continuing to follow up on some random leads from the Consumer Electronics Show. One of them was a note that I made for voice-activated faucets. Kohler has launched a not only operate on command, but can measure specific amounts of water. The faucet also connects with a smartphone app that allows households to monitor water usage and be notified if it appears anything is out of the ordinary. Some models even offer a “wash hand” command that will instruct a user through the recommended steps for handwashing, including audible guides for lathering, cleaning, and rinsing. For parents who are tired of hearing two rounds of “Happy Birthday” as they try to instill good habits, it’s tempting, but the $1,700 MSRP is daunting. Most of us will have to go back to the old-fashioned egg timer and some adult supervision.

I enjoyed having easy access to the CES materials and sessions for a reasonable time after the show. Whatever HIMSS plans for its hybrid conference in August, I hope they improve their learning management system, because trying to find the sessions you want to watch after the fact is sometimes daunting. As someone who used the HIMSS sessions in the past for Maintenance of Certification credit for my informatics boards, it always seemed like the sessions I wanted to attend were on top of each other and watching after the conference was the answer. I hope they announce more information soon about the hybrid format, because I need to make some hotel decisions soon.

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I had some additional adventures as a patient this week. The local hospital sent me an email reminding me that I had a bill due that I actually paid a month ago. I tried to use the integrated chat function to get it clarified, and the first thing I experienced was that despite the chat requiring me to enter the bill’s ID code along with the amount due (so that it could presumably be made available for the agent when he arrived in the chat), the agent asked me whether the bill was for a different amount that has never appeared on my account. I also quickly noticed that the chat client had no audio indicator that the agent had messaged me, so I had to sit there and stare at it to know if there was a communication. The agent kept telling me I had a zero balance despite the email and the home page that clearly showed a balance, and then told me not to worry about it.

I asked him to please escalate the fact that the system is sending balance due emails to patients with zero balances, since I’m a referring physician as well as a patient and know that would bother my patients as much as it bothered me. He then decided to tell me it is a known issue and that they are working with the vendor to resolve. I’m not sure why he didn’t tell me that up front when he realized my issue looked like one of the known issues, or why he decided to tell me once I said I was a physician, but either way, It wasn’t outstanding customer service. I hope the vendor gets their act together and fixes the defect soon because it’s annoying to say the least.

Do you feel like your healthcare team has accurate billing practices? Or do you see a high volume of patient complaints? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/8/21

February 8, 2021 Dr. Jayne 3 Comments

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It’s been a pretty crazy week in the clinical trenches, with COVID cases ticking up in my area. I’m approaching my one-year COVIDversary, memorializing one year since the day I saw my first COVID case, which happened to be one of the first five in my city.

I laugh a little thinking about it, since of course it presented itself at the urgent care as so many other health conditions do. It wasn’t some diagnostic mystery at a tertiary medical center, or an academic puzzle for someone like House. It was a household contact of someone suspected to be infected, who presented to our office saying she had a fever and couldn’t smell dirty diapers. My physician assistant and I spent the next several weeks wondering if we were going to die. Little did we know that the day would come when we would be seeing 15 to 20 known positive patients a day, with essentially the same level of employer-provided personal protective equipment we had prior to the pandemic (although many of us are supplying our own N95s).

Urgent care centers are healthcare’s front door for many patients who might not have a primary physician or who can’t see theirs during hours that are convenient. Even before COVID, our practice was seeing significant growth, having expanded from five locations to more than 20 in the five years I had worked there.

In November, I was having heated phone calls with our governor’s office about their vaccine plan that left non-hospital-owned urgent cares out in the cold. They were incredulous that urgent care offices treat COVID patients. “When did that start?” they asked. That would be March 14, when COVID-19 first crossed our state lines. The staffer seriously thought that all COVID patients were being seen in the emergency department, which doesn’t give me great confidence in our state understanding how healthcare is delivered to its residents. They also didn’t fully grasp that my practice performs almost 10% of the state’s COVID testing and diagnoses sometimes 500 new COVID cases a day. Seeing more than half a million patients a year, damn straight we’re on the front lines, so how about sending us some vaccine?

As I reflect back on the last year, it’s been a wild ride. At the beginning of COVID, we had to temporarily close several of our locations due to low volumes. I was furloughed without pay, something I never expected to happen as a physician. Once we started offering testing, though, it was off to the races, with volumes going crazy. I’ve mentioned before that in my clinical world I’m just a worker bee, an hourly physician with no leadership responsibility. However, due to my experience and as a consultant, I’m constantly analyzing the actions of my employers against what I might do or recommend that my clients do in a similar situation.

Some of the things they’ve done have been good. Retention bonuses for our clinical support staff helped boost morale and prevent turnover, particularly when patient volumes were high. However, they never did anything to bolster physician morale. When we brought it up, we were told that we should be glad to have jobs since one of the local health systems had completed a significant physician layoff. That never makes one feel good.

Neither does learning that your employer accepted millions of dollars in Paycheck Protection Program funds despite a clinical rebound that had us seeing more patients than we have ever seen in organization’s existence. It’s particularly special when you read about the PPP amount on the front page of the local paper right after seeing an email from your boss that everyone needs to tighten their belts because of the finances. They weren’t following any communications playbook that I would recommend as a consultant, that’s for sure.

The “acting poor” strategy also didn’t play very well when they announced that we were opening additional locations even though we couldn’t fully staff the existing ones. As a part-timer with other sources of income, I had the luxury of being able to push any negative reaction to the back of my mind, but I watched some of my full-time colleagues begin to look for employment elsewhere. Burnout is real and 12-hour shifts are rough, especially when they routinely stretch to 13 or 14 because you’re never allowed to say no to patients who are streaming in the door. I watched several of my favorite physician assistants leave for jobs with eight-hour shifts at local hospitals and have to say I was a bit envious.

I suspected something major might be up several months ago when they hired a new member of the C-suite, but didn’t announce his presence to the physicians. I met him walking through my patient care area after he had been on the job for a couple of weeks. I was underwhelmed by his demeanor and the fact that he was oblivious to my full patient board and the 40+ patients on the parking lot wait list and wanted to stand there and chat. I was even more underwhelmed a week later when his announcement email finally arrived, not from the CEO or COO, but from himself. At that point, I decided to start looking for other clinical opportunities, even though I knew that part-time physician spots basically don’t exist in my community and I’m only in this one because I’ve been here so long.

Toward the end of an already busy clinical week, we received an invitation to an all-hands meeting a couple of hours from when the email was sent. That’s never a good sign. Most of our staff meetings are at 6 a.m. so people can get to their shifts on time. During this quickie Zoom call, we learned that our previously physician-owned practice had gone the way of so many before us in being acquired.

I can’t say I’m surprised knowing the personalities involved, but it explains so much about how they’ve been managing the finances and some of the other decisions that have been made over the last several months. I’m sure it was all targeted towards making the balance sheet look as healthy as possible.

I’ve seen many versions of this movie before and I’ve never seen an ending that works out well for all parties. Inevitably, the investors want their money back and then some, and that money has to come from somewhere. I’m at a point in my career where the plot has to be pretty compelling for me to stay until the end and I’m not sure this fits the bill. I’ve done some research on the investors and I’m not impressed by their healthcare experience. Having participated in due diligence exercises with other organizations looking for outside funding, what I could find on them left me with quite a few questions and not as many answers as I would like.

Most people don’t realize that when physicians leave a clinical position, it’s not like quitting other jobs. It’s not unusual for physicians to be required to give a 90- or 120-day notice so that patients aren’t left in the lurch. Sometimes non-continuity practices like mine will accept less notice, but that’s not the case with my employer, who actually lengthened the notice period for some recent hires. There are some other things that were announced in addition to the investors, and frankly I’m not sure I want to be around when those proverbial bombs begin to drop.

I’ve been thinking about leaving for a while, and this might just be the push I need. When the handwriting on the wall wasn’t done with Sharpie but rather with red spray paint, it’s likely time to dust off the resignation letter. It’s an unsettling feeling since I’ve only resigned from two long-term jobs in my career, but I trust my gut, even in the middle of a global pandemic and without another clinical gig on the horizon. Time for my next leap into the unknown.

What’s your best job quitting story? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/4/21

February 4, 2021 Dr. Jayne 2 Comments

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I’m not sure what to make of the recent communications from HIMSS regarding HIMSS21. They are eager to confirm that the event will proceed and to tell us the next milestone where they plan to tell us more about it, but I personally would rather have information at hand than the promise of information down the road. It’s clear that the exhibit hall will be much reduced and the sessions will be a mix of in-person and digital, but beyond that, I’m not sure what we know. The reality is that HIMSS is about making money and they’re going to structure their communications in the way that they think will be most profitable.

What I do know is that August in Las Vegas is deathly hot, and the things that many of us have been doing to avoid COVID — such as having social events outside — may or may not be tenable there at that time of year. The average high for the week of August 9-13 is 103 F, with a low of 80 F. Even in a “dry heat,” it’s not my favorite way to travel back and forth from the hotel to the conference center. I’d like to stay at one of the connected conference hotels, but the charges are prohibitively high for those of us who are paying our own way for the privilege of attending a conference where we have no idea what to expect.

We also have no idea what vaccination status will look like as we move towards August, since vaccination administration is still rather messy across the US. Based on anecdotal reports, many of the would-be HIMSS attendees from US health systems may be vaccinated, since many of those health systems seem to have had plenty of vaccine for non-patient-facing workers under the premise that everyone supports the patient journey. My friends who are part of independent practices and federally qualified health centers are still struggling to find vaccine, and the process has become more challenging now that states have prioritized the elderly.

I honestly don’t have a bead on what vaccination processes look like elsewhere in the world except for the UK and Australia, where friends keep me posted on what they are experiencing. They have employed different strategies than the US or each other, so it remains to be seen who will ultimately be judged by history as having the best approach. Certain countries and alliances have bought up enough vaccine supply to more than vaccinate their own populations, and it’s not yet clear what will happen to any surplus in the end. The goal is of course to vaccinate people quickly, but there are still plenty of barriers worldwide.

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Being a clinical informaticist in the midst of a global pandemic has its challenges, since many of us are armchair quarterbacking the charts and graphs we see and trying to determine whether they’re accurately illustrating the facts or are in danger of looking like someone changed the data with a Sharpie. A neighboring state just got caught cooking the books on their COVID positivity numbers — they decided to exclude test results that have been performed by any other methodology than PCR. Many of the large urgent cares are using rapid molecular testing like the Abbott ID Now devices in use at the White House, and those numbers are going unrepresented. Also not included in the totals are other rapid tests, such as antigen tests. We use both of the latter in my practice probably 80% of the time, only sending PCRs when required, so failing to include all the data seems like a no-no.

The state health director tried to explain it away by saying that there’s enough “saturation of PCR tests in the market to be representative,” and although I understand what he’s trying to say, it just seems like it would be better to use all the data, especially since the state requires practices to report it. Why would you want to not use data that you have? Those are the kinds of decisions that lead people to question the truthfulness of public health officials and that give rise to conspiracy theories. There have been enough irregularities with data and reporting throughout this pandemic that future academics can teach full semester classes on what went wrong.

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February 3 marked National Women Physicians Day, which occurs on that date to honor the birthday of Elizabeth Blackwell, who in 1849 became the first woman to achieve a medical degree in the United States. I spent the day caring for patients, some of whom were particularly cavalier about spreading COVID to their friends and family members, which is always frustrating. I didn’t even realize it was today until I got home and was curled up with my laptop, surfing the internet while waiting for my face to stop hurting from wearing an N95 mask for 12 hours. It typically takes about three hours for the mask marks to go away and a couple more for the headache to improve if I don’t take ibuprofen or drink a martini. I’m surely in a place I never expected to be when I started my medical career.

I was proud to be part of the first majority female class at my medical school, and to be part of an all-woman residency class well known for shaking things up in the world of graduate medical education. As the first physician in my family, I didn’t really appreciate what that meant until the day I took my mother to visit the gross anatomy lab. It was there I learned, as we stood there holding a human heart, that she might have liked to have been a physician, but when she was in college women were steered towards career paths in teaching and nursing. I was surprised that she hadn’t mentioned it while I was pre-med and applying to medical school, but maybe there was something in the genes that kept me going even when training got rough.

Here’s to all the women physicians that came before us, breaking barriers, putting up with enormous amounts of harassment, and paving the way for us to be where we are today. Your courage and dedication will never be forgotten.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/1/21

February 1, 2021 Dr. Jayne 2 Comments

I mentioned in last week’s EPtalk my ongoing healthcare adventures with Big Health System. As a patient, the organization unfortunately continues to provide plenty of material for HIStalk.

It’s an interesting setup there, with the academic medical center and the non-academic hospitals not fully aligned. That leads to somewhat of a “let’s do it separately together” approach to not only the EHR, but operational and workflow elements, too.

The academic side of the house continued to have their act together. I had specifically requested that my skin biopsy be sent to the flagship hospital’s pathology department after hearing about a friend’s disastrous experience at one of the community hospitals. They didn’t disappoint. Pathology was turned around in less than 48 hours and I received a phone call from the dermatology office bright and early on Saturday morning. When I went to look at the report via the patient portal, not only was it there, but also present was a full copy of my visit note and not just the post-visit summary.

The community hospital where I was scheduled for my MRI continued to underwhelm. I showed up at 6:45 a.m. as requested. There was a backup of people waiting to enter the hospital at the COVID screening checkpoint. Based on the predominance of running shoes and scrub pants peeking out from long winter coats, I assumed that many of them were employees arriving for a 7 a.m. shift change.

It would have been useful for the facility to have separate lines for employees and patients to get people more quickly to where they needed to go. No one was standing six feet apart, but everyone was masked, so I guess that’s something. After finally making my way into the building. I noted that at least the line at the coffee kiosk was well spaced, so that was good.

I quickly found my way to the “imaging pavilion,” the name of which made me laugh since it looks like just another hallway branching off in the bowels of the mammoth complex. I’m sure the naming had something to do with fundraising, but a decade after its addition, it just seems silly. The hospital has grown up around it, and once you’re in that part, you still have to snake around to get to the particular area where your study will occur.

Despite my compliance with the pre-registration team’s phone call, they had no record that my file had been updated. I had to answer all the questions again, this time while yelling through Plexiglas to someone who acted like they couldn’t hear me despite the fact that my patient-facing work has made me very good at speaking clearly while wearing a mask. I had to sit for a full 15 minutes, which was annoying since I was the first patient of the day and had arrived at the time they specified. There was no explanation of the delay, and I was somewhat tortured by the overly-loud TV blaring a local morning show.

When I finally made it back to the MRI suite, I noted that they had turned the two curtained changing areas into a single larger one, presumably for distancing. They had rearranged a credenza and chair in the changing area, but unfortunately had not rearranged the herd of dust bunnies and leftover hair on the floor, which kind of grossed me out. I know that hospitals are running on razor-thin margins, but skimping on housekeeping services isn’t the answer.

As I finished changing, they brought in a second patient. That person was using the changing area while I was in the adjacent IV chair, so they got to listen to all kinds of personal questions that I was asked. Starting my IV was challenging, resulting in multiple attempts in which the second patient was the audience for the latter two.

I’ve had this study done numerous times and have never had someone right behind me like that. As a patient, it was unnerving. I don’t expect total privacy, but I do expect that they pace appropriately so that staff doesn’t feel rushed while they’re trying to complete satisfactory IV access.

I was greeted in the MRI room by the team member who was going to do my actual study. Turns out I recently cared for her daughter at the urgent care, so we had a bonding moment. Since this particular MRI study is face-down, they don’t make patients wear masks. We had a laugh when I handed my mask to her at the last minute — the MRI magnet was attracting the metal nose piece, and I felt for a brief second like I was in some weightless space movie as it floated upwards.

The rest of the procedure was uneventful, and I slept through it as planned. Any day the IV works right and you don’t get an arm full of contrast material is a good one. I headed home to await my results.

I usually get a call from the nurse coordinator who manages my program, but this time I got a call from the physician because they’re changing my follow-up protocol. She explained the situation and the next steps and promised to send the information through MyChart. The results arrived more than 24 hours later with this header:  

Result Letter: Not Sent
Error: The exam failed to generate a default result letter. Please review the exam information and select the correct result letter or contact your helpdesk for assistance.

Just what every patient wants to read, right? I don’t know if the issue was on the part of the radiologist or the physician who called me, but either way it’s a poor user experience and one that patients should not have to deal with. Fortunately, I’m a physician informaticist who understands what this means, but for other patients, it might have generated anxiety and phone calls.

I wonder if the institution explains to physicians how to prevent this, or what things need to look like on their side to make sure the patient gets the right letter. I have the notes I took during my phone call, but that’s it as far as commentary on the results. I also wonder what kind of user acceptance testing is done from the patient perspective, if any. I know of too many hospitals and health systems that never test the patient-side views.

I would be interested to hear how other organizations manage testing for scenarios like this, and whether they’re doing any post-visit quality checks to ensure it’s not a common occurrence. Have you seen this at your institution? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/28/21

January 28, 2021 Dr. Jayne 3 Comments

In response to my recent piece about hospital price transparency, Jenn clued me in about Turquoise Health and their pricing website. It’s still in beta and doesn’t have data for my area yet, but comparisons for a neighboring state were pretty easy to understand. It looks like they’re still building their insurance rate database, but their cash-pay display was clear.

A reader also sent some thoughts about the whole transparency situation. He notes that based on some vendor-side experiences, a large number of hospitals seem to be deliberately dragging their feet and don’t want to be the first in their market to show what’s behind the curtain. Either that, or they’re not able to meet all the requirements since many of them assumed that the rule would be killed or further delayed. He notes, “Many will presumably quietly delay until HHS starts embarrassing some folks with bad PR and the compliance / penalty process.”

He goes further to note that the online tool I mentioned in my piece isn’t compliant, since “the Rule requires that a consumer be able to access the pricing info for all contracted payers WITHOUT providing any identifying information or agreeing to anything.” He agrees that third-party aggregators (presumably like Turquoise Health above) will take the machine-readable files and create the equivalent of “Travelocity for Hospital Prices.” I think that’s going to be the best approach that will benefit consumers from an experience perspective, but agree with him that the behind-the-scenes benefit will be when plans and networks and benefits brokers can see the information and use it to drive pricing negotiations.

My reader predicts that price transparency will ultimately lead to hospital closures, as hospitals will no longer be able to “cross-subsidize underfunded services with high commercial rates.” I always love hearing from readers and understanding what’s going on in different parts of the country and this was a great discussion. Rather than watching hospitals close, I’m hoping that health systems will take this as a wakeup call and begin to help lobby for better public health infrastructure and more public funding for early prevention, screening, and treatments so that we can push back against the chronic diseases that are driving healthcare expenditures.

Unfortunately, that approach will erode the profits of hospitals and payers, and some people feel it smacks of “socialism” and we’ll see politics and economics forcing public health into the back seat again and again despite the fact that strong public health measures make good economic sense long-term. The resignations of public health officials across the country due to their COVID-fighting stances has been disheartening. I hope we’ve seen as much of that as we’re going to see for a while. I’ve enjoyed seeing Dr. Anthony Fauci smile again this week, though, so I’ll stay hopeful.

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I had another round of healthcare adventures with Big Health System this week. The first was for a physician appointment with their academic faculty dermatology practice. I received my appointment reminder in Epic and completed the online check-in process, which was seamless. I was surprised that they’re not doing any virtual waiting room strategies and that I had to physically come to the office to check in and sit in the waiting room, which is very different than what my practice does. At least the wait was brief and I was impressed by the documentation of the cleaning protocol that was posted on the exam room door. Since this was a dermatology practice, they also had signage explaining how they do a full skin exam in the time of COVID and to keep my mask on — the physician would tell me when to take my mask off and reminded me not to talk when my mask was off.

The second encounter was an unsatisfactory pre-registration phone call prior to an upcoming MRI. Apparently, my data in the system journeyed through a portal to another time and reverted to values from 2018. I just had another radiology study at the same facility less than five months ago, when I updated everything on a lovely paper form that I assume would have been uploaded. Somehow today they had my employer from 2018 listed and the wrong emergency contact. Having been in the CMIO trenches there, I asked what system the registration agent was working from, since they still use another system for some financials and Epic for clinical. She said she was working in both systems, but the data in question was not in Epic. Apparently, they  don’t have a bidirectional interface, or no one updated the information provided back in August, or both, so I got to do it all over again over the phone with someone who wasn’t that interested in my responses and wasn’t really paying attention.

She also went through the same COVID screening questions I had just answered an hour earlier, and I asked her to verify that I was flagged in Epic as an emergency doc since this was an issue during some previous visits. She actually admitted that she really didn’t look at the screen because she’s just so used to asking the same questions over and over. When I clarified that yes, I’m regularly exposed to COVID in my work, she replied, “So, you currently have COVID?” and I had to explain again. Here’s hoping she was actually doing what she said she was doing and updating their revenue cycle platform rather than just going through the motions, because I don’t want to have to update everything again at my radiology visit at the crack of dawn on Friday. These were the kinds of issues I enjoyed fixing when I worked there – making the patient experience seamless. I wonder if anyone there even knows it’s messed up, and if they do, whether they really care.

I’m not exactly looking forward to having my molecules magnetically spun, but it is what it is when you’re playing the early cancer detection game. Usually I schedule the test first thing in the morning when I’m tired so I can sleep through it, which the technicians find hilarious since “no one ever sleeps through an MRI due to the noise.” Maybe they just don’t scan enough sleep-deprived urgent care docs to have a good sample size. I figure the first appointment of the day is also good for COVID-prevention purposes.

What’s your strategy for being a patient in the time of COVID? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/25/21

January 25, 2021 Dr. Jayne 3 Comments

Many of my healthcare IT colleagues are deeply involved in their organizations’ COVID vaccine administration efforts. They’re involved in creating pre-registration and wait list systems, running analytics to determine who should be invited to receive a vaccine next, managing outreach efforts, then scheduling those patients. It’s a massive effort that, like many IT projects, can be subject to external disruptions.

One of our local health systems just went through a massive cancellation of vaccination appointments after they received fewer doses from the state than they anticipated. The sheer volume of appointments that had to be canceled and rescheduled created havoc. As their API-driven chatbot was reaching out to patients to offer them new appointments, it was creating temporary locks on the appointment slots that were being offered, which is standard when you’re doing scheduling outreach. However, the magnified consequence of trying to reschedule thousands of patients at once prevented the call center from being able to reschedule anyone else, including patient-facing healthcare providers who were needing to also reschedule after missing vaccine appointments while awaiting negative COVID tests.

The answer to the latter problem became decidedly low-tech, with the system standing up a temporary walk-in vaccine clinic to accommodate the healthcare providers with its remaining available doses. A Google Doc was used to keep track of the employees who were approved to come to the clinic and what time they planned to come, so that the vaccination team could coordinate with the call center to ensure that the correct number of doses were available real time. Since they weren’t running the public-facing vaccine clinic, they had a surplus of workers who could handle the manual scheduling, but the fact that the situation arose at all shows how much difficulty the US is having with the last mile of vaccine distribution.

With recent stories about vaccine spoilage due to temperature issues, those running the vaccination operations could learn from their IT colleagues. A Veterans Affairs hospital in Boston recently had a freezer failure from multiple contributing causes. First, a pipe burst leading to a water leak in the building, which led to the arrival of a cleaning crew who had to move a freezer to get to some standing water. The power cord for the freezer apparently wasn’t properly secured to the freezer, causing it to disconnect. Then the freezer’s alarm system didn’t function properly, which coupled with the lack of daily monitoring, led to the loss of 1,900 doses of vaccine.

The VA is still investigating why the alarm failed, but proper daily human monitoring could have saved the vaccines since the freezer was unplugged for several days before being discovered. Any small-practice primary care physician who has had to maintain thousands of dollars of vaccine inventory knows that even though you have thermometers with alarms, you still need to have someone check the logs daily and document the ranges. It’s shocking that a larger organization that is responsible for such a precious commodity didn’t have the right processes in place. However, based on some of the IT failures I’ve seen over the last several years, I’m not surprised.

Many healthcare organizations have complex automated backup systems and sophisticated disaster recovery systems that promise a rapid fail-over to sustain clinical operations. However, they may not test them often enough, and some organizations don’t test them at all. We’ve all heard horror stories of clients who went to restore from a backup, only to find that the backup contained no data or was corrupted in some way.

We’ve also encountered the unforeseen. Early in my career, a car that was involved in a police chase crashed into our hospital’s data center, which led to a small fire, which led to discharge of the fire suppression system and a complete shutdown of the building. There was a failure of the network switches that should have rerouted everyone to the disaster recovery site as well, which led to a multi-hour outage since no one could get in there to see if they could switch things manually since the building was now a crime scene. I’m sure “what if the building becomes a crime scene” was never in the minds of those who designed the downtime policies and systems, but you can bet it’s on the checklist for my consulting clients.

Organizations may also be missing physical safeguards that are needed for their systems to be effective, like the VA hospital’s freezer was missing a couple of screws that could have prevented the vaccine loss. I worked with a client not too long ago that thought they were creating nightly backups of their system. They were using removable hard drives as the media. An employee would come in every morning and disconnect the drive, place it in a manila envelope with the date, then pull the oldest backup drive and connect it to the system. They failed to lock the door to the data room consistently, however, resulting in the disappearance of the box full of envelopes and drives.

As I tell these stories, I feel a bit like a Monday-morning quarterback. However, except for the crime scene part, the preventive maneuvers for these situations are already well documented. HIPAA requires a Security Risk Assessment where covered entities must look at physical, administrative, and technical safeguards for protected health information. Participation in federal and state vaccine programs requires signing agreements on vaccine storage and accountability. Although there were technical failures in the situations above, the human error component is strong as well.

This story out of Boston isn’t the only vaccine loss story out there. Much larger losses were recently documented in Maine and Michigan. The COVID vaccine is such a scarce commodity. If I were in charge of an organization that was a vaccinator, you can bet that I would have daily touch points with the leaders involved to ensure accountability and that systems were in place to approach zero waste. Every dose that doesn’t go to someone who wants it is a tragedy in the making.

My parents and elderly relatives are scheduled for vaccines over the next two weeks. I’m crossing my fingers that they don’t get caught in one of these situations. Based on the horrors I see in my clinical role, I’ll be holding my breath to some degree until everyone in my family is fully vaccinated.

How does your organization approach disaster recovery planning? Do you have plans in place if you need to execute a massive rescheduling operation if vaccines are lost or delayed? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/21/21

January 21, 2021 Dr. Jayne 1 Comment

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I took time out this week to listen to the tolling of the funeral bell at the Washington National Cathedral. The bell tolled 400 times, once for every 1,000 COVID deaths in the United States. The 12-ton bell creates a deep and somber tone, intended to help mourn but also celebrate the lives of the lost. The recording was accompanied by video of the paper doves that form the Les Colombes installation by artist Michael Pendry, which is located in the Cathedral’s nave. It’s likely that we’ll see another 150,000 deaths by summer unless something changes significantly.

To the relief of many, Inauguration Day passed without any serious incidents, with the new US president getting straight to the business of trying to manage the COVID pandemic. I’m interested to see if the tone at the Centers for Medicare & Medicaid Services changes, since nearly every email that I’ve received over the last several years had a headline or opening paragraph celebrating the administration’s accomplishments. I suspect the new leadership may be a little more humble, and hopefully they’re getting the right kinds of leaders in place to help steer the massive bureaucracy to a more functional and productive place.

Many healthcare organizations are holding their collective breath to see if there will be major changes to policy or additional federal funds targeted towards vaccine administration. From people I’ve spoken to who have boots on the ground across the country, administration continues to be chaotic. We’ve finally been able to get my family members scheduled — they range in age from 75 to 95 — but it remains to be seen whether there will be vaccines shipped and available for their scheduled appointments.

Speaking of vaccinations, two Michigan marijuana dispensaries are offering free joints to customers who are vaccinated for COVID-19. The Detroit Free Press reports on the “Pot for Shots” campaign and its attempt at “blunting the curve.” The participating locations are Greenhouse in Walled Lake and UBaked Cannabis of Burton. You have to love a business name that clearly defines the brand.

Back to the realm of healthcare IT, I had a chance to catch up with a friend this week. We were bouncing ideas around as far as what sectors of the market might actually be heating up. Although most of my friends on the vendor side say that none of their prospects or clients is in a buying mood, there are indications that there will be money to be made. Intel Chairman Omar Ishrak is building a $1 billion war chest for a special purpose acquisition company IPO to target health technology deals. Prior to Intel, he was at Medtronic, so he’s not a stranger to the marketplace. Goldman Sachs Group Inc. is putting together the IPO. It seems that lately we’ve been hearing a lot about SPACs and I suspect this will be one to watch.

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I enjoyed reading the recent blog penned by my long-term crush Farzad Mostashari. Aledade’s premise is that primary care is the foundation of an effective health system, and that it must be strengthened if we are to deliver better patient care and lower healthcare costs. Since 2014, the company has expanded to 27 states.

The blog notes that shared savings payments have been a way for primary care practices to stay afloat while fee-for-service payments have dropped due to decreased volumes during the pandemic. Aledade hopes to grow that savings from $50 million last year, doubling it this year and tripling it for the next. Investors are taking note, resulting in a $100 million funding increase that will drive an ambitious agenda that includes a 50-state growth strategy, expanded remote patient monitoring, predictive analytics, continuation of telehealth, and upgrades to Aledade’s software. It’s exciting to watch a truly mission-driven company do well, and I wish them continued success.

The Office for Civil Rights of the US Department of Health & Human Services will not be imposing penalties for potential HIPAA violations when healthcare organizations use online or web-based scheduling applications as long as they are “used in good faith and only for the limited purpose of scheduling individual appointments for COVID-19 vaccinations during the COVID-19 nationwide public health emergency.” That’s good, because my employer was one of the potential violators. In order to try to rapidly schedule employees for the 300 doses of vaccine that we received (which had to be given within 36 hours of receipt, since it had already been thawing at another health system) they used the Calendly platform. The so-called “enforcement action” does not include appointment scheduling systems that connect directly to the EHR, but encourages healthcare providers and their business associates to continue to guard the security of protected health information.

HIMSS announces a new recognition program, the HIMSS Changemaker in Health Awards. The award recognizes “inspiring senior healthcare executives who rigorously challenge the status quo in their journey to build a brighter health future.” Recipients will be determined by peer voting and will receive a “symbol of recognition” as well as coverage in HIMSS publications and seminars. They also must agree to contribute to HIMSS content including articles, podcast interviews, and participation in webinars. I was surprised to see that candidates can nominate themselves. If you know someone who is making change, or think you’re hitting it out of the park yourself, nominations are open through February 16.

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In COVID news, the internet is full of cures and treatments that haven’t necessarily been proven. I’m interested in further research on this one, which purports that chemical compounds found in dark chocolate may interfere with COVID virus replication. Researchers at North Carolina State University are continuing to investigate, although they note that no human trials have been conducted yet. I’ve already got at least one reason to want to visit the Carolinas, so I’m happy to volunteer as a research subject.

If you’ve been holding off on travel due to COVID, what’s the first place you’d like to visit? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/18/21

January 18, 2021 Dr. Jayne 1 Comment

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It’s finally time for price transparency, with hospitals now being required to disclose their contracted prices on their websites. I decided to see how difficult it would be to find out the potential pricing for my local hospital, and also to compare it to recent Explanation of Benefit (EOB) documents from a couple of friends and family members.

I first went to the hospital website. Of course there wasn’t any kind of notice about the availability of the new data, so had to guess where it might be filed. Clicking on “Billing and Financial Assistance” took me to a health system website, and after scrolling two full screens, I found an “Understanding Your Costs” header. Under that, I could select either a customized cost estimate or the “General Estimate Tool – Shoppable Services.” A description under that link noted: “Under 2020 pricing transparency guidelines from the federal government, this tool allows you to view your costs for the most frequently used hospital services.” I knew I was at the right place.

From there, I had to again select my hospital and agree to Terms and Conditions for the tool. Next, I had to select my insurance. My my plan was unfortunately not listed on the pick list, so the system instructed me to call to speak to a financial specialist. I backtracked and just selected Cigna since I have a general working knowledge of how their plans work.

I was next asked to select whether I was choosing an inpatient or outpatient procedure. Although the system defined these strictly as “staying overnight in the hospital” versus “not planning to stay overnight,” as a physician I know there are nuances to this. When I had my emergency gall bladder surgery, I spent the night on an inpatient unit, but my visit was billed as outpatient since I was admitted less than 23 hours. Patients aren’t going to know or understand this, nor should they be expected to do so.

After that, I was asked to choose a popular procedure. I’m not sure I would have chosen the word “popular” when building this user interface. Medical procedures are rarely popular, and perhaps “common” would be a better word.

Bouncing back and forth between the inpatient and outpatient lists, I quickly determined that the system wouldn’t let me match combinations that went with the EOB documents I had. These involved my outpatient gallbladder removal, an outpatient hysterectomy, and an outpatient hip replacement (for which this particular facility is renowned). Instead, I went with the colonoscopy, although my EOB was from an ambulatory surgery center rather than the hospital. From there, I had to input my insurance benefits, including deductible, how much I’ve met for the year, my out of pocket maximum, and whether I had met it. I also needed to know my co-pay and co-insurance for the procedure. Most patients aren’t going to have this at their fingertips.

The system told me I’d be responsible for $20 for my colonoscopy, which I know isn’t remotely accurate. I played around with the “my insurance benefits” screen and could make the numbers go up and down depending on what I put as a deductible. At no point did it tell me what the contracted charge was for the procedure, only an estimate of my patient responsibility. I went back and plugged in “uninsured” for my coverage and was able to get an estimate of costs for a diagnostic colonoscopy with biopsy, which ranged from $1,286 to $3,744, with a median of $1,575. There was no explanation whether the numbers being provided reflected only the facility fee or whether they included any other fees, such as pathology. Again, I wouldn’t expect patients to know that there are going to be multiple fees from multiple sources, so they are still likely in for some sticker shock.

Other things I learned: the system thinks a cardiac catheterization costs $141,636, which is grossly inaccurate. Based on the codes and descriptions displayed, I think they confused it with a cardiac valve replacement. Patients wouldn’t know that. The only chest x-ray on the list was a one-view, which isn’t typically done for outpatients. The hospital charge for that one view was four times what my urgent care charges for both the technical and professional components. The markup for a CT scan of the abdomen and pelvis was also four times higher. I guess those big fancy marble lobbies have to be paid for one way or another. The facility fee for a hospital outpatient clinic visit was $169 and that doesn’t even include seeing the physician. An emergency department visit ranges from $2,190 to $7,573, with a median of $3,310. That definitely underscores the benefit to patients who see us at the urgent care versus going to the hospital for urgent issues.

I ran through the various procedures at a couple of the other hospitals in the health system and found that even an as uninsured patient, I could receive some procedures for dramatically less by driving 20 miles, assuming the data was accurate. The $1,800 CT scan became $900 at the hospital that is in a somewhat economically depressed part of town. However, the mysterious cardiac cath/valve procedure jumped to $171,625 at that facility. The procedure jumped to $209,451 at the system’s flagship academic medical center hospital.

Although the push for price transparency was certainly a hot topic when it was initially proposed, it quickly became a battle between the patient advocacy factions and the hospital lobbyists. From my N=1 analysis, I’m not sure patients are any better off using the tool than using other available data or even a simple Google search. The data provided was too vague to be used for real decision making.

If I was really price shopping a major surgical procedure, I would want to call and talk with the system’s staff to see if they could put together a better estimate. One would also need to research all the ancillary costs, such as laboratory, anesthesia, in-procedure radiology, pathology, etc. Don’t get me wrong, this is a step in the right direction, but we just need to realize it’s a baby step.

Have you looked at price transparency for your institution or neighboring hospitals? What did you think? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/14/21

January 14, 2021 Dr. Jayne 2 Comments

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I’ve been knee-deep in the Consumer Electronics Show the last couple of days. It’s a treasure trove of things you expected to see (smart home accessories, high-tech vacuum cleaners) and some you didn’t (high-tech sex accessories). Still, I’ve seen some cool things, and although some are not 100% healthcare related, they appear to have the potential to deliver solid benefits.

  • Abbott predictably showcased its Navica mobile app, which pairs with its BinaxNow COVID-19 antigen testing cards. Its FreeStyle Libre 2 continuous glucose monitoring system may not have received top billing, but could be a game-changer for diabetes patients age 4 and up.
  • Ampere offers the Shower Power hydropower Bluetooth shower speaker. It recharges via the water flow and is made of recycled ocean plastic. It’s pricey at $100, but the idea of having your own mini-generator to keep tunes playing is kind of cool.
  • Butterfly showed off its handheld ultrasound units that integrate with smartphones for a portable and accessible experience. This would be great for organizations that don’t want to spend the money on traditional ultrasound machines or that need to be able to deploy on the go. I was disappointed to see that some features are only available for IOS devices since Android clearly dominates the world market.
  • PenguinSmart offers individualized online speech and language therapy support for pediatric patients. It claims to be the first remote / teletherapy solution to serve developmentally delayed patients who have speech and language needs.
  • Samsung offers an AI-powered JetBot 90 robotic vacuum which “identifies messes” and avoids them. Anyone who has ever experienced a pet-related “poopocalypse” with their Roomba knows what a nightmare this can be. Pricing is expected to be upwards of $900, but depending on how bad you’re scarred from past events, it might be worth it.
  • Steri-Write is a UV-C sterilization unit that cleans and dispenses ink pens for patients or the public. An article on the device was published in the American Journal of Infection Control in 2020 and the device itself is pretty slick. It’s got a slot on the top for the pen to enter the machine, then it travels on serpentine belts while exposed to UV light. A hands-free dispenser finishes the process. Since our office has the front desk team sanitizing pens with wipes and constantly managing them throughout the office, it would save time and resources.
  • Welldoc offers app-driven solutions for management of multiple chronic conditions, including diabetes, hypertension, heart failure, prediabetes, and behavioral health diagnoses. It reportedly can integrate data sets from payers, employers, and providers, but information on the actual solution was light unless you wanted to talk to a rep.

Other offerings include an AI-powered toothbrush (Philips Sonicare) that adjusts intensity based on user-applied pressure and has its own app to track effectiveness. There was also Heatbox: The Self-Heating Lunchbox, but honestly I’d rather have a self-chilling martini shaker that I could stick in the side pocket of my backpack for those particularly challenging days. Med:na from Medipresso is a DNA-driven solution that matches consumers with tea capsules based on their profiles. Not sure about the evidence-based background on that, but I bet someone will buy it. One thing I might consider buying is the Sniffy Personal Dog Trainer App, which is desperately needed by my neighbor since I get to hear her annoying dog barking outside my office window on a daily basis.

Procter & Gamble also featured a smart toothbrush, the Oral B iO. Its companion app provides feedback on brushing and offers tips for improving technique. I always love hearing German engineers discuss things like magnetic drive in the context of a “surprisingly enjoyable brushing experience.” Its AI brushing algorithms were trained with thousands of brushing sessions in the company’s labs.

I wanted to look at wearables and Garmin didn’t really have anything that caught my eye from a running and walking standpoint. Omron showcased its HeartGuide wearable blood pressure monitor that links with its HeartAdvisor app for BP, activity, and sleep monitoring. It also presented its VitalSight remote patient monitoring solution. MySize Inc. won the buzzword bingo challenge with its sensor-based measurement technology that allows for shoppers to have a contactless fit and style experience. They won by using “AI, Big Data, and Machine Learning” in a single sentence.

CES generated about 10x the email I usually receive prior to a HIMSS conference, and it shows no signs of letting up. I flipped through all the promotional emails I received, but if I couldn’t figure out what you were presenting, I didn’t do any further investigation.

The ones that were the easiest to figure out were those with COVID in the pitch. Their offerings were often straightforward, such as thermal scanners and social distancing accessories. Several vendors offered smart masks with various fans, filters, and monitors. Others weren’t COVID related but were clearly identified, such as Nexvoo’s ergonomic office chair with health monitor app. I’ll stick with my Ikea chair (which honestly is the best office chair I’ve ever had) for now.

If I had some advice to offer to the marketing teams that create the email, it would be to at least tell the reader something about the offering. For example, a company I’m already familiar with touted its “AI Powered Platform for Pandemic Response,” but the tagline didn’t really tell me anything, and it was frustrating to try to dig through press releases to see what the new or updated solution really offers. For example, Rise Gardens hit it out of the park with a single sentence describing their modular, WiFi-connected and app-guided indoor hydroponic garden for home use. I knew in less than a second that I wanted to check it out. Font and readability are also important in emails – if your font is unreadably small, everything you have to say is unfortunately a no-go.

Home bathrooms were a hot topic at both Kohler and Toto – touch-free commodes and faucets for the home were featured as a COVID-related solution. Bidet functionality was also prominent, especially with greater awareness of their existence following the Great TP Shortage of 2020. They’re also handy for postpartum and postoperative patients, but a good number of people might not have experienced either of those situations.

I have to admit I was captivated by Kohler’s Stillness Bath, which it describes as “an immersive bathing experience that uses light, water, steam, and aroma to transport you away from the everyday” and to simulate Japanese forest bathing. I’m definitely starting a list of things to purchase if I ever win the lottery.

The CES digital venue continues to remain open through the weekend, so I’ll still be hard at work plugging away through all the emails and the vendors I flagged to visit. Did anyone else attend? What did you think? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/11/21

January 11, 2021 Dr. Jayne 1 Comment

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My weekend took a decidedly positive turn after I was able to get my second dose of COVID vaccine. The side effects were a little more noticeable compared to the first dose, with a brief temperature elevation and headache. Tylenol and a nap vanquished them both, although I felt a little more tired than usual, but it’s unclear if that was from finally being able to let go of the anxiety of whether I’d be able to get a second dose or not.

It is unreal that frontline physicians who are actively caring for COVID patients would have to worry about getting a vaccine, but that’s the reality in many states across the US. I’m active in several nationwide physician forums and the majority of states are having difficulty vaccinating all frontline healthcare workers, while others are already vaccinating the general population based on age and comorbid conditions. We certainly live in interesting times. Artwork credit: physician Cindy Hsu.

I received the Pfizer vaccine and should reach target immunity two weeks after the second dose. I still don’t get to change any of my habits since the vaccine is only proven to reduce the risk of severe disease and/or death – we don’t have strong data on reduction of transmission at this point, although those studies are ongoing. There’s still the risk of being infected with COVID. I’m just less likely to die, which is a good feeling to have when you’re exposed to 20 or more COVID-positive patients a day.

My area continues to be in a surge that is being fueled by mass defiance of the county’s “safer at home” order, which means I still get to deal with heartbreaking situations at the office as people infect their grandparents and other loved ones when we are so close to getting vaccines for them.

A non-medical friend wasn’t aware of the lack of transmissibility data and asked me how long I planned to continue strict masking. After explaining the limits of the vaccine, I mentioned that I’ll most likely be masking forever. It’s not due to a concern about disease or contagion, but the fact that I’ve lost all ability to control my facial expressions simply due to the volume of ridiculous statements I have to hear on a daily basis. Plenty of patients still believe that the vaccine contains microchips or has the capability to modify human DNA, science be damned. As a physician, the most effective treatment I have right now is education, and although I’m happy to deliver it, I miss the days when I could solve problems with a flip of my electronic prescription pad.

The best side effect of the vaccine was the fact that I received it at a facility where I hadn’t previously been a patient, which exposed me to their version of Epic’s MyChart platform. Compared to the version being used by Big Medical Center where I usually receive care, it was amazing. Clean lines, no clutter, no distracting colors, and a much cleaner view of upcoming and past appointments. The medication list was easier to read without distracting color as well. Knowing that Big Medical Center is typically reluctant to take upgrades or to stay current with general release versions of software, I can only assume my new access is to a later and greater version.

I also haven’t been overwhelmed with announcements and updates from the new platform, so perhaps their communication plan or governance is a little tighter as well. It will be interesting how these contrasts play out now that I have access to both systems. I’m also curious to see how long it will take my previous employer to upgrade to the latest and greatest.

I spent a good chunk of time preparing my plan for the Consumer Electronics Show. I’ve never been in person, but have seen a lot of media reports and the in-person version sounds pretty overwhelming. The online schedule is a full one, but I suspect that like HIMSS, most of the interesting finds are found by checking out the exhibitors, which is a bit of an interesting process for most of the virtual conferences I’ve attended. I’ve been poking around the website and haven’t found anything that looks like a virtual exhibit hall yet, although there are lists of exhibitors and I’ve been getting plenty of emails from them. We’ll have to see if new features go live once the show officially starts tomorrow.

I’ve already identified quite a few digital health, wellness, smart home, and lifestyle vendors that I want to check out. I’m involved in some efforts to promote aging in place for older patients, so I hope there are innovative solutions that won’t cost an arm and a leg but will give patients and families greater peace of mind. Based on the lockdowns of the past year, so many people are afraid of moving to retirement communities or assisted living facilities even when they could benefit from expanded services. Hopefully, organizations have moved to fill that need. Kohler is scheduled to debut some smart home kitchen and bath accessories, but I’ll also be looking for design inspiration to finally complete what is possibly the world’s longest bathroom remodeling project.

Of course, there are also cool things that are not directly related to healthcare, but may provide interesting innovations in a secondary capacity, such as the unveiling of the world’s first autonomous racecar at the Indianapolis Motor Speedway. There are over 500 university students competing to win a $1.5 million prize in what’s billed as “the world’s first high-speed, head-to-head autonomous race.” The engineering types in my household are particularly excited to hear what that’s all about.

Some of my show sessions start as early as 6:30 a.m. local time, so I’d better get my rest this week if I’m going to keep up. Unlike the typical Las Vegas show, though, I’ll be able to readily access snacks from my own refrigerator and won’t have to wait in an eternally long line for a bad cup of convention hall coffee. I’ve stocked in extra martini supplies so I can pretend like I’m actually at a trade show.

If you’re attending CES, let’s have a virtual cocktail together. You can find me on Twitter: @JayneHIStalkMD

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/7/21

January 7, 2021 Dr. Jayne No Comments

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ONC announced dates for the 2021 annual meeting, scheduled for the end of March. You can subscribe to updates to make sure you’re in the know.

I have to say I miss big meetings and getting to connect with interesting people. I’ve done several virtual conferences and they just don’t provide the level of randomness that we were used to in person. I was going to attend the Consumer Electronics Show in person for the first time in 2021 and that didn’t turn out so well. The event is scheduled to run virtually January 11-14 and I’ve been approved to attend as a member of the media. If anyone can hit a virtual conference out of the park, it should be CES.

I’m looking forward to seeing what companies have come up with as far as expanding the utility of wearables in patients’ personal health journeys. Wearable devices seem to have plateaued the last few years, so it’s going to take something novel to get people re-engaged.

I also want to see what companies are doing to make tech more accessible. Although we may be used to the majority of people around us having a smartphone in their pocket or purse, there are plenty of people in the world that don’t have that access. I’m also looking forward to seeing first hand some of the wild and crazy things that will debut at CES, and following them over time to see if they take off or not.

Speaking of conferences, HIMSS is planning a meeting for August, but I wonder what it’s going to look like in reality. A recent article described the downstream impact of the February 2020 Biogen conference. Its 100 confirmed cases were identified as causing 50,000 cases in the US alone within the first two months following the super spreader event, nearly half of which were in Massachusetts. By November 1, the virus strain from the conference was linked genetically to over 330,000 cases in 29 states plus Sweden and Australia. Even for those of us that will (hopefully) be fully vaccinated by the time HIMSS rolls around, it’s important to remember that the vaccine has not yet been shown to prevent COVID infection — it just dramatically reduces the risk of severe disease and death.

Mr. H has already reported on the wind-down of Haven, which hoped to lower healthcare costs and improve outcomes. One of the key reasons cited for its inability to disrupt healthcare is that each company continued to deliver its own projects separately, which reduced the need for the joint venture. The inability of large organizations to work together is being seen everywhere in the US, particularly with vaccine distribution. Physician colleagues are reporting from across the US that hospitals that have been entrusted with vaccine distribution are refusing to vaccinate frontline healthcare workers if they’re not employed by that particular institution. This is often in violation of state vaccinator contracts and agreements, but no one wants to enforce it. Until we understand that we can be stronger together than we can be separately, we will all continue to struggle.

My state isn’t the only one struggling: New Jersey’s vaccine registration site launched this week but immediately experienced issues attributed to high volumes. It may not be perfect, but I at least give the state credit for trying to create a list and communicate with people, which is much more than many other states have done. My home county finally received vaccine and has no way to manage a list of Tier 1a providers who are trying to get vaccinated – the only way to get through is to wade through a maze of phone prompts and hope you reach someone who can add your name to a paper list.

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JAMA Surgery published a piece this week looking at “the Empowerment/Enslavement Paradox” among surgeons and their personal communication devices. The authors note that “the same tools that empower people can also eliminate personal freedoms by increasing work pressure and blurring the boundary between work and personal life.” There are certainly benefits of being able to be continuously connected particularly with smartphones, such as being able to act quickly to care for patients and to be able to have the world’s medical literature literally at your fingertips. Unfortunately, technology can also function as an electronic leash, continuously tethering physicians to their work. I’ve experienced both extremes and it takes a tremendous amount of discipline to keep tech from taking over at times. It will be interesting to see if improvements in technology will help resolve this paradox.

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Like many of us, I tend to multitask, and I have to admit I was surfing the internet while listening to the US Senate speeches as our Congress reconvened following Wednesday’s unbelievable events. In hindsight, I probably would have benefitted from drinking a strong martini and making sure to take a sip every time a particular Senator used the word “hooligans” or “temple of democracy.” During my surfing, I enjoyed learning about a set of lava lamps that are used to drive internet encryption. The lamps are located at the Cloudflare company headquarters in San Francisco. Cameras capture the changes in the patterns and transfer them to a computer that translates it into encryption keys. The randomness inherent to lava lamps reduces the chance that hackers would be able to break the key. The Cloudflare site offers a great primer on random numbers, cryptography, and entropy. At its London office, Cloudflare uses a slightly less-groovy method of random data generation, using a double-pendulum system, which seems a bit more classically British. The Singapore office uses radioactive decay from a uranium pellet as its source.

Given the events of the day, I could use some quality time staring at a wall of lava lamps since I’m not traveling to see a nice waterfall or sunrise anytime soon. There’s also always that stout martini. Who’s with me?

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/4/21

January 4, 2021 Dr. Jayne 1 Comment

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The new year is upon us, and other than hearing quite a few more fireworks and gunshots at the appointed hour, my celebration wasn’t terribly different from years past.

As someone who has worked big-city emergency departments on New Year’s Eve, it seems like a holiday that is ripe for trouble if you decide to go out, so I kept with tradition by celebrating at home. During the day, I binge-watched “Bridgerton” on Netflix, sparing anyone else from a tour through 19th century London. As the evening unfolded, it was time for “The Mandalorian” with the rest of the household. I feel like I’m finally caught up with the rest of the sci fi-loving community now, and can move into 2021 with a full appreciation of Baby Yoda.

I took January 1 off, then returned to the clinical trenches for a full day of adventure. Our region is going through a prolonged peak for COVID cases, and we’re perpetually running our locations with a skeleton crew in part due to illness. More than 50% of our physicians, NPs, and PAs have been infected with COVID, so I count myself fortunate to have avoided it and am thankful to the folks who have been helping me source additional PPE beyond what my employer has been able to provide.

Another segment of our staff has left the healthcare labor market entirely, deciding that perhaps dealing with COVID isn’t part of their ongoing career paths. We have a lot of staff that are from dual healthcare worker households, and if the cost of childcare is a factor, it makes a lot of economic as well as health-related sense.

Our state is still woefully behind in vaccinating healthcare workers. Our organization received a limited number of doses that were shared from a local hospital. The state still doesn’t understand that urgent cares are also on the front lines of the COVID fight.

It was great to see people starting to receive vaccine and beginning to feel a little bit of hope that we may be truly rounding the corner on our battle against COVID-19. Many of the individuals who have had COVID recently deferred vaccines so that those who have not yet been infected could go to the front of the line. We still need several hundred doses to finish the first round of vaccines, plus enough to perform Round Two. I never thought that a group as big as ours, which performs over half a million patient visits a year, would be overlooked. Hopefully, we’ll get more doses soon because we still have plenty of unprotected Tier 1a healthcare workers among our ranks.

Judging from some national Facebook groups I belong to, the vaccine distribution plans in many other states are poor as well, but I would rank us in the bottom 10% for having our act together. I learned today that our state department of health violated CDC prioritization guidelines and vaccinated its non-clinical office workers, even those who can work from home. I also learned that the department has no plans to hold hospitals accountable for going outside the guidelines, which many are. With that kind of leadership, it’s no wonder that they’re not able to meet the needs of the actual patient-facing healthcare workers.

The other adventure of returning to work in 2021 was the debut of the new CMS Evaluation & Management coding guidelines. As a consultant, I did some behind the scenes work for a couple of medical groups creating educational curricula for their physicians and teaching classes to help them get ready. We’ve been working on it for several months and most of the physicians felt confident going into the new year. As a physician, my practice waited until the eleventh hour to reveal their plan and it was pretty underwhelming. They’re so worried about the coding that they’re going to let Certified Professional Coders assign the codes.

They sent us a two-page document on December 29 letting us know of a few new EHR screens we needed to be aware of. They also sent instructions about documenting free-text information to bolster our “medical decision making” discussion in an area of the chart where we don’t usually put it. Because many of us write that information in patient-facing language in the patient plan for “cover yourself” purposes, we now have to put it in two places, which seems like a pain.

I asked for clarification and was told it was for consistency for the coders to know where to look. I’d think it’s cheaper to tell the coders to look in two places rather than have the providers do double work, but I’m just a worker bee in this scenario. Given the labor cost of the coders and the sparseness of some of my colleagues’ documentation, I give this approach no more than 90 days before they decide to retool it.

Even though the new coding rules are supposed to simplify documentation for the History and Physical portion of the note, my practice didn’t change expectations for those areas, still asking us to document Review of Systems and Exam elements that are beyond what is needed for the kind of problem-focused visits that occur at an urgent care. They make sense for some of our more complex patients, where we may be co-managing chronic conditions because the patients can’t get in to see their regular care teams, but I refuse to do them when the visits are straightforward. You can bet I didn’t document a multi-point Review of Systems on the guy who came in with the 6 cm scalp laceration after having fallen into a door while tripping on his son’s skateboard.

I’m curious what other organizations have been doing to prepare their physicians for the transition, and how well they’re handling it. It will be interesting to see if groups are seeing revenue dips due to lack of documentation or whether they actually see a little bump because they’re not being nitpicked on data elements that physicians may feel aren’t meaningful. Many physicians may also choose to code their visits based on time, which may result in an increase in code levels.

It will be at least 30 days before we can see trends, and possibly longer depending on patient volumes. Traditionally January is a slow time of the year for patient visits because no one has met their deductibles. We’ll have to see if 2021 holds true for this and how long that depression lasts. Of course, it will be confounded by the pandemic, so it may be hard to tell.

How did your organization handle the rollout of new E&M coding rules, and how is it going? Leave a comment or email me.

Email Dr. Jayne.

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