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Curbside Consult with Dr. Jayne 4/6/20

April 6, 2020 Dr. Jayne 6 Comments

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I was awakened this morning by a call from my clinical employer. Usually those early morning calls are along the lines of someone being sick and asking if I can cover a shift, or it’s one of my partners asking follow-up questions on a patient visit from the night before.

This morning’s call was absolutely surreal. They were notifying me that they’re taking me off the schedule for the rest of the month.

It would have been one thing had they just laid it out cleanly and said it was a low census issue. Instead, the person calling (who probably hadn’t discussed the word track with HR) went on and on about needing to have physicians “give up their shifts” because of other providers who have student loans to pay or whose spouses have been laid off from their jobs. I suppose they assume that physicians of a certain age don’t have student loans or other critical deb, and whatever other assumptions they made about my finances made me less needy of work than others.

I was frankly shocked that they would approach it in the way that they did. It is certainly not something I would handle with an early morning phone call.

A quick check of the “under revision” schedule shows that the majority of shifts being moved around were indeed those belonging to physicians, while keeping the physician assistants and nurse practitioners working. As it is in so many things, it appears to be about the money, because it certainly doesn’t look like it’s about having the most experienced clinicians available to treat patients who might have complex presentations. And it’s definitely not about presenting such a drastic change in a way that might be palatable to those affected.

They went on to babble about needing me to provide coverage “when the surge comes, whenever that is” as if we’re supposed to just pick up extra shifts at their beck and call. Mind you, this is an organization that declined my offer to help them stand up a telehealth program at the beginning of the COVID crisis. Where other similar clinics are using technology to deliver care and allay patient concerns in a way that makes patients (and staff) feel safe, we’ve entrenched and have watched the world pass us by.

I’m certainly not alone, as plenty of hospitals and practices have furloughed physicians in various subspecialties due to lack of demand. My ophthalmologist friends have been largely benched since they spent the majority of their time performing surgeries that are now classified as elective.

As someone who is used to manning the front door of the healthcare system, I didn’t think it would be me. It certainly doesn’t scream job security to know that when the going gets tough, decisions aren’t going to be made on quality of care, patient satisfaction scores, or the ability to treat patients quickly and thoroughly (since I’m an A+ performer in those areas).

Needless to say, I’ll be doubling down on the informatics work and telehealth visits for a while. Frankly, I wish they would have just pink-slipped me, because I’ve definitely lost that loving feeling.

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EPtalk by Dr. Jayne 4/2/20

April 2, 2020 Dr. Jayne 7 Comments

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Monday was Doctors’ Day. I had pretty much forgotten until I looked in my non-work email account and saw this greeting from Cerner. Specifically, it was from their Jamboree Team that supported us at the World Scout Jamboree last summer in West Virginia. It was a nice reminder of better times, when I was able to watch 40,000 people from around the world work together and get to know each other.

Our current situation is a reminder of just how global we really are. Since that Cerner team is used to supporting an international clientele, I wonder if any of them will be deployed to support the Cerner Millennium implementation at London’s 4,000-bed Nightingale Hospital?

This is going to be a rough year (or two) for doctors. I’m glad to see that professional organizations are stepping up. Whether it’s statements about the rights of healthcare providers to wear their own personal protective equipment if their employers cannot provide it or extensions for continuing education requirements, it’s appreciated. I have several friends in private practice who have taken out personal lines of credit to try to pay their staff members and who are forgoing their own salaries indefinitely. I suspect this might be the death knell for many independent practices, depending on how solvent they were prior to the crisis.

Vice President Mike Pence sent a letter to hospital administrators this week requesting that they report data in connection with coronavirus testing along with data on bed capacity. The data is to be reported in a de-identified fashion to ensure patient privacy. In a nod to 1990, all data is to be reported based on a spreadsheet, which is due every day at 5 p.m. ET for the period ending the previous midnight. Hospitals will be submitting this critical data to a FEMA email address. Since everyone likes a redundant process, hospitals must also report daily data to the National Healthcare Safety Network’s COVID-19 module, which went live March 27.

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Unbelievable, but in cybersecurity news, hackers have targeted the World Health Organization in the midst of this crisis. Tactics include creating a fake website that poses as a WHO email login portal to try to obtain passwords. Hackers had previously tried to spoof the WHO in an attempt to get money and private details from unsuspecting users. I hope what goes around comes around for these scoundrels.

A great piece in Kaiser Health News last week illustrates what it’s really like to be in an ambulatory setting and trying to confront COVID-19. This mimics what I’m hearing across the country. Although some organizations have stopped routine visits, others are forging ahead at full speed. Practices that can are pushing telehealth, but safety net organizations and others that are unable to limit in-person visits are having to rapidly redesign processes.

There are challenges in making sure exam rooms are clean in between patients. My own practice had to do an air handling study to figure out how long it would take to circulate the air out of our largest exam rooms should a high-risk patient be treated in them.

Many practices are doing “at the door” screening and triage, which often takes the form of a clipboard. Others are turning to novel solutions using chatbots and algorithm-based screeners.

Although adaptations are being made for telehealth payments, the article notes that some states are slow to get to speed with transitioning their Medicaid programs to a new payment model. It also notes the phenomenon of patients who “misrepresented their COVID-19 risks in order to get past screening.” We’re experiencing that in our environment as well, with patients desperate to be seen. Unfortunately, we have little to offer those we genuinely suspect of having the illness since care is largely supportive. Patients have latched onto media coverage of unapproved drugs and are requesting them. I’d love to be able to put a sign on the door that says simply, “No, you cannot have a Z-pack.”

From Other Duties as Assigned: “Re: from the front lines. I spent two shifts this week as a screener for all employees, clinicians, patients, family, and vendors. I’m usually a tech guy. It was a bit harrowing. In my state, we are hard pressed to maintain our PPE supplies and are repurposing surgical units to COVID. Our revenue will drop by 40% if this continues up the curve.” The writer wanted to remain anonymous, which is not difficult since this scenario is playing out at hospitals across the country. Kudos for stepping out of your comfort zone and giving it your all. Fighting this pandemic is definitely a team sport, whether you are supporting interfaces or enforcing the use of hand sanitizer at the door.

Lots of companies are throwing out cool COVID-related dashboards, showing various things such as hospital bed capacity (Definitive Healthcare) and effectiveness at social distancing (Unacast). Some of them are pretty fascinating, but it’s easy to go down the rabbit hole of interesting data and fail to do actual work. I’m limiting my COVID-related web surfing in an effort to actually remain productive.

I’m normally not a huge fan of Eric Topol, but I did enjoy his recent piece on how the “US Betrays Healthcare Workers in Coronavirus Disaster.” I think “betrayal” is the word that many healthcare workers are feeling right now, whether you’re a physician, nurse, therapist, tech, dietary worker, housekeeper, facilities engineer, security staffer, transporter, phlebotomist, or just about any role in the healthcare ecosystem. Many of us have spent our careers in service to others, but are having difficulty coping with the fact that when the going gets tough, our employers abandon us with salary cuts and furloughs. Their ultra-lean “just in time” inventories have left millions of workers without the basic protections of a safe workplace as defined by the Occupational Safety and Health Administration.

My clinical employer is still working hard to get us PPE, but it’s an uphill battle. A shipment of 500 gowns doesn’t do much for an organization that executes over 1,500 patient visits a day. We still don’t have company-supplied N95 masks, but we do have lab goggles for everyone. I’m eternally grateful to friends and family that dug through their basements or hit stores that were rumored to have legitimate masks, because I’m now covered with a set of masks I can rotate as I work. We’ll see how they hold up since they’re supposed to be single use and I’ll be wearing them up to 14 hours a day, but at least I have them, and the generosity of my support system allowed me to provide a few to colleagues as well.

Tonight’s dinner table conversation included such topics as “remember when we used to go out to eat” and “who wants to call the elders to make sure they’re actually at home,” along with something from a college math class that I’m sure I knew once upon a time. I’ve mostly adapted from my lack of travel, although the occasional tiny bottle of hotel shampoo brightens my mood. I have thousands of dollars in airline credits just waiting until the skies are safe again, so I’m making my post-2020 bucket list.

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A friend sent me this photo, allegedly from a restaurant in Ohio. I’m not sure what all is going on with this concoction, but I do want to experience it in the future. If you know where I can find it, leave a comment or email me.

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Curbside Consult with Dr. Jayne 3/30/20

March 30, 2020 Dr. Jayne 2 Comments

I’m still getting tone-deaf emails from HIMSS touting the value of Virtual HIMSS. They are also pitching a white paper that I can download to “understand in real time how your patients experience every interaction along the continuum of care; make patient feedback quick, meaningful, and actionable; and protect and improve your market share.” Honestly, with what is coming, I don’t think health systems are worried about protecting their market share. They are either knee-deep in COVID-19 or trying to prepare for it.

The hospitals in my area are busy giving very carefully worded interviews to the press about their stock of personal protective equipment. They usually go like this: “As of today, March 29, we have enough.” Reports from friends who work at those facilities are pretty bleak and we’re not even in a hot zone.

I also heard report that HIMSS isn’t wasting any time invoicing corporate members for their annual renewals, which has to sting for vendors who recently ponied up a good chunk of change to exhibit at a conference that didn’t happen.

I tend to skewer many different parts of the industry, so I don’t want to miss the opportunity to highlight physicians who are behaving badly. States are coping with a burst of prescriptions for drugs that are being used to combat coronavirus, often being written by physicians for themselves or their families. In response, states are requiring physicians to include a diagnosis code on every prescription for the suspect drugs, one of which is azithromycin.

Although including a diagnosis code on prescriptions is a best practice for medication safety, the reality is that many physicians don’t do this unless their EHR is set to require it. Those physicians just going about their business treating strep throat in penicillin-allergic patients are getting pharmacy callbacks, which clogs up the system. Some organizations have flipped the switch to require a diagnosis code for all prescriptions, which is making everyone unhappy.

Bottom line, folks: prescribing unproven drugs for your family in a situation like this one is unethical. If you are doing it, shame on you.

On the positive side, AMIA has announced that its Clinical Informatics Conference scheduled for May 19-21 will now be virtual. The CIC is a must-attend conference for many clinical informaticists who are in the trenches with hospitals and health systems versus being in academic settings. In addition to occurring on its scheduled dates, organizers will share the content with registrants using a learning platform. The CIC has grown tremendously since its inception, roughly doubling in size every two years. I wish AMIA the best in trying to make this new format happen.

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Recently my clinical practice has hit a lull as we wait for the surge of coronavirus patients to hit. I’ve gone from delivering medically focused care to delivering care with a more psychological focus. A good number of patients in both my in-person and telehealth practices just want advice and aren’t able to get it from their primary physicians, or don’t have primary physicians to reach out to.

I’m also giving a fair amount of public health advice both in my practice and on various Facebook groups and community forums. Medical misinformation abounds these days, and people are coping with requests to stay at home with some unhealthy behaviors.

Our local high school had to recently close its athletic fields because one of the club football teams called a practice despite a stay-at-home order being in place. Parents drove their middle school children to participate in contact football, which baffles me. Other people are getting together in groups to have social distance tailgating parties, where the six feet of social distancing is just an illusion. Another group of moms got together and backed their minivans up facing each other, then crawled into the back end and drank Starbucks. People are asking me what I think about these practices, and sometimes I struggle to find the right response.

We live in the most connected time in human history. The technology to bring people together while they are apart is amazing. Most of us in the US have ready access to free video calling, conference calls, unlimited long distance, and more. However, people are struggling to feel “close” to people unless they are within a certain physical proximity. Have we lost the ability to have relationships with people unless we are literally face-to-face with them?

Some of my best friends live across the country and around the world, but I can “talk” to them within moments through texting or online messaging. They are literally at my fingertips through the magic of the cell phone. For those people who psychologically must have face-to-face contact, I’m recommending they do it with a single friend and from a distance, rather than mimicking one of the group distancing solutions I’m seeing.

People who are getting together in these groups are missing part of the point about healthcare providers wanting or needing them to stay home. When you’re on the road, you put yourself at risk for accidents, which puts first responders at risk, and possibly healthcare providers. It also puts you at risk – you can give the virus to them, and they can give it to you, since many of us don’t have adequate personal protective equipment.

It’s one thing to go out to get essentials. It’s another thing to go meet up with friends because you’re bored. I strongly encourage people to rethink what they’re doing, especially if they’re under a stay-at-home or shelter-in-place order.

For those of you who might be struggling with this, I have some tips to share from retired NASA astronaut Scott Kelly. As someone who spent her formative years wanting to be an astronaut (specifically, the first doctor in space, but I didn’t quite hit the mark), I have tremendous respect for those who journey to the ultimate frontier. As he says in the piece, “Flying in space is probably the only job you absolutely cannot quit.” Some highlights from his recommendations: follow a schedule, but pace yourself; go outside (safely and prudently); find a hobby; keep a journal; listen to experts; and take time to connect.

As an anonymous blogger, the last one is important to me. I correspond frequently with a few regular readers, and it’s good to have kindred spirits. If you’re not sure who to reach out to, check on a neighbor, reach out to an elderly person in your religious organization, or consider reaching out to someone from work who you typically see in passing but don’t get to talk to regularly. We can all make new connections as well as our existing ones, and you might just find yourself brightening someone’s day in this challenging time.

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Those of you who have been reading my work for a while know I’m an avid baker, and one of my favorite prescriptions is for pastry therapy. I didn’t write myself a script for a Z-pack to fight coronavirus, but I did treat myself to a new cast iron skillet complete with Rosie the Riveter. She reminds me that we can do this, and like our parents and grandparents during major world upheavals, it’s going to take all of us to get this done. Thank you to my friends at Lodge for keeping the foundry going and the online orders shipping.

To the rest of you, I leave you with tonight’s pastry therapy offering: the Chocolate Chip Skillet Cookie. I promise it bakes up much better in the 10-inch Rosie the Riveter skillet than it ever did in my trusty 12-inch one. Bon appetit!

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EPtalk by Dr. Jayne 3/26/20

March 26, 2020 Dr. Jayne 1 Comment

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A great piece appeared in Forbes this week about why doctors don’t perform well when they’re afraid. I would extrapolate that to, “humans don’t perform well when they are afraid.” They especially don’t perform well when they are afraid and they are receiving mixed messages from the World Health Organization, the Centers from Disease Control, and their own hospitals or employers.

People are sending me copies of documents from their employers that show policies that are directly divergent from WHO and CDC recommendations. Especially for people who have devoted their careers to scientific inquiry and the application of research to the point of care, this understandably doesn’t go over well.

The author notes that feeling under threat creates an attentional bias, where physicians’ thoughts are more focused on the threat than on caring for the patient. Lack of personal safety also reduces cognitive flexibility, which impairs problem solving and decision making. She also notes that being worried keeps us from learning from our experiences and our mistakes.

The reality is that workers are already becoming exhausted and we haven’t even scratched the surface of what’s to come in the US. Organizations are at a loss as to how to best support their workforce. One of the physicians in the article states, “I think the system is failing us. There’s so much talk of wellness and we are given more modules on wellness. The reality is this is just giving me more work. So how about you take those funds and redirect them?”

The funny thing about the article was when it rendered on my screen, an ad for St. George’s University School of Medicine appeared alongside it. I’ve been to St. George’s – it’s in Grenada and it’s a lovely place, with the anatomy lab only steps from the beach. It also has the distinction of having had the United States Marine Corps rescue its students during the 1983 invasion.

I wonder how many people who previously wanted careers in health care will still want them after all this. It’s not just the clinical teams who are being beaten up, but everyone on the front lines, from dietary to engineering to custodial to IT and so on. The physicians I’ve spoken with that are the most distressed are those who have administrative teams that are working from home since they are non-essential. That’s shocking to me, especially compared to facilities with administrators who are rolling up their sleeves and getting in there.

A friend of mine from high school lives in Taiwan. We were chatting the other night about what life looks like for them. When we spoke on February 2, his city was on partial lockdown, with schools closed through the end of the month. At this point, he reports that since the majority of new cases are coming from foreign travelers, they have shut down the airports for the next two weeks.

He notes several other differences: “We’ve got temperature and sanitizing stations everywhere. We set rations early for medical supplies, tied to nationwide health cards so people don’t get more than they’re allotted per week. Home quarantine is digitally tracked with phone and wristband – if people aren’t where they’re supposed to be, the police show up.” There’s no way that would fly in the US, but it’s an interesting view of how other countries are handling this challenge.

He sent me this piece from NBC News that explains it based on the fact that “Taiwan put lessons it learned from the 2003 SARS outbreak to good use, and this time its government and people were prepared.” Taiwan’s actions:

  • Aggressive testing and contact tracing, with swift isolation of infected patients.
  • Temperature monitors were already in place at airports to look for passengers with fever.
  • Individuals with positive contacts but who test negative are tested repeatedly to determine if they become positive.
  • Masks were rationed, but were given to lay people, which helped people feel safe and avoided panic behaviors.
  • Soldiers were sent to staff mask factories, increasing production.
  • TV and radio stations broadcast hourly public service announcements on hygiene.

Can you even imagine that in the US, where we’re still hearing in some channels that this is all a hoax?

There are other good strategies in the article, including parents monitoring children’s temperature at home and not sending them to school when febrile, which I know is not always the case in the US. We often see parents who load their children with ibuprofen and acetaminophen and send them to school sick because they can’t take off work. Once the children are sent home from school, they come to urgent care.

There’s also a plug for Taiwan’s nearly universal healthcare system, which “lets everyone not be afraid to go to the hospital. If you suspect you have coronavirus, you won’t have to worry that you can’t afford the hospital visit to get tested… you can get a free test, and if you’re forced to be isolated, during the 14 days, we pay for your food, lodging, and medical care. So no one would avoid seeing the doctor because they can’t pay for healthcare.” That’s a different world, indeed.

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I was able to do some actual informatics work this week, as I helped a couple of organizations set up their COVID response plans, including messaging campaigns and drive-through screenings. There are plenty of companies standing up solutions specific to the current crisis and I’ve heard some comments dismissing them as capitalizing on the emergency. Still, some vendors are offering some pretty cool solutions for free and I was happy to take advantage of a couple of them this week (as were my clients).

Smaller companies can be a lot more nimble. I watched a patient outreach solution go up in less than 12 hours and a drive-through screening management system go up in less than two days. It’s been fun to watch innovation at work.

I finally left the house, though, when I received the call that a colleague had an N95 mask for me. I felt like a transplant patient must feel when they get the page that an organ might be on its way. My hopes were dampened a bit after I heard the story of where it came from – it’s likely to be a counterfeit. Once it makes it out of the quarantine area in my house, I’ll check out its particulars and see if it’s the real deal. A good friend of mine might also have one in his basement, which I’ll definitely take advantage of if this one looks sketchy.

There are a lot of scams out there, “friend of a friend” kind of situations where people promise to get a high volume (and high dollar) order through when traditional supply chains have failed. Even hospitals are not immune to the scams.

Stay safe out there, and stay sane. It’s going to be a long, bumpy ride.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/23/20

March 23, 2020 Dr. Jayne 2 Comments

Another crazy week in the trenches, and the “organizational behavior” consultant part of me wishes I could get some of my clients to listen to reality and take solid advice. Everyone is completely stressed, and justifiably so, but we need to figure out how to get through this.

This morning, I had a very painful conversation with a client who asked me to update him on what other similar organizations are doing with their outpatient clinics. Are they closing, running modified hours, consolidating by patient needs, etc. I put together a careful analysis with summaries and walked through them.

The client proceeded to yell at me and explain why each option wouldn’t work for their organization. I tried to gently remind him that his “ask” was for me to answer the question of “what are similar organizations doing in this situation” as opposed to “how should we handle this?” Because frankly, if he had asked the latter question, I’d have been likely to tell him it’s time to just pack it up and go home, because their lack of understanding of this pandemic and failure to follow CDC and OSHA guidance is putting their staff and patients at risk.

The bright spot of the week was a patient who asked me how I was doing as a person and how my family was holding up with me being on the front lines. He was sincere and caring. It was a welcome change from having to deal with the previous patient, who was self-absorbed and flatly refused to quarantine himself “because it’s boring and I can’t stand it any more” despite his fever of 102 and symptoms that were consistent with COVID.

Like just about every healthcare worker in the US at this point, I’ve been exposed to multiple positive patients, and without the recommended gold-standard N95 mask. Still, I can control the environment in the office and can wash my hands immediately after every single interaction, which is a lot better than what happens when you make a furtive trip to the grocery store. Plenty of people are still picking up items, looking at them, and putting them back, which is less than ideal during a pandemic. Our local grocer installed handwashing stations outside the front door, but I’d give myself even odds of being infected at work versus by the general public.

Our non-clinical staff members are having the hardest time with the situation. They are not trained for it and really didn’t know what they were getting into compared to the clinical workers. They’re constantly on edge, and one of them was crying in the break room during my last shift. Talking to physician colleagues across the country, they’re seeing the same thing.

We’re all supposed to act tough and not afraid, but as people, we want to validate our staff’s concerns and let them know that we share some of the same feelings. Unfortunately, some administrators across the country see such empathy as akin to “feeding into fear mongering.” I have two friends who received verbal counseling about the conversations they had with staff because they didn’t toe the corporate sunshine and lollipops line. When the CDC is telling healthcare workers to tie a bandana on their face if they don’t have appropriate personal protective equipment, we’re well past the sunshine zone.

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Friday, March 20 was Match Day for fourth-year medical students across the country, many of whom have had their classes canceled and rotations ended for the rest of the year. Graduations have been canceled as well. Instead of learning their fate in an auditorium with friends, they learned it online. Good luck to each and every one of them. I remember what that day was like and can’t imagine how surreal it must feel to the class of 2020.

Speaking of surreal, I urge all organizations to go through any automated or pre-scheduled communications and make sure they make sense given the current situation. When the schools are closed and parents receive a notice about the 7 a.m. ACT prep session, that’s not a confidence builder.

Similarly, when vendors send out tone-deaf emails about patient loyalty or market share to health systems that have publicly announced that they will run out hospital beds within 10 days, that’s not a winning marketing strategy.

I’ve received several emails from HIMSS that are utterly devoid of acknowledgement of the present situation. Given that HIMSS might not survive after the loss of revenue from HIMSS20, I would urge them to not aggravate people. Their constant blasts about Virtual HIMSS are bordering on the absurd for people who are knee deep managing issues at their hospitals and health systems as the new normal.

On the flip side, I received a call from my bank, which is checking in with their small business banking customers to see if they can help with anything. The business they were calling about is my side hustle that I’m cultivating for retirement, so it’s not a major source of income. Still, it was a nice gesture.

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Last week, on March 18, CMS announced that all elective surgeries and non-essential medical, surgical, and dental procedures should be delayed during the COVID outbreak. This is not only to preserve hospital capacity (some of those elective patients have poor outcomes and wind up in the ICU), but also to conserve personal protective equipment. Many outpatient offices have canceled well visits unless they include vaccinations.

My primary physician and ophthalmologist canceled all their annual visits and offered refills for the next six months, so thank you. Unfortunately, some major players in the healthcare industry are behaving badly and refusing to follow this directive. You know who you are, and shame on you. Please get with the program, I’m betting you’ll wish later you had all those masks and gowns back. If you’re organization is still doing elective procedures, this piece from a Seattle vascular surgeon is a great read.

I’m keeping this brief so I can go back to the telehealth front lines. I haven’t been able to exercise my newly granted ability to see patients in states where I don’t have a license since there are so many patients to be seen in my home state. To all of you on the in-person front lines, stay safe, stay sane, and just keep putting one foot in front of the other.

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EPtalk by Dr. Jayne 3/19/20

March 19, 2020 Dr. Jayne No Comments

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I was back in the clinical trenches today. At least in the urgent care world, it was eerily calm at times, although we did see some big rushes at the beginning of the day. People are getting the message to stay home, although some ventured out.

I want to offer some advice for those of you who need to seek medical care. First, this is not a time to take the family. If you need someone to drive you, great, but have them wait outside and not enter the facility. I saw two families today with multiple children in tow, but multiple parents. It would have been better if the second parent, who didn’t participate in the visit at all, remained in the car with the siblings.

Second, look out for your healthcare workers. If you see that something has gone wrong with their personal protective equipment, say something. Although I’m sure the worker in the picture above knows that their forearms are exposed, therefore defeating the point of a gown, maybe they would have done something different if a patient or co-worker had said something.

Third, please do not question why your provider is wearing a mask. We have our reasons, and some are personal health issues. We might also be protecting you from our cough or sneezing since it’s also allergy season. We are healthcare providers and you need to trust us to make decisions for our health and yours. I have had colleagues at other facilities that have been told they can’t wear masks because they’re “panic-inducing” for patients.

Many of your healthcare workers are terrified. If they wear the one crummy mask they have access to and have been wearing every day for a week, give them a break. Maybe they’re just scared because physicians in our area have already been infected.

Last, please think before you complain about wait times. You never know when the team is tied up transferring a critical patient to the hospital or doing another critical task, like starting the autoclave so we can get more instruments sterilized. For those patients who are coming in apologizing for being sick, it’s OK and you don’t need to apologize. That’s what we’re here for.

I was excited to hear announcements that licensure requirements for telehealth are going to be relaxed. The reality, though, is that it is on a state-by-state basis, and not all the states are playing along. I can see patients in Florida and North Carolina as well as the states where I have licenses, but we’re a long way from letting available physicians flex to cover the areas with the most need.

Most of the telehealth visits I’ve done in my off hours have been for routine things. Patients either don’t want to risk going to a physician’s office or the offices are overwhelmed and not keeping up with phone volumes. I handled some medication refills along with sinus infections, urinary tract infections, and pinkeye. These are routine things in primary care and I’m glad to be part of the solution as clinics struggle to cope with their new normal.

CMS has also relaxed telehealth rules for Medicare and Medicaid as far as which visits providers can bill. Medicaid is still subject to state regulation, so that might take time, just as with the state license issue. New federal policies also let clinicians use technology beyond established telehealth platforms, such as Apple’s FaceTime, Facebook Messenger, Google Hangouts, Microsoft Skype, and more .

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Speaking of virtual care, I practiced some virtual self-care this week as my cello instructor moved my lessons online. I had to run a cable from my laptop to the router to make it work and we experienced some distortion of the sound when I was too close to the microphone, but it worked out well. I only started playing last summer, so I smiled when I saw this article about two young cellists who played a socially distant concert on the porch of their elderly neighbor. The article mentions that their repertoire included Suzuki Book 1 and Book 2. I’m just finishing the latter, so perhaps it’s time for a concert.

From Cultural Afficionado: “Re: Google Arts & Culture. I was led there by an article about virtual tours of museums around the world for folks who are self-quarantining (is that a proper verb?) While looking over the rest of the site, I found a ‘Spotlight on Shoes’ section that included this story, ‘Amazing Shoes of Turin.’ Enjoy, and thanks for your contributions to HIStalk!” I’ve been enjoying all kinds of virtual adventures as I force myself to take frequent breaks away from scientific articles and other reports about COVID-19. My favorite video is the one of the penguins at the Shedd Aquarium in Chicago, who were allowed to roam the building after it closed to visitors. We need a little levity in times like these, and penguins always get the job done.

From Homeward Bound: “Re: telecommuting. I work for a health plan with about 2,000 employees. The organization had very little telecommuting before this outbreak. This crisis has forced a huge amount of scrambling to get hardware to people who need it, and more importantly, get management to figure out how to manage people they don’t see on a daily basis. It will be very bumpy for the time that everyone is working remotely. Work will get done, but not as much as usual. It will be interesting to see whether the old-school leadership tries to put the genie back in the bottle once we don’t all have to be remote. The lack of telecommuting has been a real negative for recruiting for a long time.” I hope managers are keeping an eye on productivity because they might be surprised. Of course it varies from employee to employee, but some of us get much more done in a non face-to-face situation. I’m sure others have trouble focusing or maintaining the self-discipline needed to work remotely. Lack of childcare is another factor in this situation compared to other work from home efforts, so if productivity dips, I hope they don’t judge too harshly.

It’s time to announce the results of my virtual Shoe-A-Palooza and Sock-It-To-Me competitions. A single champion dominated in both categories — Dr. Nick van Terheyden. In his submission, he notes: “My Scottish Leather Ghillie Brogues. Not for the whole show, but for my now-cancelled Whisky Tasting at the NextGate booth on Tuesday.”

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There’s a potential 18-month trajectory for the COVID-19 crisis, so let’s hope we get to see that ensemble at HIMSS21.

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Curbside Consult with Dr. Jayne 3/16/20

March 16, 2020 Dr. Jayne 4 Comments

Mr. H recently published a reader comment that asked for more COVID-19 news that isn’t necessarily healthcare IT specific. While he waits for responses to his poll about the issue, I’m going to go with the leading response and share some reports from the field.

The American Medical Association recently published “A physician’s guide to COVID-19” that I will use it as the framework for some comments. Before I begin, please note that the comments below are not necessarily my own. Some have been culled from my personal Facebook feed, text messages, and chats with friends. All are presented anonymously. They are the words or thoughts of the individual physicians, nurses, medics, techs, and frontline folks and in no way reflect the opinions of their employers. Readers, please excuse my digression from the usual, because what we are experiencing right now is anything but usual.

Communicate your COVID-19 updates and details about your preparedness plan with both staff and patients.

  • OMG, the president of our medical group just went on TV and bragged about our testing capabilities at the same time an email went out to the staff that said that we were not telling the public we could test. #cluster
  • TV reporter knew more about hospital plan than MDs did.
  • Admin is more focused on updating the EHR (which they did without telling us, then had to roll it back, then updated again without so much as an email). Makes us feel unstable and vulnerable and we don’t need that right now.

Take measures to keep “Persons Under Investigation” (PUI) and others with suspected COVID-19 symptoms separate from the rest of your patients.

  • We are a walk-in facility and we don’t know whether a person is high risk until they’re at the front desk with the receptionist. They are taken to the first available exam room and the door is marked with a Post-it to let people know they’re high risk. The medical assistant and physician who see the patient put their initials on the Post-it so that no one else inadvertently walks in. Anyone else think this crazy low tech? What if the sticky falls off?
  • Our office canceled all well visits and are seeing sick only. They have to call and be triaged by RN or provider. They wait in their cars and we text them when they can come in.
  • It’s still flu season. Who has symptoms that DON’T look like coronavirus?

The CDC recommends specific measures to minimize the spread of infection that include: proper use of PPE, including eye protection.

  • LOL! We haven’t reliably had masks in clinic since February. Admin seems to think that outpatient departments don’t see sick people. No gowns and no face shields, either. Other hospitals have drive-through testing clinics with nurses in full PPE reaching through car windows. We’re swabbing patients in our street clothes. No showers at work and nowhere to change. Most of us are stripping in our garages before going straight to a hot shower at home. I haven’t seen an N-95 mask since residency.
  • Why do nurses in China have three layers of protective gear but I can’t get a disposable gown?

Misinformation about COVID-19 is being shared across social medial and other platforms at alarming speed. Physicians have a duty to correct dangerous and misleading myths that could harm patients’ health. Read the biggest misconceptions.

  • I continue to encounter people who think this is all media hype or a political tool. Do they really think that millions of people in Italy give a damn if this makes Trump or anyone else look bad?
  • OMG. If I see one more post about “quarantine babies” nine months from now, I want to scream. As an OB/GYN, does anyone remember Zika Virus? We don’t know what this virus will do to a developing fetus. Use protection, people!

I worked today, and it was a rough one. Although patient volumes were (thankfully) down by about one-third, nearly every visit involved an in-depth discussion about risk factors for coronavirus infection. I had to counsel multiple patients that they should not go visit their grandparents or other elders, even if feeling well. Probably half of them seemed to take my advice, the other half plan to do it anyway.

People were still asking if they should take spring break trips, despite footage of the crushes of travelers at O’Hare and DFW airports all over the news. Friends texted from Colorado, miffed that the ski resorts were closed. I mentioned that hospitals there are communicating with physicians that they are past containment in the state, moving to a strategy of mitigation, where only hospitalized patients would be tested. It will just be assumed that symptomatic patients have it and need to be quarantined and managed at home if they are well enough. Patients are upset that elective procedures have been canceled, and apparently Sunday at the urgent care is the place they have chosen to try to get their issues addressed.

We’re still in early days with this pandemic in the US and the stress levels I’m seeing are off the charts. People are using humor to try to get through, but as a veteran of a Level 1 trauma ED, I can tell it’s a mask for some who are really scared. I’m in a lower acuity setting now, but I can’t imagine what this is going to look like over the next 30 days.

Workers in non-healthcare environments are also stressed, including supermarket employees and restaurant workers. Parents don’t know what they’re going to do for childcare when schools close. People living paycheck to paycheck don’t have the means to stock up on supplies. Han Solo would definitely have a bad feeling about this one. I’m sure we’ll all find our new normal, but it’s going to take some time.

I had intended to judge the results of the non-HIMSS shoe and sock contests tonight, but after I came home, worked through my well-planned decontamination routine, and then discovered my hot shower would be hampered by a broken shower head that was akin to standing under a garden hose, I was just done. I have plenty to be grateful for – I’m not working the intensive care unit, I’m not working a big-city trauma service, and at least part of the time I can work from home. I have plenty of non-perishable food and I know how to recognize good leaves and bad leaves in case I need to operate without toilet paper. My sense of humor is still intact, or at least I hope so.

What has changed in your life in a post-COVID world? Leave a comment or email me.

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EPtalk by Dr. Jayne 3/12/20

March 12, 2020 Dr. Jayne No Comments

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The time change came and went on Sunday, but my Outlook calendar is still messed up for the week. The ET zone is once again correct starting next week, so I’ll just have to be extra vigilant for the next couple of days about making sure I’m on the right call at the right time.

My calendar was still accurate for the lunch and learn session on Wednesday with Dr. John Halamka, sponsored by Arcadia. The company rolled this over into a virtual session almost seamlessly, and a good number of people attended. For those of you not familiar with the company, they have a tremendous population health platform and have helped their customers save over $2.4 billion through 2018. The platform is mapped to over 50 EHR vendors, which is a feat in itself.

Dr. Halamka joined from the library at Unity Farm Sanctuary and talked about the concept of platforms in healthcare. Central points included the challenge of de-identifying data when creating data analytics platforms along with how to best use machine learning for early disease identification, cost reduction, and preventive intervention. There was also a good discussion of the need to use the right kinds of data sets to do investigations. For example, if you’re looking at data on Hispanic females, you probably don’t want to use the dataset for Rochester, MN if one is available that is more representative.

I got a chuckle out of the inadvertent activation of his Google Assistant while talking about their use of Google Cloud for data storage. That happens to me all the time. There was also a good discussion of strategies for delivering high-acuity care in the home, which is top of mind given the surge in COVID-19 around the globe. Mayo Clinic is apparently partnering with third parties to provide much of this infrastructure, with a pilot scheduled in July for Florida and Wisconsin. There was an audience question about how much of Mayo’s technology is homegrown versus using vendors. Mayo’s preference is to buy solutions rather than build, whenever possible.

There was a good discussion about the recent interoperability rules and the potential risks for patients managing their own data. Halamka anticipates an increase in innovation with data being under patient control. There was also a discussion about COVID-19 and Halamka voiced concerns about the number of entrepreneurs jumping on the problem. He hopes that solutions come from non-profit organizations or technology companies in support of non-profits as an alternative to profit-driven approaches to a major healthcare crisis. He also lamented the inability of solutions to determine the cost of medications based on a patient’s insurance coverage that goes to the individual plan level. There are some solutions that can get you in the neighborhood, but none that are truly accurate.

The moderator asked about the impact of AI on the animals at Unity Farm. He has 103 devices on the farm, including cameras that can monitor the impact of coyotes and other predators on its 250 animals. They haven’t gone to automated feeding yet since a major focus of the institution is care and compassion for the animals. I have enough trouble managing the handful of devices in my house, so I can’t imagine what that looks like. (If any has suggestions on why I suddenly have to reboot my laptop any time I want to print something, please let me know.) All in all it was a great call, and I appreciate Arcadia’s ability to pivot the session to a virtual format quickly.

I also made sure to honor GlobalMed’s invitation to their Wine and Whiskey Happy Hour by lifting a glass of Jameson. I was looking forward to seeing their backpack telehealth exam station, but I guess I’ll have to wait a bit.

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FormFast has rebranded as Interlace Health, noting that it “started as an electronic forms company and evolved into something much more valuable.” It now defines itself (along with thousands of other companies) as “a solutions company.” They go on to state that having the word “forms” in the name was limiting the perceptions of the company. I understand it, but I’m not sure the new name helps me understand their focus on “enabling seamless data capture and information exchange among providers, staff, and patients” either.

Lest we forget there’s a world out there beyond HIMSS and COVID-19, MIPS-eligible clinicians still have until March 31 to submit their 2019 data for the Merit-based Incentive Payment System. Data can be submitted until 8 p.m. ET on that day. Data submitted by claims have been ongoing throughout the year, and practices can also login for preliminary feedback on their Medicare Part B claims measure data. Clinicians are encouraged not to wait until the eleventh hour in case they need assistance from the Quality Payment Program Service Center.

If you’re bored, you can always choose to read from the pair of final rules released this week. Do we really need to get hit by both ONC and CMS at the same time? Although there are many aspirational comments that have been made by various government folks, let’s take a look at some of them.

From National Coordinator for Health IT Don Rucker, MD: “Delivering interoperability actually gives patients the ability to manage their healthcare the same way they manage their finances, travel, and every other component of their lives.” Although patients will have greater access, that’s not going to automatically make them more capable of better healthcare decisions. Healthcare is not ordering a pizza or booking a flight to Milwaukee. And comparing it to finances? Financial literacy isn’t exactly a strong point for many in the US. We need to spend money increasing health literacy, helping people understand the consequences of unhealthy behaviors, and teaching them basic facts about their own bodies and how to keep them running in good health.

I work with patients all the time who have amazing access to their data, but no way to interpret it or really understand what it means to them. I’m sure the counterargument is that third-party apps will help with that, but how many third-party apps are really going to be around purely for altruistic purposes? They will be there to gather data to sell it to other third parties, to pitch unproven solutions to medical concerns using unregulated supplements or other dubious methods, and more.

I’ll be judging the virtual shoe contest and socktastic submissions over the weekend, so please get your entries in for consideration!

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Curbside Consult with Dr. Jayne 3/9/20

March 9, 2020 Dr. Jayne 1 Comment

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I’m beyond aggravated at the lack of communication from HIMSS regarding hotel cancellations and refunds.

All of the FAQ entries on the conference page say they’ll provide a notice within 14 business days. I called my hotel on Friday and tried to cancel and inquire about a refund, but was told that, “Our GM is handling it and we’ve been instructed not to speak with you.” I emailed the HIMSS refund email address with a formal request instead. (Did I mention I still haven’t received a notification that the conference was canceled?) Today, I was reading Mr. H’s Monday Morning Update and saw the link to an OnPeak refund. Although the link is no longer live, it instructed me to call the hotel directly.

After multiple calls and being rolled over to Marriott’s corporate reservation line, I was at least given a cancellation number, as well as the direct phone number for an assistant GM at the hotel. We’ll see if she returns my call. I’ve stayed at the same hotel eight years in a row and have status with Marriott, so I hope they at least make an effort. I don’t expect a full refund, but anything at all would be appreciated for those of us who pay for our trip to the show out of pocket.

Many of the folks I was scheduled to meet with at HIMSS just rolled our already-scheduled appointments into ones by phone, which made things easy. I’ve decided I’m still going to keep other pieces of my conference schedule, including starting to drink wine, whisky, or other cocktails at 4 p.m. on Tuesday and Wednesday, depending on which vendor events I was scheduled to attend. I’m going to be sure to eat seafood on Monday night in honor of Nordic Consulting’s elegant (but canceled) event at The Oceanaire Seafood Room. Tuesday’s dinner will be Italian in honor of the canceled Citrix event at Maggiano’s, and Wednesday will be contemporary Southern cuisine in honor of Red Hat’s event at Itta Bena. Thursday night I was most likely to be eating some kind of granola bar on the plane while flying home, so I don’t plan to replicate that evening.

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I’d like to invite all our readers to participate in my own virtual “Shoe-A-Palooza” and “Sock-It-To-Me” competitions. Send me your photos of the shoes and socks you planned to wear this week and I’ll pick my favorites. Be sure to let me know if you want to be added to the history books using your real name or if I should pick a kicky pseudonym to keep you anonymous.

COVID-19 has made it to my community, leading to considerable angst as patients panic and community physicians struggle to understand how we are supposed to care for patients. The biggest point of contention is the fact that we can’t even protect ourselves. Outpatient physicians who aren’t employed by big health systems have either no access to simple surgical masks or access that is intermittent at best. An informal survey of close friends reveals that 10 out of 10 of us don’t have access to gowns.

I’ve had to call the state epidemiologist several times for suspected patients. It’s an arduous process that hasn’t led to testing for any of the patients involved. Due to the shortages, we can’t care for flu patients properly by having them wear a mask when they’re diagnosed, which might be contributing to a bump in flu in our area despite numbers from the CDC that it should be waning.

I never thought I’d have to start thinking about whether to quarantine myself when I come home from work, emerging from my room only to run out the door and head to the office. I’m fortunate in not having small children or childcare issues. Many of my physician peers are struggling to figure out how they’re going to be able to see patients if more schools close. Right now it’s just a handful, but only time will tell.

It’s unclear how the recently-passed $8.3 billion in funding will impact the efforts of frontline providers. I’m monitoring news sources from across the country as well as around the world to see how our local response compares to that of others. Kudos to the Washington Post for offering free access to their articles covering the novel coronavirus. You have to subscribe to an email newsletter to get the access, but it’s good to have multiple sources of information. I’m heartened by the decision of some insurers to cover coronavirus testing, but the devil will be in the details as far as how it actually works out. Some payers are considering policies to waive co-pays for testing, but most patients won’t know how their coverage is until they get the bill.

In positive news, the CDC’s Advisory Committee on Immunization Practices voted to recommend a pre-exposure vaccine for the Ebola virus. It’s at least some comfort for the healthcare providers who work at federally designated Ebola treatment centers in the US, for those who work at Biosafety Level 4 labs, and for the genuine heroes who volunteer to respond to Ebola virus outbreaks across the globe. The single-dose vaccine has been shown to be 100% effective when used in a ring vaccination strategy, which basically means that everyone socially connected with a patient within 21 days of their illness must be vaccinated. Ebola virus outbreaks have taken a back seat to COVID-19, but the virus is still classified as a “public health emergency of international concern” in the Democratic Republic of the Congo.

The focus on vaccines is also good news for biotech firm Moderna Inc. whose experimental coronavirus vaccine is being tested on a small group of adults. The study is only a test of the safety of various doses of the vaccine and whether the subjects produce an immune response. Actual vaccines are likely to be more than a year away. Participants will receive two vaccines over the course of a month and will have to complete 11 face-to-face visits and four phone visits during a 14-month period. Those completing the entire trial will receive $1,100. I would say the real value of participation is priceless, should the vaccine progress to a full recommendation. My medical school is also working on vaccine research, so I’m eager to follow the developments.

I’ll be reporting later this week on my at-home virtual HIMSS efforts, so be sure to send those shoe and sock photos along. I’ll be glad to have something else to focus on than the reality of counting the days until I’m personally exposed to COVID-19.

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EPtalk by Dr. Jayne 3/5/20

March 5, 2020 Dr. Jayne 1 Comment

I’m grateful to Mr. H for posting the list of companies who have decided to cancel their attendance at HIMSS20. I think it’s useful for people to be able to plan their activities for the meeting and decide whether it will be valuable for them to attend.

Like Mr. H, I’m still planning on attending. I’m curious about the panel of medical experts that HIMSS has supposedly convened to advise them on the issue and whether they would even consider cancelling given the announcement that President Trump will be delivering a speech. HIMSS has clarified that the speech is not a HIMSS event but a White House event that happens to be occurring at the same place as HIMSS. This is a bit disingenuous since HIMSS controls the convention center for the whole week and had to agree to it.

A reader reported that the planned security protocol includes “no bags allowed in the keynote room,” which should be interesting. At least at the Daytona 500, I could bring a cooler containing up to 24 adult beverages along with a 17-inch backpack to see the President. We’re only a few days away, so we’ll have to see how things play out.

I still find it somewhat unthinkable that many healthcare organizations can’t get masks but HIMSS said they would be handing them out, although mention of masks was missing in the March 3 HIMSS Coronavirus update email.

The organizers of the Redox / AWS / PointClickCare party reached out asking registered attendees to confirm whether they would still be there or if their plans had changed. The sheer scope of potentially unused (but paid for) alcohol that won’t be appearing in glasses at HIMSS is staggering. I’d be interested to hear (anonymously, of course) about HIMSS-related contracts and when the deadlines are to lock in headcounts versus what kinds of refunds might occur for a cancellation.

From Gentle Reader: “Re: HIMSS. I’m attending on my own dime as well. If canceled, I like the idea of going anyway, to lounge poolside. My wife might object. Maybe there could be a spontaneous conference, flash-mob style, of unrefunded, self-paying attendees. I’m resigned to getting the virus eventually from my kids, if not in the clinic, so maybe I’m less concerned about going.” Ditto here. I’m exposed to everything in the clinical trenches and agree with the sentiment that it’s likely only a matter of time. See you in Orlando!

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I’m not looking forward to the upcoming spring time change. A recent Current Biology article notes an increase in the risk of fatal traffic accidents in the week following the time change Researchers looked at data on over 700,000 motor vehicle accidents from 1996 to 2017, finding a 6% increase in accidents during the week immediately following the clock change compared to the weeks before and after. My outlook calendar is still messed up, so I’m curious what it will look like after 2 a.m. hits.

Lots of chatter about the role of telehealth as it relates to COVID-19. Vendors are positioning themselves to handle increased utilization while they create the policies and tools necessary to handle potential cases. Payer and provider organizations are also beefing up their infrastructures.

In some ways, it may be easier for telehealth organizations to ramp up their capacities than brick-and-mortar practices. Telehealth vendors who are providing direct-to-consumer services don’t have to worry about the time it takes to credential providers with payers. They can also tap vast pools of physicians looking make extra money in their off hours. Many non-telehealth practices, even large ones, are reluctant to even pay for providers to be on-call or in a float pool, so it’s more likely that they’ll try to just pass increased volumes onto existing physicians rather than thinking outside the box with new models.

From the specific vendor perspective, American Well has a webinar planned for March 5 and I plan to be on it. The topic is “How to use telehealth as a key element of your infection control and prevention strategy.” InTouch Health is extending a couple of offers to help support organizations in their preparedness. They can opt for use of the technology free of monthly fees for up to six months with minimal charges for shipping, network setup, and decommissioning. Another option is a software-only offering using an organization’s existing devices. Additionally, refurbished telehealth devices can be shipped to existing customers. They were also hosting an informational webinar but it conflicted with my schedule, so I didn’t make it.

My next post should be from beautiful sunny Florida, unless something changes drastically. I’ll spend the rest of today trying to figure out my wardrobe and of course which shoes I’ll be taking, this year with a focus on comfort. Since Sunday and Monday look to be low-key with fewer meetings than planned, I hope to get some nice walks, in which will be a welcome break from the chill I’ve been in for the last several months.

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I flew yesterday with the Honor Flight Network, which was truly a remarkable experience. From the moment we stepped off the plane to be greeted by the welcoming team at the Baltimore airport to the final goodbyes from the send-off team at Reagan National, it was well organized. I didn’t see any travelers behaving differently due to coronavirus – no masks, no one (except me due to flu concerns) wiping down airplane tray tables, and plenty of people touching magazines and other goodies at the airport gift shops.

I did, however, see one traveler behaving badly in general because our group of wheelchairs slowed him down by approximately three minutes at the Reagan National checkpoint. Perhaps karma will catch up with the guy that was dropping f-bombs under his breath and giving our veterans dirty looks. To use his words, the only “ridiculous BS” that was happening at the security checkpoint was his failure to pay proper respect to a group of octogenarians and nonagenarians who risked their lives (many as volunteers) to answer their country’s call to service. To the ladies and gentlemen that I had the privilege of assisting, it was truly an honor to spend the day with you.

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Curbside Consult with Dr. Jayne 3/2/20

March 2, 2020 Dr. Jayne No Comments

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We’re definitely in the pre-HIMSS doldrums, with very little going on and even less news about it. Anyone who has a major announcement is going to hold it for the big show, even though odds are it will get lost in all the noise. Or the silence, if HIMSS chooses to cancel the event.

Most of the non-IT news out there in the healthcare realm is about the novel coronavirus and its transition to community spread within the US. Lots of chatter about how organizations are gearing up to identify and track it, but there are still serious challenges as far as how healthcare organizations are actually going to manage the patients especially given shortages of masks, gowns, and other critical supplies.

We finally had some surgical masks appear in our workplace this weekend, although it’s not clear if the supply will hold out or if the office will be replenished if we run out again. Most of the time we’re using them to help reduce the risk of flu transmission.

I was glad to see the most recent CDC numbers show a sharp decrease in positive flu tests. However, I think some of that downturn might be driven by people who aren’t coming in to be tested because they know just about everyone they’ve come in contact with has flu, so they’re just assuming a diagnosis and staying home. Several local schools have closed for deep cleaning as well, so at least they will be well practiced when coronavirus arrives. Our practice is as busy as ever with multiple providers covering extra shifts to make up for those who are out with flu.

Mr. H mentioned in his Monday Morning Update that Cisco is canceling, and there are plenty of rumors about other companies that are bailing out but haven’t announced it yet. HIMSS has been uncharacteristically slow in sending out invites (or “sorry, you’re not invited” notices) for many of their breakfast and lunch events, which is annoying both to the attendees who tried to register for them as well as the vendors who are paying for them. I’ve heard of many companies that had previously decided to downsize their exhibit hall presence and were planning on sending fewer employees than past years, so it would be less of a loss if they decide to cancel.

For those of us who aren’t being subsidized by a vendor or employer and who attend out of pocket, it’s not a small financial hit. Even if it is canceled, I have half a mind to go anyway and just enjoy being somewhere warm with a pool. On the other hand, I could stay home and catch up on all the things I haven’t been able to do since flu season has been so exhausting. I have some Maintenance of Certification questions I need to do for my boards and I would no longer have an excuse to dodge them. There’s also taxes to file and a shower to re-caulk, so the possibilities are endless for fun and excitement.

In the event that HIMSS goes forward, and a good chunk of exhibitors decide to show, I always get the question about what I’ll be looking for or what I want to see at the event. Here’s a short list of things I’m interested in:

  • Ambient intelligence, smart exam rooms, and the like. How close are they to being able to make this work for in-the-trenches primary care practices? Are the solutions able to handle the scenarios where anything could walk through the door, and most of the time patients present with multiple and complex problems? Are they able to integrate with multiple EHR platforms or just the big ones? There are thousands of physicians across the US who are in need of such solutions but who don’t have Epic or Cerner.
  • Telehealth. What do consumer-facing organizations have planned for the next five years? Will hospitals and health systems continue to try to do internal programs, or will they partner with some of the national players? Will the institutionally-focused vendors merge or partner with the consumer-facing ones? Will they be able to thrive financially, or will they continue to run on thin margins?
  • Patient engagement. Are vendors really able to drive the needle for deliver patient outcomes, or is it all flash? Do the apps have staying power for patients or are they like fitness trackers and other solutions that patients use for a few weeks or a few months and then abandon?
  • Helping the “little guys” succeed. What solutions are out there to help small practices or organizations that aren’t in the 800-pound gorilla range? What’s out there for people that don’t have half a billion dollars in the bank ready to spend on IT solutions?
  • And finally, one of the least provider-facing but very important topics. What’s new in terminology, taxonomies, and all the “guts” that make the systems run while trying to facilitate interoperability and data exchange? I’ve heard that there may be some cool things on the horizon that could be transformative from the informatics perspective. I do love the logic and organization of a well put-together system, and if there are tools that can make that better, I say bring them on.

We should know soon whether HIMSS is a go or no-go and people can start adjusting their plans accordingly. If you’ve already decided you’re not going to attend, how do you plan to spend your time? Will you play catch-up on projects or are you so busy that staying home will just keep you from falling behind? Leave a comment or email me.

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EPtalk by Dr. Jayne 2/27/20

February 27, 2020 Dr. Jayne 1 Comment

I’m always on the lookout for good outcomes from all the work that goes into EHRs. I enjoyed reading about an EHR “nudge” that was shown to reduce inappropriate testing for the nasty C. difficile infection. The system flags patients with contraindications to testing and the authors looked at data across four hospitals ranging two years before and after the intervention. The percentage of inappropriate orders fell by 2% with the intervention, and overall orders were down 21%.

I attended a medical seminar this week and was surprised that no one is modifying their behavior in response to flu season or even fears of coronavirus. Still a lot of hand shaking going on and a couple of people gave me the side eye when I declined to shake hands. I guess everyone has forgotten the pandemic flu of 2009 when everyone was doing elbow bumps instead. CDC has raised their level of dialogue around coronavirus preparedness and HIMSS has followed suit by announcing it will be a handshake-free meeting. I anticipate some other behavior changes around whether people will accept samples of food or candy and whether people will even want to travel to such a large event. HIMSS notes that registrations are up over 2019 and the cancellation rate is below 0.05%.

Still, HIMSS has announced its preparedness plan, including collaboration with ED physicians, onsite support from the Florida Department of Health, onsite screening and isolation as needed, and more. They plan to have three medical offices at the convention center, with one of them dedicated to flu-like symptoms. There will also be an increased number of hand sanitation stations, increased wipe-down of commonly used surfaces, and the availability of medical-grade face masks at the information booths.

That’s more masks than I currently have at my office, which makes me sad. I’m a bit of a prepper already, so making sure I have enough personal supplies stocked in wasn’t a stretch, and I’ve warned my younger colleagues who rely on DoorDash and GrubHub for every meal that they might want to consider having at least a small ramen noodle supply at home. The next couple of weeks should be interesting.

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CDC is also circulating their infographic about the proper fit for high-end masks. I had no idea some of these facial hair styles even had names.

Anyone who has ever worked in hospital IT knows the fear that an upcoming visit from The Joint Commission strikes into the hearts of coworkers. There are many accrediting organizations out there, and often they are cited as the source of rules and regulations that don’t actually exist, leading to frustration for operational and technology teams alike. A recent report notes that CMS plans to strengthen oversight of accrediting organizations due to concerns about conflicts of interest. Some of the organizations provide both accreditation and consulting services which can be an issue, and CMS Administrator Seema Verma also called out accrediting organizations that use standards that are different from the CMS conditions of participation. The Joint Commission is one such organization that has created requirements above and beyond the CMS standards.

Verma also mentioned the upcoming Meaningful Measurement 2.0 program, which is a follow-up to the 2017 Meaningful Measures program. (Language nerd side note: Why did they have to change it from Measures to Measurement? That’s going to be annoying.)

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There are strong feelings out there about the way that technology is escalating the medicalization of things that were previously “normal” physiological process. From smart toilets that analyze stool patterns to diet and nutrition trackers, technology is everywhere. I’m part of an online group that mentors young mothers and nearly everyone either has or wishes they had a multi-hundred dollar smart bassinet to help their babies sleep better. A recent Washington Post article looked at the impact of AI baby monitors on nervous parents. It’s gone beyond the walkie-talkie style units of the past, with camera systems that transmit data to parents while they are away and also those that process the video to determine whether infants are in risky positions or getting tangled with blankets. Privacy advocates are concerned about the sharing of such private data and clinicians are worried that monitor companies are promising a level of safety that is not supported by research.

I’ve definitely noticed a heightened level of anxiety in the moms in my group, although I recognize that to some degree it might self-select anxious mothers since they’re participating in the group in the first place. Some of them are desperately trying to track and quantify every element of their babies’ existence, from feeding to diapers, sleep, and developmental milestones. I’ve seen mothers who have lost the ability to trust their instincts and are relying too much on data.

It’s similar to when physicians are in training and have to learn to “treat the patient, not the numbers.” The privacy issue is certainly a big one, with parents having no control over the images of their children once they’re transmitted to the vendor. Definitely food for thought.

Speaking of the quantified self, approximately a third of fitness trackers are abandoned after a while, winding up in nightstand drawers or the landfill. Recycle Health, affiliated with Tufts Medical School, has collected more than 5,000 wearables for redeployment to exercise and nutrition programs for low-income patients. Vendors have gotten into the act, with Fitbit, Fossil, and Withings sending excess inventory. Apple has not donated. In addition to individual donations, they also gather unclaimed lost devices from theme parks and tourist sites, which is a novel approach. Corporate wellness programs donate as well.

In other wellness news, recent research shows that odd-shaped parks may be better for public health. The authors used satellite imagery, cause of death statistics, and residence near a green space larger than 900 square feet as indicators. They found a decrease in deaths for every percentage point increase in green space. They found that irregular parks were beneficial because they might be more appealing to be in, or might be easier to stumble upon compared to formal parks with limited entrances. Complex-shaped parks were also linked to reduction in chronic health conditions. Recommendations for civic planners include finding ways to connect small or fragmented parks via greenways or other natural features.

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I always enjoy when a scholarly publication has a sense of humor, and a recent article in the Journal of Surgical Education did not disappoint. In “The Sorting Hat of Medicine: Why Hufflepuffs Wear Stethoscopes and Slytherins Carry Scalpels,” the authors surveyed surgical coordinator and residents to score various personality traits that tend to define medical specialties. There were more self-reported Slytherins in surgical subspecialties, particularly in orthopedic surgery. Family medicine had no Slytherins, which is not surprising. I don’t think students are going to start selecting their specialties based on their Hogwarts sympathies, but it was an amusing read.

Lots of chatter among the scribes in our office this week as the folks at Mayo Clinic Medical School mistakenly sent acceptance letters to 364 applicants. The school is blaming it on a technical glitch and said that as soon as they knew about it they withdrew the offers via email. Everyone affected has also been contacted by phone. The letters went to everyone who had interviewed, and there are typically only 46 actual spots available for students, with initial offers usually being made by phone.

The medical school admissions process isn’t something I would wish on anyone. It’s an emotional roller coaster and it’s expensive. Based on the fact that they were invited to interview, the applicants affected are generally qualified to attend, and I feel bad for them.

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I got a chuckle out of reader Matt’s comment on my post about HIMSS shoes. He recommends HOKA, but notes that “they’re not inexpensive so you may have to add laser hair removal to your practice, add retail vitamin sales, or go into orthopedics.” You have to love a company that has a shoe named “Speedgoat” and their color combinations are certainly appealing.

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Curbside Consult with Dr. Jayne 2/24/20

February 24, 2020 Dr. Jayne 2 Comments

A new report from the UPMC Center for Connected Medicine finds that only four in 10 providers feel that digital technology is being successfully integrated into the overall patient experience. The team at UPMC surveyed more than 130 health systems and found that many of them are experiencing challenges around the costs associated with purchasing, implementing, and maintaining digital tools. Integration remains a concern due to interoperability issues with third-party applications. Unsurprisingly, organizations are ranking patient engagement tools as high priority projects and hope they will assist with major clinical initiatives such as chronic disease management.

According to Katie Scott, vice-president of digital strategy and innovation, UPMC Enterprises, “Patients now assume they’ll have the same digital experience in healthcare that they get everywhere else in their lives, and they’re dissatisfied when we don’t deliver. Increasingly, if hospitals and health systems can’t provide a feature-rich and seamless digital experience for their patients, those individuals are going to look elsewhere for care.”

Based on recent experiences with two patient portals, I can’t say I disagree. One of the portals took me in circles as I tried to figure out what was going on with a bill for a date of service that occurred more than eight months ago. Apparently the organization’s Division of Ophthalmology follows billing rules from some other universe, and according to the folks I had to call for help, these delayed bills are pretty much routine.

The other one allowed me to access data from two practices, both of which had different access settings for my information. While one practice had shared full office notes and lots of discrete data to the portal, the other only had lab results, but there were no annotations on the results. I ended up clicking dozens of links trying to figure out what my blood pressure might have been running over the last couple of years, and ultimately wound up with two useful data points and a lot of frustration. Although more than 80% of organizations cite the patient portals as one of the top three currently implemented technologies, it’s unclear how much benefit patients and practices are truly receiving from them.

The UPMC Center for Connected Medicine is a joint venture between UPMC, GE Healthcare, and Nokia. Other findings of the survey include: more than 75% of organizations are offering at least one digital health tool to patients, with 25% offering four or more tools; of the quarter of organizations who haven’t deployed digital health tools, 97% of them have plans to do so; half of respondents labeled digital tools as critical or high priority, with larger organizations more apt to call them critical; and less than one-third of organizations agreed that their organizations are able to deliver a digital experience that is “on par with the best digital consumer experience.”

There have been a couple of articles discussing the results of the report, and all of them focus on the perceived advantages held by organizations that are leading with digital health tools. They also predict that organizations that don’t embrace digital tools will be left behind as patients vote with their feet to move to organizations with a more seamless experience.

This reminds me of how hospitals were behaving years ago as they all competed based on their beautiful birthing suites, on-demand dining, and bedside entertainment systems. They may have gotten people to look twice, but I’m not sure it really made a difference in how patients selected their hospitals,since often that decision is driven by insurance contracts or where physicians have chosen to be on staff.

As patients have become consumers and people are increasingly sensitive to the cost of healthcare, I’d like to propose a new paradigm in hospital competition. Rather than pushing for just price transparency and infection rates, let’s get some real competition. Let’s get hospitals to publish their data on accurate billing, clean claims, and responsiveness to patient inquiries. In addition to your wait time in the emergency department, what is your wait time when you have to call about a bill from six months ago that finally dropped? How quickly can you deliver medical records upon request? How do your score on the ability to deliver those records in the format patients want?

Let’s create some metrics for care team communication with families, adequate discharge planning, and appropriate end-of-life decisions and get them circulating in the community. As far as other metrics, how quickly does someone answer the patient call light/bell, and how efficiently can someone help an elderly or immobilized patient to the bathroom? Let’s get that metric up on a billboard just like the emergency department wait times.

For anyone who has ever been an inpatient or had to closely take care of a hospitalized family member, let’s add some other ones like timeliness of medication administration, the percentage of time that handwashing is done properly, and the speed with which staff can silence or otherwise address the alarm on an IV pump.

I’m now at the point in my career where I’ve spent more time as a clinical informaticist than I did as a “regular” physician, and trust me, I do love the technology side of things. But as we are with so many things in our society, we’re focused on the wrong things. Is digital technology just a distraction from other issues? Are we trying to use it as a proxy for the actual healthcare that our patients deserve? Do patients really want an interactive, immersive experience or do they just want to get out of the hospital without a hospital-acquired infection? Do they really need online bill pay or would they be much happier with a bill that was simply understandable and accurate?

I’m curious what others think about this and what your organization’s relative spend is on digital patient engagement versus what many of us would consider the staples of running a healthcare organization. Do you spend more on technology than infection control? How does it compare to salaries for nursing staff and other critical patient care resources? Are we just experiencing the healthcare equivalent of bread and circuses? Leave a comment or email me.

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EPtalk by Dr. Jayne 2/20/20

February 20, 2020 Dr. Jayne 6 Comments

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I’m all about the data, but I’m not happy to have been faked out by this year’s influenza numbers. We were lulled into a sense of hope by what appeared to be an early peak followed by a decline in flu cases, only to have a second (and higher) peak.

To date, there have been 26 million cases of influenza and 14,000 flu-related deaths, including 92 children. We’ve been seeing a lot of influenza pneumonia in the practice and I’ve just about washed all the skin off my hands. I hope we start to see the end of this soon. Everyone’s keyed up about COVID-19, but few average people are aware of how many people influenza kills each year.

I had a chance to connect with a colleague who lives in Taiwan and who was looking for in the trenches commentary on what people in the US think about COVID-19. He and his family have battened down the hatches for the most part and his children’s school is closed until the end of the month as a precaution. Fortunately, he telecommutes to a job in the continental US, so his livelihood hasn’t been impacted. He’s going to keep me posted from the man on the street perspective as the situation unfolds.

It’s definitely starting to get interesting at work, as we are having difficulty with supplies that typically originate in China, including masks, gowns, and other disposable sterile supplies such as staple remover kits. Fortunately, we have a good stock of standard surgical instruments that can be autoclaved for sterilization, so it’s just a question of shifting to that workflow. Nothing beats a good pair of precision surgical scissors from Germany, so I’m not complaining.

Based on the flu and COVID-19, I expect to see an increase in vendors at HIMSS selling supplies to keep the workplace safe, including washable keyboards, touchscreen covers, sterilization carts, and more. I haven’t received any mailings from them or invitations to any booth events, so if you’re in this part of the industry and you’re not strutting your stuff, you might be missing out. I enjoy touring all the booths that have practical items to promote and aren’t just full of buzzwords and the stuff of pipe dreams. If you have something cool for us to check out, drop us a line and let us know your booth number. We’ll do our best to make it by.

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For a while, I was doing quite a bit of consulting around Patient-Centered Medical Home, so I spent a lot of time on the National Committee for Quality Assurance (NCQA) website. That business kind of died down and I drifted away, so I was happy to be drawn back by their involvement in the pursuit of Natural Language Processing. Their recent blog covers NCQA’s efforts to convene a NLP working group to help them explore how the technology can be used for quality measurement and reporting. The group includes representatives from Apixio, UPMC, and Wave Health Technologies.

The working group is focused on approaches to ensure that data generated from NLP is accurate. It plans to work toward developing a standard for validating NLP data. Since the working group is vendor focused, NCWA will be running parallel meetings with an independent advisory panel that includes NLP experts and researchers who will also weigh in on the potential validation model. I’ll definitely be keeping an eye on their work and how it might impact frontline clinical organizations.

I recently caught up with a vendor friend to talk about their strategy for the new Evaluation & Management coding guidelines that will come into play in 2021. The guidelines are designed to allow physicians to be paid without the onerous documentation they had to do in the past, which theoretically would allow vendors to tailor their clinical documentation to the actual clinical scenario rather than allowing physicians to bill at the highest level possible. I’m looking forward to not having to do more of a Review of Systems than is actually relevant for the visit and to writing notes that are closer to “Strep: Penicillin” than to the multi-page nonsense we generate today. I hope multiple vendors are looking at ways to make documentation easier as well as more coherent.

Time to “Ditch the Disk” in healthcare. Various tech leaders are encouraging the healthcare industry to move beyond CD-ROMs and make sharing images as easy as sending a text message. The task force meets every few months and looks at ways to improve the process. My organization burns an incredible number of discs every month and I’m sure they wind up in piles at patients’ homes, so I’m all for it.

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I’m excited to report that readers are responding to my plea for pre-HIMSS shoe shopping tips. Apparently Jeffrey Campbell boots come highly recommended, with one reader noting “I have three of these…  I can even wear them with a broken toe.” That’s high praise indeed. I’m disappointed they don’t have them in my size in the red and blue snake pattern, because they’d be perfect for my upcoming trip to Washington, DC. A little bird told me you can sometimes find them on third party sites, so I’ll have to check them out. I definitely need something comfortable because I’m going to be hitting all the military memorials with a group of Honor Flight veterans.

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Another reader recommends Irregular Choice, saying, “My artist sister is obsessed, and I am tempted to peruse their men’s section for the show floor.” I was completely blown away by their creations, especially the Muppets and Disney options. If I had an endless shoe budget, I could definitely go crazy there.

Good luck on your HIMSS prep. As usual, I’ll be on the lookout for the best reader footwear (both shoe and sock varieties). Will your shoes make the hall of fame or the hall of shame? What are your other favorite sites for awesome shoes? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 2/17/20

February 17, 2020 Dr. Jayne 3 Comments

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It was a wild and crazy weekend, as I got to experience what it was like to get rained on with 100,000 of my closest NASCAR friends. The race was postponed, so I get to do it again Monday, minus the presidential visit and military flyover since I doubt they’re going to send Air Force One and the Thunderbirds again.

I’ll be spending a lot of time in airports trying to get home due to the changes. When I fly, I usually try to catch up on continuing education or read something for my book club, because it doesn’t matter as much if I get distracted versus trying to do actual work. Most of my continuing ed journals are in the realm of emergency medicine or primary care, so I was happy to run across an interesting read in the healthcare IT arena.

A couple of days ago, a “published ahead of print” manuscript authored by some prominent clinical informaticists made some waves. Appearing in the online version of the journal Academic Medicine, it addresses the idea of commercial interests in continuing medical education, and how electronic health record vendors play a role.

Looking back 20 years, there was a great deal of continuing education that was sponsored either directly or indirectly by pharmaceutical companies. During medical school, pharmaceutical representatives would bring breakfast to a session with the not-so-subtle title of “Drugs and Donuts.” They would talk about their products and when they should be used, and I don’t doubt this led to heavy prescribing of the products.

A few years later, this evolved to a more subtle sponsorship of our Grand Rounds lunchtime lectures, where it was obvious who was paying for the steaming pans of sweet and sour chicken and what drug they sold. The reps no longer addressed the crowd, but were available to detail folks afterwards and hand out promotional items. At my school, some of these sessions were accredited for formal continuing education credits and the objectivity of the program was addressed, but others were much looser.

As the authors note, the Accreditation Council for Continuing Medical Education (ACCME) won’t give accreditation to commercial entities that produce, market, resell, or distribute health care goods or services used by or on patients. However, they will accredit academic institutions and other bodies who want to provide credit for courses they sponsor, and those institutions can accept pharmaceutical funding.

For now, ACCME doesn’t categorize EHR vendors as commercial interests and thus provides them accreditation to deliver continuing medical education. The authors note, “Like pharmaceutical company-sponsored CME events, EHR vendor activities, which inherently only focus on use of the sponsoring vendor’s EHR system despite its potential intrinsic limitations, can lead to physician reciprocity. Such events also may inappropriately influence EHR system purchases, upgrades, and implementation decisions. These actions can negatively influence patient safety and care.” They continue to “call on the ACCME to recognize EHR vendors as commercial interests and remove them from the list of accredited CME providers.”

I’ve had the opportunity to attend CME sessions put on by multiple vendors. They vary greatly in their content and how much general education is given versus how much it is really just a veiled training session. Some of the best sessions I’ve been to revolve around newer models of care delivery such as Patient-Centered Medical Home, Chronic Care Management, or Transitional Care Management. A good session will include an in-depth discussion of how the programs benefit patients, what they entail, how to bill for them, and what outcomes you might be able to glean from using them. Only a small percentage of the session is actually learning how to document the program in a given EHR. Bad sessions are little more than click-by-click directions for how to use the EHR, with CME provided to entice providers to attend when they otherwise didn’t participate in training.

I fully agree that being able to execute a workflow well in the EHR is beneficial to patients, as their data is more likely to be documented accurately and comprehensively. That doesn’t necessarily make a class worthy of continuing education credits, but I’ve seen it done.

The authors go on to explain why EHR vendors should be considered commercial entities. They note, “Even though the 21st Century Cures Act excluded EHR systems from the Food and Drug Administration’s (FDA’s) oversight they should be considered medical devices similar to pacemakers, insulin pumps, and CT scanners, which are all under the purview of the FDA. No other commercial device or technology is used more often by physicians and other health care professionals than EHRs.”

One of their major points is that when EHR vendors sponsor CME sessions, they focus only on the vendor’s system and its benefits without mentioning competitor options. “Because every EHR system has intrinsic limitations, attendees are not adequately trained on alternate ways to solve problems… Instead of learning best clinical informatics practices and challenging the vendor to improve its product, attendees are presented with only the vendor’s worldview, which may result in their suboptimal or inappropriate use of EHR products or services on patients.”

One of their comments particularly resonated with me: “EHR vendors focus physicians’ attention on future enhancements to their systems so physicians may miss opportunities to implement available solutions that are more congruent with the needs of their patients, organizations, and the community.” I’m still waiting for an enhancement I requested back in 2006, despite the fact that other vendors include the request in their core functionality. Because the vendor kept promising it, there was no way my employer was going to fund an alternative solution.

The authors made some outstanding points, which was to be expected since several of them are leaders in the American Medical Informatics Association. This fact prompted a statement from AMIA noting that the article wasn’t reviewed or endorsed by the AMIA board of directors. Regardless, the AMIA statement calls on the ACCME to “recognize and consider the potential for bias when HIT vendors offer education to health care professionals” and goes further to urge ACCME to define EHR vendors as “commercial interests” in the same way that pharmaceutical or device manufacturers fit the definition.

AMIA states that although education on the use of EHR products is appropriate and relevant, it may not be appropriate for continuing education credit. The AMIA board asks CME organizations to “establish rules and processes by which they may support certified CME in a manner that is independent and unbiased,” just like drug and device companies must.

Knowing what I know about the ACCME, it will likely be some time before they respond to these calls to action. I’ll be curious whether they make a decision or whether they take it under advisement for further review. For many physicians who stay current in their specialties, it’s not hard to accrue all your required CME hours without relying on vendor-sponsored hours. Many of my colleagues have two to three times the number of mandatory hours simply but doing what they’re already doing to further their knowledge for patient care. I’ve got a couple of friends on vendor CME committees, and I’ll reach out and report back on what they have to say.

What do you think about EHR vendor-sponsored continuing medical education credits? Leave a comment or email me.

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EPtalk by Dr. Jayne 2/13/20

February 13, 2020 Dr. Jayne 2 Comments

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My HIMSS schedule planning is being hampered by some kind of bug in Outlook, where the time zones aren’t displaying correctly for HIMSS week. They are accurate the weeks before and after, but the week of the 8th is a mess. I suspect it has to do with the time change to DST, but it’s weird. I’ve asked a couple of other Outlook users and they’re not having the issue, which leaves me doing all kinds of shenanigans with my calendar to make sure I know when and where I need to be. If you have any tips on this, or are seeing it yourself, let me know. I doubt too many people run three time zones on their calendars, so it may be a fairly limited problem.

Signing up for events at HIMSS is becoming more complicated. Gone are the days when you could just attend vendor events as a mere HIMSS attendee. Citrix is requiring people to be “qualified” to attend and will get back to me in 48 hours to let me know if I’m on the list. Others such as Capital One / Ziegler are a little more accessible. One of the things I loved about HIStalkapalooza was that everyone was invited – there was a great mix of people which led to lots of interesting conversations. I respond to invitations with my real name and credentials, so I’m getting a feel for how the average attendee is handled.

I worked some unscheduled clinical time this week in order to cover a colleague with influenza. I was surprised that the EHR had been upgraded with no notification or explanation. Although the changes were minor, it created an unsettled feeling as you wondered what was different that you might be missing. Although some of the enhancements were nice, a few missed the mark in that they were only partial fixes to issues. Our vendor is going through some growing pains and I’ve heard good things are coming, so I’ll remain optimistic.

The lack of notification may be part of an overall change in communication patterns for the practice, and not necessarily for the better. I’d love for them to hire me to put on my standard “Effective Communication Strategies” workshop because they’re not doing a great job. In order to prevent people’s email from being inundated, they’ve gone from a “push” communication strategy to a “pull” one, and unfortunately, it’s not working.

When I do my workshop as a consultant, I walk organizations through the creation of a communications matrix, where they define the different kinds of communications, the audience, and how they should best be delivered. For some critical communications, such as how to handle the novel coronavirus (now named COVID-19 by the World Health Organization), you might want to communicate in multiple channels and blast the important items to people via text or email.

Instead, our practice leadership sent an email that essentially said, “So that we don’t send you emails that would quickly become outdated, we’ve put everything on a website that you should check daily.” Unfortunately, the website doesn’t have a clear section that spells out “what’s new,” which means providers have to read through the whole thing and try to figure out what has changed since the last update. It’s not a terribly effective way to communicate key information in a rapidly evolving situation. I can pretty safely predict that people will just stop looking at it, much like they stopped looking at a quality improvement website that worked in the same way.

Several of my clients have reached out for advice on how to handle various aspects of the COVID-19 situation. If you’re not already freaked out about being exposed to germs because you’re part of the healthcare IT infrastructure, you might be when you hear the latest data. According to the Journal of Hospital Infection, coronaviruses can survive on surfaces for up to nine days, although the majority die after four or five days. Low temperatures and high humidity increase the lifespan. I wonder if vendors whose products include solutions for disinfection and sanitation will see an uptick in foot traffic at HIMSS.

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I was glad to see that National Coordinator for Health Information Technology Don Rucker called out the hospitals that signed Epic’s anti-interoperability rule letter. He notes that only three in 100 academic medical centers signed it. He went further to criticize one of the signers, saying, “One of the signers of the letter is known for taking thousands of patients to court. If you take someone to court, that information becomes public discovery. Their medical care is now public. It’s part of the court record… Looking at protecting privacy, we need to walk the walk here as we look at who is saying what and letter-writing campaigns.” It’s always good to look below the surface – sometimes what you find is pretty interesting.

In other news from ONC, the Health IT Advisory Committee (HITAC) is launching a new task force, the Intersection of Administrative and Clinical Data Task Force. It will focus on connecting data standards to improve interoperability, reducing clinician burden, and improving efficiency. Additional information on task forces is available on the HITAC website.

A recent article noted that little news has come out of Amazon, Berkshire Hathaway, and JPMorgan Chase’s Haven since its founding. It last issued a public statement in March 2019. We’ll have to see if there’s any buzz around or after HIMSS. If anyone has anything to share, feel free to reach out and we’ll keep you anonymous.

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If you’re still doing your Valentine’s Day shopping, there’s always the Samsung Galaxy X Flip phone, which launches on February 14 in the US. It’s got a slick one-inch OLED display on the cover that shows notifications when the phone is closed, and when the phone is open, you can use it as a full-screen or split-screen display for different apps. The screen is rated for 200,000 folds, which based on the phone habits of some teens I’ve seen lately, might last a year. Is $1,380 too much to pay for someone’s undying love and affection?

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Curbside Consult with Dr. Jayne 2/10/20

February 10, 2020 Dr. Jayne 2 Comments

I’ve had a crazy couple of weeks working on a big project that finally reached a major milestone. Now I feel like I’m operating in a bit of a vacuum. I’m taking a break from the clinical trenches for a while and will be doing some traveling.

I have to admit that I feel a little guilty about having a couple of weeks where I’m not operating under multiple timelines. I do pretty well with work-life balance, keeping track of how many hours I actually work compared to my capacity. It started as a way to make sure I could stay afloat financially without an actual employer, but I discovered it was also a reflection of how much non-productive time I had so that I could better reflect on what I was doing with that time.

When I applied for medical school, the majority of applicants went straight through from their undergraduate institutions to medical school. There were a handful of people in my college class who did research or something else for a year before applying, but often that was because they weren’t sure they wanted to go to medical school. The students I work with now typically take at least a year off between college and medical school applications. Many are doing research or looking for ways to distinguish themselves from the growing pool of applicants. Others are studying and prepping for the Medical College Admissions Test (MCAT) that they didn’t take as undergrads because they didn’t feel they had enough time to study. Still more are taking post-baccalaureate courses to make themselves look more competitive.

Most of my scribes fall into the “study and prep” group. We’ve had some thoughtful discussions about what it was like back in my day (I never thought I’d be saying that, but here I am) versus how it is for them now. Initially, I thought that having time before they went to medical school might make them more rounded and less stressed when they finally got there, but I’m finding that the extra year or two might be adding to the overall stress level as admissions become more competitive.

Many other things have changed in medical education. For example, work hour limits and other protections that were designed to try to make the process more humane for learners. Additionally, students are much more digitally enabled and technology savvy than we were when I was in school. I wonder what kind of impact the combination of changes will have on physician burnout down the line. Will they see the EHR and other systems more as tools or mere annoyances rather than as their arch enemies? Will technology be able to evolve with their expectations?

Expectations are so important when we consider how we perceive things. I recently had a phone interview with a potential clinical employer. He’s someone I know from a past employer and perhaps that made him a little too comfortable as we were chatting. He made some comments about some of the other candidates he had passed on interviewing, generally around what he considered a relative lack of work ethic compared to physicians of his age group. I’m a little younger than him training-wise, but not much.

I was floored by the fact that he was only offering two weeks of vacation plus three days of continuing education for his potential new partner, regardless of their experience. In our area, most of the health systems are offering new grads three weeks of vacation plus a full week of continuing ed time. He seemed unaware of the competition’s benefits, which again had me thinking about expectations and how they influence our thinking.

It was in that frame of mind that I read the recent JAMIA article on metrics for assessing physician activity using EHR log data. The authors believe that reporting standardized efficiency measures would help experts understand the environments in which physicians practice. I don’t disagree that data is important, but it doesn’t take into account data about the practice patterns that physicians had before and to which they continuously compare their current experience, whether consciously or unconsciously. We don’t have many measures of total charting / message time for each eight hours of scheduled patient time, except in practices that were forward-thinking and performed time studies and optimization exercises.

I’ve done operational efficiency projects for the better part of a decade, whether as part of an employed CMIO role or as a consultant. Many of the measures that the authors hope to manage are often best addressed by non-technology solutions. These have been around a long time, but practices continue to be resistant to implementing them:

  • Time spent prescribing and managing refills. I still see physicians who only prescribe medications a month at a time, or who won’t even give enough refills through the next anticipated office visit. Experts have long advised year-long refills for stable patients, yet this is still a struggle for many. I also see people unwilling to delegate refill authority to other clinicians, insisting on reviewing each request themselves.
  • Inbox time per eight hours of scheduled patient time. This is another area where operational issues can have an impact. Is the inbox overloaded because patients want appointments and can’t get them? Is the schedule double booked, or has the practice taken steps to manage its panel size so that those who want appointments can get them and aren’t forced to leave or send messages? Does the inbox contain remote patient monitoring information that could be handled by ancillary team members?
  • Time spent writing notes. I often see physicians who used paper templates or dictation macros in the paper / dictation world who won’t spend the time to create provider-specific defaults or templates within their EHR. I still do not understand why it is so difficult to convince these providers that spending a little time will benefit them later.

Even though we may not have data on legacy work patterns, the authors pose some excellent research questions that are important for future research, including the impact of staffing ratios on various endpoints. They also note challenges with implementation of the measurements, including EHR idle time-outs, variable definitions of “work outside of work,” and the variability of prep work done prior to clinic sessions. They also noted that not all work is done in the EHR – clinicians spend time on the phone with patients and colleagues, have family meetings, complete FMLA and other paperwork, and otherwise interact with patients and the care team.

The authors are careful to note that data capture may lead to “unintended negative consequences” as physicians change their behaviors because they are being monitored. Perhaps they will write briefer notes or otherwise be less comprehensive than they might otherwise have been because they will be concerned about the appearance of inefficiency. They also are clear that they “do not suggest that these new measures be included as requirements in any federal reporting programs.”

As much as quantitative research is important, I’d love to see a greater focus on qualitative research with regards to clinicians’ perceptions and expectations. Do their past experiences and biases inordinately impact their use of technology? What level of impact do other forces have, such as documentation requirements, payer constraints on diagnostics and treatment, and government regulations? How much do various stressors impact our performance and our level of compassion for our patients? It would take time and resources to examine these questions.

What do you think about standardized metrics for assessing physician EHR activity? Leave a comment or email me.

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