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EPtalk by Dr. Jayne 5/13/21

May 13, 2021 Dr. Jayne No Comments

Not surprisingly, the big news around the virtual water cooler this week was the approval of the Pfizer COVID-19 vaccine for the 12- to 15-year-old age group. In my community, most of the health system vaccination sites began to schedule vaccination appointments for that group for Thursday and Friday in advance of the expected approval. Only the retail clinics held the line, and my guess is they were frantically updating websites Wednesday evening. Colleagues in several other states reported that vaccination sites weren’t waiting for the final CDC approval but took the FDA emergency use authorization as enough to go ahead and start vaccinating younger teens on Tuesday. It will be interesting to see what happens to vaccine rates now, with many parents wanting their children vaccinated so they can get “back to normal.”

Another boost to vaccination rates, particularly among young healthy men, might be this article that explores concerns about COVID-19 causing erectile dysfunction. Researchers at the University of Miami Miller School of Medicine found detectable viral RNA in the penile cells of COVID-19 positive patients at a substantial interval after the initial infection. They conclude that the same kinds of cellular dysfunction caused elsewhere by COVID-19 infections may be contributing to erectile dysfunction. I’ve been saying for a while now that this is a weird virus and we’re a long way from understanding exactly what it can do. I suspect this isn’t the last of the unusual complications that we’ll learn of.

Another journal article that crossed my desk this week should be near and dear to many healthcare IT professionals. Molecular Psychiatry published a piece describing how “Habitual coffee drinkers display a distinct pattern of brain functional connectivity.” Researchers used functional magnetic resonance imaging (fMRI) to assess brain changes. The findings support an association between coffee consumption, improved motor control, cognitive focus, and alertness. Similar changes could also be seen in the brains of non-coffee drinkers after consuming even a small amount of coffee. I’m not a huge coffee drinker, but do like an iced coffee from time to time, although too much tends to make my hands shake, which is not good when you have to sew people up for a living. Maybe I’ll be able to enjoy it more often now that I’m no longer in the urgent care trenches.

We’ve certainly moved into a new phase of the pandemic, and that’s the one where drug companies begin direct-to-consumer advertising for COVID-19 related treatments. Regeneron has started its advertising campaign for monoclonal antibodies. The advertisements are permissible under the FDA’s emergency use authorization, and four commercials have been developed. As with nearly every other drug ad, patients are told to “ask your doctor” about the treatment. We screened people for potential treatment at my former employer, and the reality was that very few patients qualified and even fewer actually wanted to go to the infusion center for a treatment. It will be interesting to see if the ads actually drive business.

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The HIMSS21 schedule for in-person general education sessions is now live. I went ahead and dropped the keynotes, exhibit hall times, and registration info on my calendar, but it’s hard to get excited about choosing sessions just yet. Many of my healthcare IT colleagues are still debating whether they’re going or not, wondering if the expense will be worth it, especially if they have to pay out of pocket. My local university is still on a travel ban as are several of my favorite vendors, so right now very few of my besties are planning to attend. Those of us going will make the most of it, though, and it will certainly be good to see people in person.

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Sometimes I run across products that are solutions in search of a problem, and I’m fairly certain the Q-Pad by vendor Qvin fits this description. The device is a menstrual pad with an embedded test strip used for laboratory-based hemoglobin A1c testing. The company differentiates itself based on needle-free blood testing without regard for the fact that patients who are in need of hemoglobin A1c testing also need a variety of blood tests that aren’t available on their platform. Like any good device vendor, the company provides a smartphone app. Direct-to-consumer pricing is available on a one-time, monthly, or quarterly basis despite the lack of evidence for random testing in the menstrual-age population. The website contains a video interview with the founder, who says the device appeals to the “quantified self” crowd.

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I’m a big fan of the Honor Flight Network and had the privilege of traveling on a flight with my favorite Korean War veteran. It’s an amazing experience that was curtailed by the COVID-19 pandemic, with only one flight going in 2020 before everything shut down. I was glad to see an outstanding application for virtual reality technology to help continuing honoring veterans, as T-Mobile partnered with Healium and the Honor Flight Network to virtually transport veterans to see their memorials in Washington, DC. Honor Flight is gearing up to restore the trips as soon as it is safe and practical, but the reality is that we will lose many of our WWII veterans before they can travel, and many more are not physically able to make the trip. Kudos to these organizations for their support of our veterans.

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Marketing folks of the world – I highly recommend testing your email blast software on a small distribution list before just cutting it loose. Clearly the email I got didn’t format as intended, and since it’s supposed to be coming from a communications specialist, it doesn’t inspire confidence.

For fans of “The Six Million Dollar Man,” the time for “bionic” eyes has arrived. Researchers at the Keck School of Medicine at the University of Southern California have created the Argus II to provide limited vision to blind individuals. Although it’s currently limited to helping people recognize shapes and patterns, they hope to eventually provide the ability to see colors and details.

What’s your favorite technology from vintage TV that has become a reality, or that you can’t wait to see some day? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/10/21

May 10, 2021 Dr. Jayne No Comments

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As the healthcare industry begins to shift more towards telehealth and non-office-based management strategies, there’s a greater need for devices that patients can use at home or on the go. I’ve long been a fan of my Garmin watch, which tracks my daily steps, maps my runs, and reminds me to get moving when I’ve been sitting too long. Beyond that, I’ve not gotten too deep into the quantified self movement. I’m more motivated by being able to watch frivolous Netflix on the treadmill than I am by tracking performance numbers, so I haven’t needed that external reinforcement.

At a recent medical visit, I had an uncharacteristically high blood pressure reading, which I mostly attributed to the fact that I was about to be stuck with a bunch of needles. However, as a student of data and given my family history, I figured it might be time to invest in my own home blood pressure monitor to make sure nothing more sinister was going on. Plus, as a physician practicing telehealth and relying on patients providing their own data, it would give me some visibility into the experiences my patients might be having.

A couple of my physician friends have hypertension and monitor themselves religiously, so I asked around the virtual physician lounge for recommendations. Nearly everyone recommended the Withings BPM Connect, which is supposed to be easy to use and compact. It also supports both Bluetooth and Wi-Fi connectivity. I’ve had some experience with the Withings scales as part of a congestive heart failure project I did for a health system client, so decided to take their recommendation. Through the wonders of internet commerce, I was able to have one delivered to my home quickly and was eager to get it up and running. Since I was evaluating the device from different perspectives – patient, clinician, and informaticist – I had a lot of different elements I wanted to look at.

The first challenge with the device was the printed instructions that came with it. The user manual appeared to be printed on environmentally friendly brown paper. Although it’s a good idea from a sustainability standpoint, for users of a certain age where contrast is important for printed materials, it was a bust. I became one of those folks that uses the flashlight function on their phone just to read it, which made one of the younger members of my household laugh. Rather than watch me struggle with it, he proceeded to take the manual and read the German version to me, seeing if I could figure it out from the bits and pieces of the language that I understand. Based on that experience, I can see how the written documentation alone would be challenging to older users or those with low vision.

Eventually I got to the point where I needed to pair it with my phone, which was an adventure in itself. I downloaded the app easily and followed the instructions to connect. That’s where things started heading downhill. After what seemed like an interminably long “trying to connect” screen, it failed to connect. I repeated the process multiple times with the same results. Even though my phone identified the cuff as an available device from within the phone’s connectivity settings, it wouldn’t connect. In true IT fashion, I rebooted the phone and tried again.

This time I was able to get it to connect, and a firmware upgrade was applied to the cuff. Unfortunately, it immediately disconnected and wouldn’t reconnect. Multiple trips through the “trying to connect” screen and a couple more reboots later, I finally got it to connect to the phone. Eventually it also allowed me to connect the cuff to my home Wi-Fi network and I was ready to try to take an actual blood pressure reading. By this point, though, I had a fairly ripping headache and was a bit frustrating, so I expected a less-than-perfect result. The cuff itself is fairly easy to put on and take off, although patients with less dexterity in their arms or hands might benefit from having some assistance.

The Withings Health Mate app has a helpful video for those who have never taken a blood pressure that explains how you should sit quietly for five minutes and make sure your arm is supported at the level of your heart prior to taking a reading. As a matter of logistics, these steps are almost never followed at medical offices, which re-emphasizes the role home monitoring devices might play in helping patients and physicians obtain accurate results. The cuff itself has two modes – one where a single blood pressure is taken, and one that takes three blood pressures over a short period of time and then averages the results. I decided three data points were better than one and gave it a whirl. The LED display was easy to read and includes your name in the final display, which is helpful since the device will support up to eight users.

The Health Mate app does a nice job of graphing your results as well as displaying your latest measurements and highest and lowest values. I found it annoying, though, that it keeps asking me to connect to Google Fit, which I have no desire to do. There didn’t seem to be a way to get it the reminder to snooze, so we’ll have to see if it keeps coming back. The app offers functionality to send patient data to the physician, but I haven’t experimented with that yet. The device advertises six months of use on a single charge (via USB), but doesn’t specify whether that’s one person checking blood pressure daily, or some other combination of variables. As a physician, the timeframe we recommend for BP checks varies from person to person, and sometimes it’s not ideal for patients to check it too often. The app does offer patient-facing reminders to encourage regular measurements.

Withings advertises the BPM Connect as “travel friendly” and I agree it’s rather compact – the cuff wraps tightly around the display unit and it’s about the same diameter as a flat iron used for hairstyling, although much shorter. The company also sells a protective travel case for $29.95 but I don’t think it’s necessary, unless you’re tossing it in a gym bag where it might come into contact with sweaty or dirty clothes or where it might be rattling around with something that might catch on the Velcro.

I got a kick out of reading some of the reviews on the Withings website. One noted that the device “feels like a premium home health product with soft, heathered fabric around the outside and a soft-touch plastic to the tube…” I guess I didn’t think much about the fabric or the feel of the plastic since I’m used to conventional nylon office-style blood pressure cuffs, but that might be an important aesthetic for some users. My absolute favorite customer review was a product manager’s wildest dream, stating, “I never thought I’d buy into the ecosystem so much, but they are *genuinely* delighting me with their user experience.”

My initial user experience was less than delightful, and had I been someone who was less tech savvy, I might have given up. It definitely felt like one of those moments where people call their grandchildren and ask them for help. Fortunately, even with the aggravation with the connectivity, my blood pressure wasn’t all that exciting and I’m glad to know I still have a resting heart rate that borders on being abnormally slow. We’ll have to see how it performs over the next several months and whether the old adage about what gets measured gets managed applies.

What’s your favorite piece of home monitoring equipment? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/6/21

May 6, 2021 Dr. Jayne No Comments

I was intrigued by an article in the Journal of the American Medical Informatics Association (JAMIA) that looked at “Public vs. Physician Views of Liability for Artificial Intelligence in Health Care.” The authors found that although a majority of both physicians and the public believe that physicians should be liable for errors occurring during AI-assisted care, the public was more likely to do so (66% versus 57%). Compared to the public, physicians were more likely to believe that both vendors and healthcare organizations should be liable. In summarizing the background, the authors note that there are more than 60 AI-based algorithms and devices approved by the US Food and Drug Administration. Although they didn’t find significant differences across specialties, they only surveyed internal medicine physicians, oncologists, and radiologists. The number of physicians surveyed was also fairly small – 750 physicians were invited, but only 192 responded.

Another article, also in JAMIA, reported on interviews with medical scribes and how their work might reduce clinician burnout. I’ve got a fair amount of experience with scribes, from using them in practice to helping health systems set up scribe training programs. It was a fairly small study with only 32 interviews. The authors looked at different types of clinical tasks from documenting visit notes to tracking down clinical information. I liked the way they referred to clinicians delegating these tasks to their scribes as “outsourcing.” Especially if you have an EHR that makes finding information challenging, as many of us do, it’s a heck of a lot easier to ask your scribe “what was her blood pressure at the last visit?” versus having to dig for it yourself, especially if you’re on the high-volume hamster wheel where you’re asking patients questions and synthesizing information at the same time you are conducting your examination.

Unfortunately, some organizations don’t embrace scribes fully and leave it up to individual physicians to determine if they want or need a scribe, which usually means that the cost of hiring, training, and using the scribe falls entirely on the single physician. Practices that incorporate scribes as part of the overall infrastructure can see additional benefit, including being able to have appropriately-trained scribes help perform clinical tasks (such as rooming patients or helping handle phone calls) during any downtime where the physician may be doing work that isn’t best supported by a scribe. In my soon-to-be-departed clinical gig, it was also a plus that nearly all the scribes were doing a gap year between undergraduate studies and hopefully being admitted to medical school or a physician assistant program. Across the board, they are a highly motivated bunch who seem to genuinely want to learn about clinical care and the health system. Unfortunately, that meant that nearly the entire scribe workforce turns over every spring and summer, which is a challenge.

JAMIA hit the trifecta with an article on reducing EHR-related burnout through a “personalized efficiency program.” This is the kind of work I do as a consulting CMIO – helping organizations figure out not only how to technically optimize their EHR, but how to get providers to adopt time-saving workflows. There are a variety of strategies I like to use, so I was eager to hear what kind of offerings their efficiency program included. I felt validated in my approach – their individual coaching sessions included a focus on increasing EHR knowledge and maximizing user-level customization. In the study, a good number of providers participated in the optimization sessions, 87%. However, not all participants returned both the pre-survey and post-survey, so they weren’t included in the research sample.

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This week’s Health IT Buzz blog focused on sunsetting the interoperability roadmap. It was a nice walk down memory lane, thinking back to 2015 when the roadmap was introduced and sparked plenty of comments before it was finalized. It made plenty of people nervous, especially the parts that talked about patients having expanded access to their records. Many of the milestones it laid out have been achieved. The last pandemic-filled year has been impactful on health IT and has accelerated numerous interoperability projects. Although the new developments are appreciated, let’s hope it doesn’t take a pandemic to continue moving organizations and the industry in the right direction.

As a big-time science nerd, I was excited to see that the team at Fermilab published an article that they have successfully achieved sustained, high-fidelity quantum teleportation. It’s a step closer to a quantum internet, which would revolutionize how we use and manage data. The research team — made up of folks from Fermilab, AT&T, Caltech, Harvard University, the University of Calgary, and the NASA Jet Propulsion Laboratory — plans to continue to upgrade its systems over the next several months to further refine its results.

May is Mental Health Awareness Month. The ongoing pandemic has certainly brought discussion of many mental health issues to the forefront. Among my patients, I’ve seen increases in depression, anxiety, and insomnia. Many people have their symptoms compounded by difficulty accessing both primary care and psychiatric services, and although I know the urgent care isn’t the best place to handle those issues, we can typically help connect patients with additional resources and supports. A good number of my colleagues have had their own mental health struggles during the past year. Due to the challenges with physicians having to report mental health treatment in many states, a number of them are untreated or undertreated, and that is a sad commentary on healthcare in the US and our willingness to understand that everyone is human.

I’m glad we are past the panic attack-inducing days of the early pandemic, when we didn’t know what we were dealing with or whether we would make it out the other side. There are a number of physicians and other clinicians who may be whole in body but not in spirit, and I hope the health system starts to look seriously at what needs to be done to help them heal. In the short term, I see a lot of them leaving medicine. I’m curious whether other countries that don’t have the same stressors are seeing the same outcomes. In the immortal words of U2, “we get to carry each other.” If you sense your colleagues are in need of help, do what you can to get them to a better place.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/3/21

May 3, 2021 Dr. Jayne No Comments

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HIMSS invited me to complete “a quick five-question survey” regarding attendance at HIMSS21. I’m no stranger to research around user and consumer needs, so I was curious what kinds of questions they would ask. The first question was “What are you most looking forward to at HIMSS21?” Choices included: attending world-class sessions, building new relationships, finding tech solutions, reuniting with colleagues, or other.

In the past, I’ve struggled with the quality of sessions. Part of that is due to HIMSS-related factors, including the long lead time between when the submissions are due and the actual conference. Presenters can’t show off the latest and greatest when they have to declare their intentions 10 months prior to the conference. We’ll have to see what that looks like this time since HIMSS20 was canceled and HIMSS21 was pushed back. To be honest, I haven’t paid much attention to the submission process or timeline because I wasn’t sure this year’s conference was even going to happen.

The second question was about professional goals, and to be sure, “getting material for everyone’s favorite healthcare IT blog and looking for sassy shoes” was not a choice. Maybe I should have selected the “other” block and done that as a write-in, but knowing HIMSS, there was probably tracking information attached and I wouldn’t want to give up my anonymity.

The options for this question included: attaining actionable education, building peer connections, developing my career, earning CE credits, experiencing innovation, finding new partnerships, job seeking, and problem solving. I’m not sure how well HIMSS21 will be able to deliver on some of these options given the relatively small number of exhibitors and the hybrid virtual / in-person format. Not to mention that many organizations are still under travel bans. A number of my favorite CMIOs aren’t going to be able to attend in-person for that reason. Most of the big exhibitors are staying home as well.

The third question was whether we’ve booked hotels yet, which I’ve done. I’ll be staying at one of the connected conference hotels so I can minimize my time outdoors in Las Vegas in August. I’m not fond of the heat even when people remind me “it’s a dry heat” and the best people watching in Las Vegas happens after the sun goes down, anyway. There are supposed to be sessions at Caesar’s which would involve a trip outside, so it may not help as much as I thought, but I’m playing the odds as most gamblers do.

The final question was “How can HIMSS staff make your conference experience exemplary?” At this point and specific to HIMSS21, I really don’t know. It’s going to be an interesting year and we just have to keep open minds. Thinking more broadly though, HIMSS needs to consider lowing the attendance costs for individual attendees. It’s a relatively pricey conference considering the minimal return on investment for those of us who aren’t attached to institutions that are footing the bill. Plus, as we all know, nearly all healthcare costs are ultimately passed on to the patient in one way or another, and it’s really difficult to justify attending at times.

I precepted a nursing student today, and due to a relatively slow urgent care day, she didn’t get a lot of clinical experience. She did learn how to work through an EHR downtime, though, and I was grateful that we weren’t completely slammed with patients when it crashed. Fortunately, this outage lasted less than half an hour and we still had access to our PACS, so we could keep seeing patients. It was nostalgic to pull out the paper script pad, though. She also learned a fair amount about healthcare finance, as one of my clinical assistants is working on a health administration certificate and wanted to pick my brain about operational structures at for-profit versus not-for-profit organizations.

Most people that fall into the student category tend to be younger and have had fewer interactions with the healthcare system. They have not experienced the sticker shock of receiving an out-of-network explanation of benefits statement for a hospitalization and may not have had the experience of receiving multiple bills from all the different vendors and clinicians involved in a diagnostic procedure. Most people go into healthcare fields because they want to help patients, and I think understanding the sausage-making that goes on behind the scenes is critical to their education. Understanding the costs of healthcare helps them appreciate why patients may not fill their prescriptions or make the specialist appointments that we recommend.

We also had a good conversation about health insurance and how most patients have their coverage tied to their employers, which is something most students who are still on their parents’ coverage or using student health services at their universities might not understand. She was surprised to learn that sometimes patients stay in jobs they don’t like strictly because of insurance benefits and not wanting to change because of the risk of having to change to new providers or a different care team just because their coverage changes. My state requires all high school graduates to take a personal finance class, and although the curriculum covers things like homeowners’ insurance and auto insurance, there’s not much discussion of healthcare expenses. Since I’ll have some free time after I finish up my last urgent care shift on Friday, maybe I should volunteer to teach a session on understanding health insurance, how to read an explanation of benefits statement, how medical billing works, and how to navigate referrals and prior authorizations. Failure to understand those elements can have an impact on your personal finances, indeed.

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Back to thinking about educational conferences, my friends at West Virginia University are offering a seminar that seems like a much better use of limited conference dollars, focusing on point-of-care ultrasound. It’s being hosted at a resort that caters to whitewater rafting enthusiasts, and attendees can take advantage of the whitewater at the New River Gorge National Park. Having run this section of the river in 2019, I would rather be there than Las Vegas. See if you can spot me in the photo – I’m the one in the helmet.

What are your favorite conference locales? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/29/21

April 29, 2021 Dr. Jayne No Comments

The big news around the virtual physician lounge this week is the decline in COVID-19 vaccination rates. President Biden is pushing for small businesses to make use of tax credits to support paid time off for employees seeking vaccination.

At this point, anything we can do to incentivize people to become vaccinated is welcome. The more the virus continues to spread, the more it can mutate, which counters the progress we’ve made. Some employers understand this. Supermarket chain Kroger has offered cash incentive payments for employee vaccinations, as has hospital Houston Methodist and several health systems. Some decry this as coercion, but the reality is that someone won’t get a vaccine if they really don’t want one, based on a $100 cash payment. The incentives are also rewarding those who do the right thing, as additional vaccinations help strengthen the workforce and reduce burden on co-workers.

I remember when I received my first vaccine, we thought it would really be something if we got a million doses in arms. That would really be an indicator of safety and effectiveness. Now that we’re at the 200 million dose point, it’s clear that the risks of the vaccines are minimal. Even with the questions around the Johnson & Johnson vaccine and the potential for increased blood clots, these vaccines are remarkably safe and effective. Based on what I’ve seen with the COVID-19 illness in my patients, the vaccine is much more desirable. On the home front, I’m just waiting on a couple of second doses within my family, and then I’ll really be able to breathe a sigh of relief. It’s been a long year, for sure.

Healthcare workers have been at the tip of the spear, not only fighting the pandemic, but also dealing with increasing numbers of unstable patients and sometimes public hostility. The Journal of the American Medical Association published a recent article on “Navigating Attacks Against Health Care Workers in the COVID-19 Era.” Initially, health workers were on the receiving end of discrimination as well as violence. Several colleagues were asked not to attend church or told that their children couldn’t participate in activities because they were potentially in contact with COVID-19 patients. There are also social media attacks – I’ve experienced them personally, although what I’ve encountered has been on the mild side compared to that experienced by others.

During my career, I’ve experienced patients ranging from “creepy stalker” to verbally abusive to downright threatening. Fortunately, the only physical threats have occurred within the hospital emergency department, so I had security staff at the ready. Still, there’s always that worry that a disgruntled patient or drug seeker will be waiting for you at the end of your shift. Hospitals and larger facilities may have security staff that can help mitigate this risk, but for healthcare workers in small practices or isolated environments, we’re pretty much left with the buddy system to help keep each other safe.

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Uber sent me an email this week, inviting me to schedule my COVID-19 vaccine at a nearby Walgreens through the Uber app, while also being able to book a ride. Of course there were caveats about vaccine availability and whether Uber Reserve service is available in my area, but it’s still a good option for people who might not otherwise be able to get a vaccine scheduled. In my area right now, there is an overwhelming surplus of vaccines and a lot of hesitancy, so anything that gets people to think about the process is okay in my book.

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I was excited to hear that Meditech is integrating genomics into its EHR. If you are an EHR vendor thinking about incorporating it, there are some serious options not only for documenting the data for how they enable clinicians to use it. The most basic need is to be able to document specific genes that patients have in a discrete fashion so that they can be used by clinical decision support algorithms. That’s critical for those genes associated with diseases where the mere presence of the gene changes the need for preventive screenings or management. Systems need to be able to track what type of genes are present, whether they are sex linked or not, and whether patients have a single copy or two copies of a given mutation. They also need to be flexible enough to manage new discoveries, such as when a gene is found to have a new level of clinical importance.

For its Expanse Genomics solution, Meditech is partnering with First Databank. To be honest, I didn’t know how far First Databank had gotten into the world of genomics. I always enjoy stopping by the FDB booth at HIMSS and remember vaguely hearing about them moving into pharmacogenomics. Certainly, some specialties are going to be more drawn to the value of integrating genomics than others. Many of my primary care colleagues are concerned about being able to keep up with the basics of making sure all their patients are receiving preventive screenings and that diagnoses are managed optimally, let alone being able to manage the impact of genomics on precision medicine.

I was particularly excited to hear about the Expanse solution being able to import genomic data and integrate it into the patient record in what sounds like a discrete fashion. My own recent genomic results are sitting in a PDF within the chart and aren’t even accessible to me as a patient through the patient portal. My physician was supposed to mail me a copy (snail mail – shocking, I know) but the results never arrived, so they did send me a PDF version. Good thing, since when I look in the patient portal, it just says “see outside report.” If my physician’s EHR can’t even display the results, there’s no way it can use them to tell me how often I should get a colonoscopy or how my risk changes depending on what is found during the procedure.

It will be interesting to see how long it takes other EHR vendors to get on board with a similar solution, as well as how long it will take existing Meditech clients to embrace the new content.

How is your system currently handling genomics? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/26/21

April 26, 2021 Dr. Jayne 2 Comments

Even though I’m a relative insider, I read HIStalk regularly so I can keep up. The recent Monday Morning Update contained a couple of reader comments that really got me thinking. The first was a mention of healthcare costs and the technologies that promise to lower them. Mr. H noted that “healthcare savings rarely trickle down to the actual patients – they just swell the profits and executive payroll of billion-dollar health systems, insurers, and employers…” Based on my experiences over the last few years, I have to say I agree.

Payers and patients alike are drawn in by the convenience and relative cost savings of certain care venues, such as urgent care centers. The marketing around this usually involves the fact that they are “cheaper than the emergency room,” which although true, doesn’t necessarily make them the most economical venue. My soon-to-be-former urgent care employer posts charges that are typically one-sixth that of what you would see for similar services delivered in a hospital emergency department. That seems like a good deal until you realize that the services are still significantly more expensive than they would be if they were delivered by a primary care physician.

Due to the care setting and the need to practice more defensive medicine than that practiced by primary physicians, patients are likely to receive more services than they would in a lower-acuity environment. As an independent facility, we don’t have access to patients’ recent labs or tests unless they want to hand us their phones so we can access the patient-side MyChart accounts. We also don’t know the patients as well as their primary physicians, so we don’t know how likely they are to follow up as we recommend, so we might recommend subspecialty follow up as a backup plan when there might be more cost-effective options. Patients certainly have higher up-front costs with co-pays when they visit urgent care rather than a primary physician, and although it’s cheaper than the emergency department, it costs more than it needs to.

Although we hoped price transparency would help drive patients to more economical care settings, we failed to fully understand how patients value convenience. There are certain conditions that need to be managed immediately, such as lacerations or serious injuries, but the vast majority of patients seen in our urgent care could be managed within a day or two by a primary physician with no difference in outcome for the patients. However, patients typically don’t want to wait. Patients are also concerned about access issues and even getting in to see their primary physician since there’s not only a shortage of appointments, but of providers in general. Our culture is one of instant gratification and patients want their problems addressed right away. Sometimes it seems strange, though, because they often haven’t even tried over-the-counter remedies that might have helped them before making the decision to seek care.

That ties nicely to the second reader comment, about the US Food and Drug Administration requiring prescriptions for many items despite the fact that they’re fairly straightforward or even available without a prescription in other countries. I agree with Mr. H that the need for prescriptions has driven growth in telehealth and online pharmacies, who end up becoming de facto prescription mills because they rarely deny the patient’s request. Even as a face-to-face physician, taking a solid history and performing a thorough physical exam doesn’t typically change the outcome when a patient with sporadic bladder infections and early minimal symptoms comes in asking for antibiotics or when a parent brings in a symptom-free child with a COVID-19 exposure. Now that we’re more than a year into the pandemic, we are just getting to the point where patients can buy testing kits over the counter without a prescription. It remains to be seen whether that will make any difference in how the pandemic rolls forward.

Especially at the beginning of the pandemic, and through the first couple of peaks, in the absence of over-the-counter testing, it made sense to have large-scale clinics that would test patients based on a standing order rather than having patients see their own physicians. Now that most of those clinics are closed, at least in my area, patients are forced into the urgent care system due to lack of options. A friend shared her husband’s Explanation of Benefits with me for a recent COVID-19 test. The charge was $1,900, which is absurd. This included the physician visit, the facility fee tacked on by the hospital since it owns the urgent care, and the cost of testing for not only COVID-19, but also influenza. Due to having a fever in the office and not having taken any medications for it, the patient was also charged an exorbitant amount for a couple of ibuprofen tablets. To add insult to injury, her husband went to the “wrong” urgent care and it was out of network, so they’re on the hook for the full amount of the charges without any payer-negotiated discount.

It certainly would be a lot cheaper if we had a viable public health infrastructure and could channel these patients appropriately, not only to reduce their costs, but the overall cost to the nation. Or in the absence of that, if we could start to manage people using less-costly resources, such as over-the-counter testing. But as long as the big healthcare systems and for-profit organizations stand to lose out on what they perceive as their piece of the pie, it will be difficult to truly drive change no matter what technologies we create. Even though many of us think disruptive technologies are cool, they scare the living daylights out of good portions of the healthcare industry.

Still, I’ll keep plying the clinical informatics trade in the patient engagement sector and in the telehealth trenches. Even if we’re making incremental change, it’s still movement in the right direction. I’ll also keep lobbying to address some of the fundamental issues, such as the shortage of primary care physicians and lack of support for their efforts. I’ll also continue to advocate for increased funding for public health infrastructure and the technology needed to support population-based health.

What are your thoughts on healthcare savings being pushed to the patients, or on increased availability of over the counter products? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/22/21

April 22, 2021 Dr. Jayne 2 Comments

Clinical informaticists and genomics experts are excited about the recent announcement that the US will spend $1.7 billion to create a national network to track coronavirus variants. The main components of the plan include funding to help the CDC and state health agencies expand gene mapping; identification of six academic centers to research gene-based surveillance; and creation of a National Bioinformatics Infrastructure for sharing and analysis of data around emerging pathogens. The proposed budget is significant in that it provides funding to build systems for the future, not just for the current crisis. I look forward to seeing the transformative discoveries that could be produced by this kind of initiative.

Healthcare workers have been significantly impacted by the COVID-19 pandemic, whether it’s physically, emotionally, or economically. A research letter in the Journal of the American Medical Association looks at symptoms and functional impairments tjat are found in healthcare workers who had mild cases of COVID-19. More than a quarter of patients who had the disease had at least one moderate to severe symptom that lasted for at least two months, while 15% reported at least one moderate to severe symptom that lasted for at least eight months. The most common symptoms were fatigue, shortness of breath, and change in the senses of taste or smell. The study mentioned in the letter did have some limitations, but since healthcare workers became infected on the leading edge of the pandemic, they do make an interesting research population. It will be interesting to see the percentage of subjects who continue to have long-term symptoms and what kinds of interventions might help people recover more quickly.

The American Medical Association offers up some tips on how physicians can improve their telehealth skills. The issues they cite, such as eye contact and lighting, continue to be problematic, not only for physicians, but for many of the video meetings I attend on a daily basis. With this in mind, I offer up Dr. Jayne’s tips for successful video calls:

  • Make sure your camera is stationary. Use a stand, prop it up, put it on a table, but don’t let it move during the call. I continue to get vertigo when people’s cameras are bouncing around, particularly when it’s obvious they have their laptop balanced on their thighs. The worst is when people walk around the house with the camera on. Pro tip: no one wants to see your laundry baskets.
  • Ensure that the camera is at a good height for eye contact. I’ve seen up enough people’s noses in the last 13 months that I’m considering a second career as an ear, nose, and throat specialist. I also can recognize the office spaces of many of my colleagues just by their ceiling fans.
  • Figure out your lighting and your background. If you’re sitting in the shadows, it can be distracting. Having a window behind you isn’t generally a good idea unless you have an additional light source in front of you to balance it out. You don’t have to buy anything special – I’m repurposing a floor lamp that I purchased for sewing to help even out the lighting when I get too much natural light coming from the wrong direction.
  • Check your microphone. Look at the audio settings within your meeting app and make sure your microphone isn’t set so low that it can’t pick up your voice. Experiment with background noise reduction settings if excess noise is an issue in your workspace. Some of the conferencing platforms have added fairly sophisticated settings that can allow you to adjust these settings with some specificity. I recently attended an all-Zoom musical recital, and you could really tell who followed the instructions to configure their accounts and who didn’t.
  • Keep any battery-powered accessories charged and have a backup plan. I’m so tired of people’s headsets dying on afternoon calls.
  • If you’re going to use in-app backgrounds, make sure they work technically and professionally. Some app/background combinations cause weird video artifacts like hairstyles disappearing or making it look like you’re just a disembodied face. Consider neutral choices – although being on the bridge of the Enterprise might seem cool, your clients might not share your enthusiasm. If using personal pictures or designs for backgrounds, make sure they’re professional. I recently saw a “taco Tuesday” themed background that was highly offensive and had to have a sidebar conversation with the presenter.
  • If you’re going to share your screen, make sure you understand how it works if you have multiple monitors, multiple windows, or multiple apps open. If you’re sharing a video with sound, be sure you know how to make it work. Practice is a good idea! And to be safe, make sure any browser tabs that you don’t want the audience to see are closed. I’ve seen more than my share of cringeworthy content, including a couple of things I will never be able to unsee.
  • By this point in the game, it should go without saying: LEARN HOW TO USE THE MUTE BUTTON. We all have those moments where we forget to unmute ourselves and wind up talking into the void, and I understand. I’m with you. But when the lawn service appears outside your window or family members have invaded your space, be considerate enough to mute before someone has to ask you to do so.

Of course, this last bullet point goes for non-video calls as well. If you’re not sure about making the most of your conferencing tools, don’t be shy about asking for help. Especially if your struggles negatively impact the meetings you attend, your co-workers will be grateful.

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Many of us in healthcare IT are science nerds in general and have been watching the adventures of NASA’s Ingenuity Mars Helicopter in anticipation of the first powered, controlled flight on another planet. After a delay during a test sequence, the four-pound helicopter took flight on Monday. Although Ingenuity’s first flight was only 39 seconds, that’s three times longer than the first flight undertaken by the Wright Brothers. The helicopter paid tribute by carrying a piece of fabric from the original Wright flyer. Science is cool, y’all.

What scientific advancements do you think hold the most promise for humanity? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/19/21

April 19, 2021 Dr. Jayne No Comments

I’m less than three weeks from departing my clinical work at urgent care. My employer has been shockingly silent since I gave notice, and at times I struggle to decide if that’s passive-aggressive or just benign neglect. (I’m pretty sure not getting a bonus since then is passive-aggressive, but I’m letting that go.)

In the absence of any communication regarding a formal off-boarding process, I’ve started telling people and saying my goodbyes, since the shiftwork nature of our schedules means that I won’t be seeing most of the people I work with again before I leave. It’s been an interesting experience, because when I share the news, lots of people are admitting that they, too are leaving. Hopefully a not insignificant exodus will send a message to the leadership, but I doubt they will take it as anything that would mean they need to change how they operate.

The in-the-trenches teams I have worked with have been topnotch, and unlike other places I’ve worked, I can say honestly that there have only been two people that I’d never want to work with again. Both of them quickly departed the company, which is a testament to the leadership’s fail-fast ethos.

However, we’ve lost dozens of good people over the last year. On the provider side, most of those who left went to other provider jobs in the same metropolitan area, usually with eight-hour shifts instead of 12-hour days (which always end up being 13 somehow) or more predictable schedules rather than a constant rotation. In most other urgent care or emergency settings, a provider might work at a couple of facilities rather than having the potential of being sent to 30 different locations over a 40-mile radius. Several became hospitalists or tele-ICU practitioners.

Among the support staff, reasons for leaving were mixed. Many of our scribes went on to medical school or physician assistant school, and some of those who failed to gain admission went off to do research or pursue graduate coursework. Some of our paramedics and clinical techs went back to school for additional training such as radiologic technology or were accepted to the fire academies. Others went to lower-acuity situations such as medical offices or social services agencies. Certainly not less stressful, but with fewer people potentially dying in front of you or needing an ambulance transfer to a Level 1 trauma center.

Quite a few left healthcare altogether, with one of the most common reasons being the difficulty in managing childcare with 12-hour shifts. The stress and risk of working in a healthcare facility in the middle of a global pandemic was certainly a factor for others who didn’t want to take a novel pathogen home to their families, especially when personal protective equipment was scarce. One of my favorite paramedics became a personal trainer and another went into real estate. A third one has a thriving beekeeping business as a side hustle and is expanding his colonies in the hopes of being able to get out of the clinical game.

I’m grateful that I stumbled into clinical informatics years ago because it gives me options that my purely clinical colleagues don’t have. My only experience was having been a “paperless practice” pilot and being able to tell a good story, and I’m grateful to the boss who took a chance on a young, sassy doctor who wanted to change the world through technology. I’ve learned quite a bit since then, especially that CMIOs are the “little bit country, little bit rock ‘n roll” of healthcare IT and we can play either genre depending on who we’re sitting with at the table. Sometimes we’re translators and sometimes we’re mediators. Other times we’re punching bags, but having been through medical residencies, most of us developed fairly thick skins.

In hindsight, clinical informatics has saved me more than once. The first time it allowed me to take an administrative role with a health system and to leave a toxic practice environment without having to pay for medical liability tail coverage, do a buy-out, or be subject to a non-compete clause. I literally transferred my patients to my partners and walked away. That was difficult at the time, but it was the right choice, not only professionally, but personally. It saved me again when the health system eliminated full-time informatics positions and I was able to do some work in the EHR industry. In recent years, it has allowed me to work for dozens of healthcare organizations, practices, and technology companies, where I’ve had a front row seat to the evolution of healthcare IT.

Not to mention that clinical informatics has allowed me to write for HIStalk for more than a decade now, which I could never have imagined when I sent Mr. H a “top 10 reasons you should hire me” email all those years ago. I’ll even admit I wrote it on a Blackberry, which should give me some kind of legacy IT street cred. Long live the touchscreen Blackberry Torch, which is still one of my all-time favorite pieces of technology, although I do love the outstanding screen resolution, sound, and functionality of my latest phone.

Clinical informatics has also allowed me to meet some of the most amazing people. How else could I rub shoulders with the biggest names in healthcare IT in the same bowling alley? (New Orleans, I miss you!) Or meet my not-so-secret, bowtie-wearing ONC crush? I’ve had some pretty entertaining “don’t ask, don’t tell” conversations with people who were trying to figure out if I might be Dr. Jayne and I appreciate your graciousness while I dodged your questions.

I’m hoping that the next decade brings equal adventures, although the industry has changed quite a bit over the last year. I’m pretty sure the wild and crazy HIMSS parties are over, and of course there will never be anything that will quite rival HIStalkapalooza. Still, it’s not about the parties. There is plenty of work to do to make healthcare IT a better place for our patients, our families, and the generations to come.

As one of my favorite southern writers, William Faulkner, once said: “You cannot swim for new horizons until you have courage to lose sight of the shore.” I’ve got my swim cap and my goggles and I’m ready to go. Who’s with me?

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/15/21

April 15, 2021 Dr. Jayne No Comments

It’s a good day to be a clinical informaticist when you can put your knowledge to work and try to help people understand complex clinical topics. The recent pause in administration of the Johnson & Johnson COVID-19 vaccine made today one of those days.

I put on my statistics hat and was able to deliver a quick educational webinar for one of my clients, helping the team understand the reason for the pause and what is being done to better understand the situation. The reported blood clots are cerebral venous sinus thromboses and present with low platelets in addition to the clot. They have occurred in women aged 18 to 48 within two weeks of vaccination, so we should be able to look at administration data to watch those patients more closely. Should our clinicians suspect one of these potentially vaccine-related clots, the treatment is significantly different than that for a “regular” blood clot, so we’re starting to talk about clinical decision support tools to make sure physicians check vaccine status before giving a potentially harmful drug. For my family members who don’t understand what I do when I’m not “being a regular doctor,” this is it.

When I sat for my clinical informatics board exam in 2014, a significant part of the potential content was in the realm of public health informatics. If we’ve learned nothing else during the COVID-19 pandemic, it’s that shortchanging funding for public health hasn’t done anyone much good. The Centers for Disease Control and Prevention released annual sexually transmitted disease surveillance data for 2019, and for the sixth straight year, diseases are at an all-time high. More than 2.5 million cases of chlamydia, gonorrhea, and syphilis were reported. Although the CDC data is older, we definitely saw a boom in STDs in 2020 especially during the initial lockdown phases of the pandemic.

It’s clear that “six feet apart” means different things to different people, but it’s always good to see the visits, because it means people are being tested and treated. People underestimate the impact of STDs and their unintended consequences. While syphilis is up 74% from 2015, congenital syphilis (passed from infected mothers to their babies) is up 279%. Understanding the power of data is a big part of what I do and I’m glad to be in clinical informatics.

Since the recent requirement to make hospital pricing data public, there have been allegations that organizations are using code to block pricing data from appearing in web searches. The House Energy and Commerce committee sent a letter earlier this week to the Department of Health and Human Services, asking for strict enforcement of the price transparency rules. The letter includes a citation from a recent analysis that shows more than 3,000 sites using search-blocking code. Given competing priorities, it remains to be seen how quickly any enforcement efforts will unfold. I’ve seen news stories where physicians who violate federal controlled substance rules are hauled out of their offices by the DEA, so seeing hospital administrators being escorted out in handcuffs would make my day.

With the recent regulations requiring release of visit notes to patients, a corresponding article in the Journal of the American Medical Informatics Association was timely. It focused on patient and family experiences after identifying what they perceive as serious errors in visit notes. The data was from a 2016 survey of patients at two academic medical centers, and although it wasn’t recent, many of the principles likely still apply today. The authors found that among more than 8,000 patients who read at least one note, 17% identified at least one mistake. More than 40% of those patients felt the mistake was serious, and 56% contacted their providers. Barriers to reporting perceived mistakes included not knowing how to do so and concerns about being thought of as a troublemaker. Study participants also had the opportunity to provide suggestions and recommendations for how medical centers can partner with patients and families.

Some of the suggestions included making sure that the reporting process is clear; reassuring patients that there will be no retribution; making reporting templates available; normalizing the idea of patient feedback; and otherwise making feedback easier for patients. Other suggestions included creating some kind of sign-off that would show that a patient had read and approved a note, or the ability for patients to easily add an addendum to a note. Given the resistance of physicians and healthcare organizations to releasing notes in the first place, I think it will be some time before there is support for the latter suggestions. Organizations are much more likely to make the reporting process clear or create reporting templates before they will let patients write in their own charts.

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I just finished reading a book about women doing unspeakable and unladylike things. “Women in White Coats” by Olivia Campbell chronicles the lives of some of the first women physicians in the US and the UK during the 1800s. The first female medical students had to endure all kinds of harassment, including being pelted with mud and physically blocked from attending class by their male classmates. Even after earning degrees and entering practice, they encountered landlords who refused to rent office space to them because it was felt their actions were unseemly. Despite the energy spent simply enduring the experience, early women physicians brought new perspectives to medicine, including a focus on public health, hygiene, and educating mothers on how to keep their families healthy. I enjoyed the read and it definitely added perspective to my career, especially since my medical school class was the first in my institution to have more women students than men and my residency class was all women.

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Rideshare service Uber has teamed up with PayPal, Walgreens, and the Local Initiatives Support Group to create the Vaccine Access Fund. The goal is providing free transportation for patients who don’t have the ability to get to a vaccine site. Funds will be directed to local nonprofits who are working to ensure vaccine access.

I have some friends working towards this locally and there are still significant barriers for some patients, including long shifts at work and lack of paid time off. There are also plenty of people juggling multiple jobs and that certainly doesn’t make it any easier. I’ve made jokes about this, but it’s starting to sound more like something that could actually work: a hybrid food truck / vaccine delivery platform. It would be an ideal way to raise interest and could be routed to a different workplace every day. Throw out some lawn chairs and a couple of pop-up shelters and your clients can enjoy sliders while completing their 15-minute observation period. Who’s with me?

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/12/21

April 12, 2021 Dr. Jayne 3 Comments

Lots of chatter in the hospital world this week following a recent Washington Post article that said wealthy hospitals were benefiting from COVID-19 provider relief funds. Some of the data coming out of the larger health systems has been pretty stunning, although hospitals claim they are still struggling. The Post published a letter to the editor from American Hospital Association President and CEO Rick Pollack, who alleged that the Post was cherry-picking data and that the original piece didn’t truly reflect the challenges that hospitals are facing.

I don’t disagree that the pandemic wreaked havoc on many healthcare organizations. For others, the availability of relief funds (including those from the Paycheck Protection Program) may have spurred spending in ways not exactly intended by the programs that provided them. Specific to the Paycheck Protection Program, whose funds came in the form of a potentially forgivable loan, there is certainly room to use the funds for things other than paychecks, since the forgiveness terms only require that 60% of the proceeds must be spent on payroll costs. The terms do require that “employee and compensation levels are maintained,” which certainly didn’t happen at my soon-to-be-former employer, who received $5.5 million in PPP funds but furloughed a good portion of the physicians and cut support staff shifts throughout the month of April 2020.

I was personally furloughed for almost two months with zero compensation, which led to some surprise when the local paper reported the company had taken that amount of PPP funding. Business has been booming since May 2020 with COVID-19 testing and an uptick in sick visits, and it didn’t stop the organization from opening additional locations even before it took on investors. Having personally experienced this type of accounting shenanigans (not to mention the absence of a paycheck for a while), I’m not that sympathetic when I see healthcare organizations posting sizable profits, yet crying poor when they’re called out on it. None of the employed nurses I know received raises during the pandemic, even though travel nurses were paid two to three times the typical nursing salary to provide coverage when times were tough. Organizations in my area weren’t generous with hazard pay or overtime, either.

I also find it somewhat questionable that certain health systems are charging administration fees for COVID-19 vaccines they are delivering, despite using mostly volunteer labor to perform the services. Even in the absence of labor and supply costs (since many of the supplies are provided with the vaccines) some of them can’t claim real estate or utility costs since they are using space donated by local businesses and community organizations. I could see some incremental technology costs if they’re needing computers to run the process, and I certainly support charging a fee if they’re paying people to administer the vaccines, but there are just so many elements of the process that feel a little off as the situation unfolds.

The pandemic has brought into focus many of the more unsavory aspects of our profit-driven healthcare non-system in the US. However, I don’t see a lot of forces aligning to try to change things in the short term. We’re still struggling with disparities in accessibility of in-person care, and even with telehealth we’re seeing that the greatest utilization was among patients in affluent or urban areas. A recent study looked at insurance claims for more than six million patients in the US who received coverage through employer-sponsored health plans. The data was drawn from January 2019 through July 2020 and represented nearly 200 employers across all 50 states. Where in-person patient visits declined at the onset of the pandemic, there was a significant (nearly 20 times) increase in telehealth services. Although telehealth didn’t fully offset the missed patient visits, it certainly helped many patients through the worst months.

The study found that the most notable increases in telehealth visits were in counties with low levels of poverty – 48 visits per 10,000 people. In comparison, counties with high levels of poverty averaged 15 visits per 10,000 people. There was also a difference comparing urban to rural areas – 50 versus 31 visits per 10,000 people, respectively. Pediatric virtual visits were also lower than adult visits (50 versus 65 visits per 10,000 people). The US government is trying to mitigate some of these factors, providing funding for increased broadband services to enable telehealth, including the Telehealth Broadband Pilot, which promises $8 million in improve connectivity in Alaska, Michigan, Texas, and West Virginia.

The authors conclude that there is much to be done to better understand the forces impacting telehealth utilization and to assess what the rates and disparities look like in the future. They call for greater reimbursement for telehealth services and updates to clinical guidelines to encourage telehealth practice.

I agree wholeheartedly, and additionally, I’d like to see more focus on how to make physicians successful with telehealth. Prior to the pandemic, the majority of our experience with telehealth was either with relatively minor acute problems, delivered either by large telehealth-specific vendors or through smaller health system pilots, or through facilitated subspecialty consultations where a patient and their “host” provider would consult remotely with a subspecialist, often at a tertiary center. As the pandemic unfolded, we saw the urgent care services delivering more primary care services, such as medication refills, while brick-and-mortar providers began to scale up their telehealth offerings.

Even as the pandemic eased last summer, a number of my colleagues continued to do more telehealth visits than in person, citing lack of personal protective equipment and the risk of infection. Even now that they’re vaccinated, they still haven’t returned to the office, and are delivering more and more primary care services remotely. That’s a dynamic that certainly needs exploration since the compensation models being used for those visits vary dramatically across organizations. I enjoy delivering telehealth care and am about to add virtual primary care to my bag of tricks, so we’ll see how that goes. I plan to offer some pretty non-traditional hours for my visits, so I’m curious to see what kind of patient demographic I attract. I have just about 80 hours of in-person care left on my schedule and am definitely ready for the next adventure.

What does your hospital or health system have to say about its profitability and acceptance of COVID-19 relief funds? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/8/21

April 8, 2021 Dr. Jayne 3 Comments

The big conversation around the virtual physician lounge this week was about the ONC information blocking rule that took effect this week. The majority of non-informaticist physicians who I spoke to really don’t understand what is required and have been receiving varying degrees of information from their employers and professional societies. The American Academy of Family Physicians had a nice article that summarized the situation for those who might not have been following for the last several years. AAFP points out the difference between HIPAA, which allows sharing of protected health information, and the new rule, which requires information sharing unless a short list of exceptions applies.

The exceptions identify when organizations can legitimately decline to fulfill a request for information, or when the surrounding procedures can be excepted. For most of the physicians I spoke with, their biggest use of the exceptions will be under the “do not harm” provision, which applies to adolescents being treated for things like pregnancy, sexual health issues, or mental health diagnoses. I was on an outstanding webinar earlier this week, presented by the American Medical Informatics Association. Natalie Pageler, MD, MEd from Stanford Children’s Health presented on strategies for managing the sharing of data within pediatric populations, where there are concerns not only about sensitive information, but also the capacity of the minor to consent for sharing. If you’re an AMIA member, it’s well worth tracking down the recording.

In the short term, organizations have to provide access to certain types of information: consultations, discharge summaries, histories, physical examination notes, imaging / laboratory / pathology reports, procedure notes, and progress notes. Additional types of information will be mandated in the fall of 2022, and penalties are in the future as well.

I have a few pointers for physicians who are concerned about patients reading their notes. First, write your plans like you would talk to a patient in the office. Avoid medical jargon and be clear on what you discussed with the patient and what the next steps might be. Physicians who dictate their notes in front of the patient have been doing this for decades. Second, make sure your office has a policy and/or process for when patients contact you with concerns about something they saw in a note. Should they come in for an appointment, schedule a telehealth visit, or wait for a return phone call? Decide this now before there’s a time-sensitive issue in front of you. I’m interested to hear from readers who have had significant fallout from this week’s change, so if you’ve got a great story, let me know.

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I always scoop up cut-rate Easter candy and take it to my clinical team, because every urgent care shift is better with the addition of chocolate. We joked about having to go to the local Walgreens to get the best selection of candy, and of course the topic turned to retail pharmacies and their role in COVID-19 vaccination policy. Pharmacy appointments are widely available in my area at the moment, which seems somewhat surprising since my office was recently allocated a measly 100 doses (yes, one hundred) of Johnson & Johnson vaccine despite the fact that we see 2,000 patients a day and could be a force to be reckoned with if the state decided to give us adequate vaccine.

Others have noted the issues with retail pharmacies playing such a big role, including Politico, which featured a discussion of pharmacies using vaccine-related patient data for marketing and other purposes. I was trying to find an appointment at Walgreens or Walmart for a family member, but was stopped when I found that they require you to register for an account before searching for vaccine appointments, which means they have your email address. I didn’t want to create a new account for them in case they already had one, and certainly didn’t want anything tied to my own email. Privacy and consumer advocates are calling on state governments to investigate how the data is used and are asking retail pharmacies to avoid using the data for marketing purposes. At this point, patients are more interested in getting a vaccine wherever they can and probably aren’t reading the fine print when they sign up. We’ll have to see how this plays out in the longer-term.

I had a recent client project around home monitoring of blood pressure, weight, and blood sugar, so I was excited to see this article in the Journal of the American Medical Informatics Association regarding the impact of patient-generated health data on clinician burnout. There is a ton of data out there that patients want to provide us – information from wearables, home glucose monitors, blood pressure cuffs, and more. Many physicians are terrified to let this information into their EHRs for fear it will overwhelm them with data as well as that it might increase their liability. For many conditions it’s not so much the individual data points that are important, but the ranges in which a patient’s data typically falls or how often they have outlier values. For certain conditions such as heart failure, however, individual daily values are important, and action has to be taken if there are dramatic changes from day to day.

The authors identified three factors that they believe contribute to burnout related to the integration of patient-generated health data within the EHR. These factors are time pressure, techno-stress, and workflow-related issues. They suggest mitigating techno-stress through several interventions: ensuring that healthcare providers have clear roles and responsibilities for monitoring and responding to patient-generated data; improving the usability of data integrated in EHR; and greater education and training. They go on to suggest reduction of time pressure through standardized EHR templates, greater financial reimbursement, and incorporation of artificial intelligence and the use of algorithms to review data. Regarding workflow issues, they suggest better usability, policies around reviewing data and responding to patients, and identifying the types of data that are best suited to inclusion in EHR. All of these are easier said than done, so I’d love to hear from readers who have tried to tackle this particular issue.

How is your organization handling patient-generated health data? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/5/21

April 5, 2021 Dr. Jayne 4 Comments

A major part of my consulting practice involves trying to help physicians become more proficient EHR users. As I evaluate their current state workflows, I usually discover a number of operational processes in their practices that are adding to their workload. Often the perception is that the EHR is causing more work when it’s really a combination of poor EHR implementation, poor EHR configuration, and continuing to try to use processes that were designed for paper even though the paper is long gone.

Increasing practice-related stresses contribute to physicians feeling like they’ve lost control of their work lives, which can ultimately result in burnout. I’m always on the lookout for strategies to help my clients beyond optimizing their EHRs and their office processes. Sometimes this involves referring them for executive coaching to discuss work-life balance and their willingness (or lack thereof) to alter their work schedules to try to reduce stress. Other times, physicians are resistant to any advice that advocates for work habits different than what they’ve grown to accept.

I ran across an article from the AMA this week that advertised four approaches to reduce the mental workload that physicians face. This was presented as a strategy for reducing burnout. Cognitive workload is a real phenomenon that a lot of organizations don’t think about. I’ve had many conversations with EHR designers and UX experts about it over the years, and certainly systems can be designed in a way to make things easier on the user. However, what users see on the screen is only a small part of the stressors they face each day.

The article cites a recent webinar with Elizabeth Harry, MD, who is senior director of clinical affairs at the University of Colorado Hospital. The first point that the article makes is that an individual’s attention is a limited resource, and that we need to “have space to actually give proper attention to things” in order to avoid making mistakes. She suggests that people use a task-based approach, where they focus on a single task for a period of time in order to saturate their working memory. An ideal time for focused attention would be 25 minutes, followed by a break during which the cognitive load would be discharged.

That sounds well and good from an academic perspective, but I’m not sure how to apply it to the typical workflow physicians face in the outpatient setting, where they’re bouncing from 10- to 15-minute visits with “breaks” in between, during when they are expected to finish documentation, field telephone messages, address medication refills, and perform numerous other tasks.

Dr. Harry goes on to suggest four strategies to address systems issues that contribute to burnout.

The first strategy is to increase standardization. She cites Steve Jobs and his standardized wardrobe as an example. She notes that building intentional habits can reduce stress and that organizations should try to standardize as much as possible across medical care unites.

I wholeheartedly agree with this idea. My urgent care employer has more than 30 locations, and all of them are built on the same blueprints except for three locations. I work at two of the three non-standard sites from time to time and find them incredibly frustrating. One site was acquired from another urgent care organization and has different cabinetry, so the drawers are laid out differently and the rooms have different configurations, which results in the physician opening random cabinets trying to find things. I’m sure that doesn’t build confidence for patients, and it definitely injects a small amount of stress into your day. The other site has the standard layout in the rooms, but the doors to the exam rooms all open opposite of how they should, resulting in some shimmying and dodging of trash cans and exam tables as you enter the room. It also makes you try to grab for a handle on the wrong side of the door as you exit, which just makes you feel foolish as well as slowing you down.

The second strategy she advocates is decreasing redundancy so that organizations have a single high-reliability process for completing a task rather than having multiple ways a process can run. She uses the example of notifying a physician regarding lab results. We need to receive results the same way each time rather than a different way each time we order labs. I think most organizations are doing a fairly good job with this, although there are some levels where redundancy is important, especially where critical patient safety situations are involved.

The third anti-burnout strategy involves consolidation of clinical data. This is where she cites EHR design as an example, setting up the workflow so that key information is located in a single space rather than requiring users to bounce around to find the information they need. Disease-specific workflows are an example of this, where users can find relevant patient history, clinical indicators, and labs all in the same place. This approach builds on the concept of reducing split attention as well as creating routines and habits.

The fourth strategy involves reducing interruptions. Dr. Harry notes that physicians need to have agreements with their support staff about what merits an interruption and what doesn’t. Interruptions can disrupt important thought processes, and she again advocates for physicians to have blocks of time where they can focus.

This may be a possibility for outpatient visits in certain subspecialties that are allowed longer appointments for complex consultations, and might be even more of a possibility where physicians own their own practices and can control their own schedules. However, I can’t see how it would be much of an option for specialties where physicians are expected to juggle multiple patients who are having acute problems simultaneously, such as in the emergency department or in the intensive care unit. In those settings, our attention is constantly drawn away from what we’re looking at and towards something that is potentially less stable or more serious.

The reality is that inability to focus doesn’t just lead to stress for physicians and caregivers, but it also leads to poor care when patients don’t have our complete attention. Having time to focus has become a luxury and our patients deserve better.

What are your organizations doing to help physicians achieve greater focus, and is it helping reduce burnout? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/1/21

April 1, 2021 Dr. Jayne No Comments

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March 30 marked Doctors’ Day in the US. The date was selected in honor of the anniversary of the first use of general anesthesia in the US, when Dr. Crawford Long used ether prior to a tumor surgery. The US formalized the date in 1990, when President Bush signed a joint resolution created by the 101st US Congress. My practice did nothing to celebrate, so I marked it on my own by scrolling through some photos of my physician exploits. By far one of my most challenging (and rewarding) experiences as a physician was staffing the 24th World Scout Jamboree in 2019. I never thought I would be practicing in a tent, but it was an experience I’ll never forget.

This week also included the ONC 2021 Annual Meeting. I initially had high hopes of making a number of the sessions, but was quickly sidelined as I had to put out some fires with my clients. I was able to catch bits and pieces of some of the presentations but will have to use the on-demand recordings to see the rest of the ones that were on my must-see list. From the sessions I made it to, predictable themes included the use of health IT in the COVID-19 response and interoperability. Major pushes for the former include a basic FHIR approach for vaccine scheduling that could make it easier for patients to find vaccine compared to the “Hunger Games” approach that many patients are experiencing as they compete for scarce spots.

National Coordinator Micky Tripathi credited the health IT industry with making progress on interoperability. He also noted that ONC is helping the White House with plans for vaccine passports. There was also discussion of how health information exchanges fit within the context of nationwide health networks such as the CommonWell Health Alliance. The meeting had over 2,000 attendees in an all-virtual environment and I heard mention of several post-meeting happy hours and get-togethers, also virtual.

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I did a little bit of traveling last week. Even though it was a mid-week trip, my overall impression was one of very few business travelers and mostly leisure travelers, despite the CDC’s recommendation against leisure travel. Fewer seasoned business travelers makes for a messier boarding and deplaning experience, for sure. Most passengers were well behaved and kept their masks on and I didn’t see any flight attendants having to give people extra warnings. My work took me to New Orleans, where I spotted this great mini-pharmacy kiosk. Since many of the patients I see in urgent care haven’t tried any home remedies before coming in, maybe we need strategies like this to encourage people to try a Tylenol or a Claritin before running to the doctor.

One of my best friends is a surgeon. We have been having ongoing conversations about the role of telehealth in his practice versus mine. A recent JAMA Surgery article reported on a study that showed a rise in new patient visits being conducted via telehealth in surgical subspecialties, at least during the first wave of the COVID-19 pandemic in April 2020. The study was conducted in Michigan and found that almost 40% of new patient visits were telehealth-based (compared to 1% pre-pandemic) and decreased as the first peak of the pandemic began to subside.

My last visit to a surgeon could definitely have occurred via telehealth since the physical examination performed was cursory at best and added nothing to the case, other than forcing me to sit for 20 minutes waiting in an awful pink gown that was four sizes too big. As a patient just seeking a second opinion about my MRI and ultrasound results, I could have avoided the hour-long round-trip commute, dealing with the parking garage, and taking more time off work than I wanted to.

Speaking of that visit, it also included some genetic testing, and I was a bit surprised at how the process went compared to previous testing I had done in 2017. The practice didn’t give me any kind of anticipatory guidance on what to expect other than to tell me that results would be back in two weeks (which actually took three). A few days after I had my blood drawn, I received a text from the lab vendor offering me a preliminary cost estimate for my labs, which the surgeon had told me verbally would be fully covered by my insurance. When I followed the link, I had to verify some basic demographic information, then was taken to a page that told me it actually couldn’t give me the estimate due to insurance issues.

When the results were available, I received a MyChart message rather than a phone call from the physician, who claimed that they had a wrong number in the chart and therefore couldn’t reach me. After confirming that every single phone field in Epic has my cell number, I wondered if she even tried to redial after reaching someone else. The message let me know my results were “fine” except for a mutation I already knew I had, and she told me to make sure I’m getting colonoscopies, which I already do, and which she should know since we discussed both the mutation and my recent scope at the visit.

All of that data should be in the EHR from previous visits, so I was left with the impression that she wasn’t fully contemplating my case when she sent the results. Since the outside labs can’t be displayed in MyChart, I’m still waiting for a paper copy of them to be sent to my home. After a previous medical misadventure when the ordering provider missed an abnormal result and told me results were “fine,” I’m not closing the book on this one until I have the paper copy in hand. Just when I think healthcare can’t get any more disorganized or that I can’t have yet one more less-than-optimal patient experience, I continue to be surprised.

Also in the journals this week was a paper on “Factors associated with opting out of automated text and telephone messages among adult members of an integrated health care system.” The authors looked specifically at the volume of messages as a predictor of opting out. They found that patients who received 10 or more text messages or two or more interactive voice response messages were more likely to opt out of receiving future messages. As anyone who has ever opted out of a consumer loyalty program knows, text fatigue is real. Healthcare providers should consider message volumes carefully and make sure they’re balancing what they send with the desired outcomes.

Back to telehealth, a recent piece discussed the realities of telehealth contacts and the things physicians observe in that context. Physicians are able to observe clues from the home environment or interact with families in ways they haven’t been able to previously, sometimes leading to more effective care. I’ve certainly seen some eye-opening situations during telehealth interactions, but as part of a nationwide telehealth-only organization, have even less ability to intervene than I might if I was a traditional primary care physician performing telehealth visits with my own patients. My organization doesn’t have the ability to connect patients with social services or home health referrals, so usually we end up referring patients to brick-and-mortar providers in a process that can take months if the patient doesn’t already have a PCP. We’ll see if payers continue to cover telehealth services as the pandemic dynamics change. Everyone is concerned about the potential for fraud, so we’ll just have to see how things go.

What’s your prediction for the ongoing availability of telehealth services? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/29/21

March 29, 2021 Dr. Jayne No Comments

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I recently received an email from Doximity, which is kind of like a physician-specific LinkedIn that also offers some services such as being able to call patients using your cell phone but have your office number display in the caller ID. The email invited me to review a personalized report on diagnostic behavior among US clinicians, comparing me to other family physicians using data provided by CMS. It sounded interesting, so of course I clicked the button. It goes without saying that when CMS data is your kind of clickbait, you must be a clinical informaticist.

The actual report was less exciting than the teaser – it only showed five diagnoses for a total of seven claims. Sinusitis was the leader, with pinkeye, wrist sprain, allergic rhinitis, and right lower quadrant pain following. That’s a typical day in urgent care, but I was surprised to see such a small number of claims. Digging deeper into the information that came with the report, the data was drawn from CMS claims files available at Data.CMS.gov. It also reflected the 2019 calendar year. I’m pretty sure I saw more than seven Medicare beneficiaries in 2019, but who knows how the data was parsed.

There was also a set of comparison data, looking at how I fared versus other physicians in my specialty in the same state. I apparently see significantly fewer cases of hip pain, cellulitis, and bronchitis than my peers. I found that funny since I’m an urgent care physician and those kinds of acute conditions make up the bulk of my practice. I’m sure they were pulling the data using the CMS specialty taxonomy codes alone and not stratifying by place of service. I wonder how I would stack up against other urgent care docs in my area. The top diagnoses in my state were not surprising – hypertension, hyperlipidemia, and type 2 diabetes. These were similar to national diagnosis rates.

The one thing I did find surprising was the number of encounters that they said family physicians were billing for “Encounter for screening mammogram for malignant neoplasm of breast.” I don’t know a single family physician who performs or interprets mammograms, so I was surprised that the data said that more than 71,000 of my peers have been documenting it on claims. Based on the coding education I’ve received, it should only be coded by the person reading the mammogram, but maybe something has changed and I missed it because I’ve been deep in the COVID-19 trenches.

I visited the CMS data site and try to find the raw data to see if I could come up with other conclusions, but was never able to find the correct file for 2019. Probably it was there but named something that didn’t click in my brain as being a claims data file, even though I tried various filters and searches including just trying to restrict to outpatient data. I would be curious to see how the diagnosis patterns shifted over the years and whether the usual problems are still the usual problems. I know there have been some shifts in conditions like sinusitis due to the pandemic, since more people are wearing masks.

I’m not sure how useful the data would be if I had it since it’s just Medicare data, and Medicare beneficiaries represent a small percentage of my practice. It would be much more useful as a provider to be able to see a big, aggregated data set that looked at multiple years, irrespective of where I’ve practiced. Sure, you could get your diagnosis mix out of your EHR, but for people like me who have worked in a variety of settings and places, that’s easier said than done.

Data is interesting stuff, but it’s only as powerful as the people who have access to it and the tools they have to manipulate it. If we really want to use it to make change, we need to be able to further stratify it. For example, what does my data look like when compared against other in-person urgent care settings? How does an independently-owned urgent care’s treatment habits compare against one that is owned by a hospital system? Does it make a difference whether physicians are full-time or part-time, or how long it has been since they finished their medical training? It would be fun to have that kind of data at your fingertips, at least if you’re someone who’s into that sort of thing.

Although I’m pretty good at manipulating data, I miss having easy access to dedicated data analysts on a daily basis. As a CMIO, I loved having a team where I could explain a business problem and trust that they knew not only how to find the data in the applications (or who would know, if they didn’t) but also the best ways to render it depending on the intended audience. Working with my health system clients, I tend to be at the mercy of their IT teams and sometimes it can take weeks for a request ticket to make it through the support queues before I hear from someone who will attempt to track down the information I’m looking for. Sometimes it even takes so long that by the time we have an answer to the question, the team has moved forward with a decision without the benefit of data. That can be maddening, but it’s common when there is a mismatch of supply and demand.

I think the more useful type of report looks at not only what you diagnosed, but how you treated it, as well as whether the condition was well controlled if it’s a chronic one. Physicians seem to see some of those reports more often in the post-Meaningful Use era than they used to previously, but I know that some organizations only present their clinicians with data a couple of times a year where others may have monthly or real-time access. If there are any physicians out there who received a similar report from Doximity, I’m curious what you thought of your data and whether it was useful in any way.

What kind of reports would help your clinicians deliver the best care and best outcomes? How often should they be reviewed? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/25/21

March 25, 2021 Dr. Jayne No Comments

Last week marked Match Day 2021, which is the day that the majority of the graduating physicians in the US learn where they’ll spend the next several years training. According to the National Resident Matching Program, which runs the residency program application process, this was the largest Match on record. More than 48,000 people applied for 38,000 available positions, and 95% of the positions were filled. Nearly 6,000 programs participated in Match Day. Primary care specialties such as family medicine, pediatrics, and internal medicine made up about half of the positions available for first-year residents. The number of MD medical students applying broke records with 19,866 applicants; DO applicants participating in The Match also broke records at 7,101.

Due to the COVID-19 pandemic, residency programs had to conduct interviews online and students were challenged to figure out which schools might be a good fit without having the benefit of visiting them in person. Overall, nearly 95% of the offered positions were filled. Although many specialties recruited a majority of US seniors, some specialties like pathology had less than 50% of its positions filled by US grads. The number of international grads applying who are US citizens increased this year, although their success rate remained static. The count of international grads applying who are not US citizens grew by over 1,000, representing a 15% increase from last year and resulting in the highest number of matched candidates ever.

The success of non-US citizen international grads seemed to surprise some given the restrictions on travel, but I would argue that being able to interview via videoconference might have placed them on a more equal footing as their US citizen competitors. Although it might be harder to select your top training programs without in-person visits, the graduating seniors I’ve spoken with are happy that they didn’t have to accrue tens of thousands of dollars of additional debt crisscrossing the country. Congratulations to everyone heading off to training. It’s a brave new medical world and we’re happy to have you in it.

For patients suffering from prolonged symptoms related to COVID-19, the condition finally has a name. Anthony Fauci, MD announced that it will be called Post-Acute Sequelae of SARS-CoV-2 infection, or PASC. The National Institutes of Health will be starting research to further study the condition, which can happen even when patients have mild initial infections. Some of the symptoms include: fatigue, “brain fog” or trouble focusing, digestive issues, depression, anxiety, sleep disturbance, and decreased lung function. A recent study from the University of Washington found that 30% of the patients had symptoms that lasted up to nine months. Other viral infections such as varicella (chicken pox) can have manifestations that don’t appear for decades, as anyone who has experienced an episode of shingles can attest. I certainly hope COVID-19 doesn’t have another shoe waiting to drop in the future.

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DoorDash is slated to offer same-day delivery of COVID-19 test collection kits through partnerships with Vault Health and Everlywell. The kits will initially be available in Chicago, Dallas, Cleveland, Phoenix, Baltimore, Denver, and Minneapolis with other cities to follow. The test kits are approved under FDA Emergency Use Authorization. The Vault Health kit costs $119 and uses a saliva test that requires proctoring via Zoom. The Everlywell kit costs $109 and features a nasal swab that can be performed without observation.

Researchers at the University of Cincinnati are working on a drone that can facilitate telehealth visits and even enter the home to assess living conditions. The drone includes a compartment to carry laboratory specimens and supplies and includes audio-visual tools. Researchers liken it to the telehealth robots that hospitals are using within brick-and-mortar environments and hope that it can assist in management of chronic conditions, health coaching, and consultations.

I spend the majority of my time looking at how technology impacts healthcare, but the pandemic has uncovered ways that low-tech services could really make a difference. I was surprised to read a recent piece in JAMA Internal Medicine that addressed unmet basic healthcare needs. The study found that more than 42% of individuals with decreased ability to bathe or toilet independently lacked equipment that could help them – things such as shower chairs, raised toilet seats, and grab bars. As a representative sample, it could indicate that more than 5 million people have unmet needs. The study participants were followed for more than four years to determine if they eventually acquired the assistive equipment. Approximately 35% of those with bathing needs and 52% of those with toileting needs never received it. Such low-cost interventions can reduce injuries, promote independence, and improve quality of life. Sure, it’s not as sexy as mRNA vaccines or monoclonal antibodies, but we should be able to do better.

A headline on “How Hospitals are Using AI to Teach Physicians to Better Express Empathy” caught my eye recently. Startup company Virti has been working with hospitals, including Cedars-Sinai Medical Center (which is also an investor) and the UK’s National Health Service, to use AI-powered virtual patients to coach patients on bedside manner. The animations are designed to test users on empathetic interactions and interpersonal skills while collecting data on performance. The software can be used on smart phones or computers and there is also an option for virtual reality headsets. Users are scored on their speed, what questions they asked, and whether they arrived at an accurate diagnosis.

Mr. H recently ran a poll on company culture, asking respondents to compare current culture to a year ago. Responses had a fairly equal distribution – 33% “about the same,” 32% “worse,” and 26% “better” with 9% reporting they have changed employers, quit working, or don’t have an employer. I had the opportunity to think about this in depth this week as I spent some time with an executive recruiter. The conversation was made more enjoyable by the fact that it occurred in New Orleans and involved cocktails, which always makes things more interesting.

We also had a chance to talk about toxic workplace culture, which I’ve experienced several times in my career. It’s always interesting in healthcare when leadership promotes safety publicly, but does not support it behind the scenes. I’ve heard reports from several institutions recently as staff are refused adequate personal protective equipment (PPE) while caring for COVID-19 patients. One of my nursing colleagues reported that additional PPE was delivered to their unit for a media visit, and then the carts full of isolation gowns and face shields were removed once the reporters left. Another hospital was floating specialized nurses (such as labor and delivery nurses) to medical/surgical units, where they were not comfortable caring for patients outside their usual scope of practice. Only after a half dozen nurses resigned did they decide that it was probably not the best plan. Organizations are offering meditation rooms and wellness apps to employees that are stressed to the max rather than adjusting caregiver to bed ratios or looking at other tangible solutions.

How is your workplace culture evolving to meet the new normal? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/22/21

March 22, 2021 Dr. Jayne 4 Comments

Both the virtual physician lounge and the informatics community were buzzing this week about the Amazon telemedicine announcement. For those that missed it, Amazon plans to expand its Amazon Care telehealth program nationally. The program will be available for all 50 states plus Washington, DC later this summer.

Amazon Care has been providing both telehealth and in-person primary care services to company employees and dependents in the Seattle area since September 2019 and expanded it throughout Washington state in September 2020. The first phase of the national expansion will cover other companies in Washington state, with the rest of the US following for in-person services in Washington, DC and Baltimore and virtual services in other locations. Planners note that the virtual clinic will offer both urgent care and primary care services as well as COVID-19 testing, flu testing, and vaccines. Patients also have the option of scheduling follow-up visits in their homes or offices. Patient can schedule them through the Amazon Care app, which also provides care summaries and follow up reminders.

Amazon has offered additional home services in the pilot program, including administering pediatric vaccines in patients’ homes as well as evaluation of the work-from-home arrangements of employees to help them avoid ergonomic issues. Employers will be able to access the service and offer it as a benefit to employees.

It will be interesting to see how it scales. In the current offering, patients are typically able to connect with healthcare providers in around a minute through the app, which offers live chat, messaging, and video. Unless they have a tremendous number of resources on standby, response times like that are typically only achieved when agents are managing multiple patient streams at a time. That’s what I’ve seen with some clinical call centers that add messaging to the mix. Maybe Amazon has some kind of secret sauce that will make things work differently.

The purported value as a workplace benefit is clear – employees would miss less time trying to seek care for minor illnesses or more straightforward services such as prescription refills. Those services are available through existing telehealth offerings. However, the Amazon name is likely to represent speed and efficiency, which are both attractive to employers. Amazon prescription delivery is also attractive.

Still, I wonder what their clinical quality data looks like in their pilots. How are they managing antibiotic stewardship? What are the metrics they are following to determine whether they are successful? Are they able to monitor downstream metrics, such as emergency department visits or hospital admissions? The availability of home visits is certainly a differentiator compared to other available offerings.

As a physician, I’m curious to understand what their compensation structure looks like for clinical resources. Are they using all employed physicians with enough licensure coverage to hit all 50 states? Are they using independent contractors? Most of the major telehealth organizations use independent contractors, who may have arrangements with multiple vendors and who practice on the different platforms depending on supply and demand factors. The Amazon press release notes that the service “allows employees and dependents to see the same dedicated teams of medical professionals, which creates long-term relationships that benefit overall health.” That would seem to describe employed physicians who would be focused on Amazon patients, but I would be interesting to understand how that kind of arrangement would compare to the salaries generated by brick-and-mortar physicians.

The Amazon press release also mentions same-day COVID-19 testing, so I’m curious to understand who they are partnering with to deliver the proverbial last mile of service for testing and vaccinations. That might not scale across the US in the same way it would in the Seattle area.

I’m concerned about the potential mismatch between patient expectations and reality, as well as how the extreme focus on convenience somewhat diminishes the value of the relationship with the physician. The release cites a patient who appreciates the convenience of Amazon Care and not having to wait at a doctor’s office. She states that using the services “makes me feel like I have more control over the healthcare system than the healthcare system has over me. It’s at my leisure. That’s power. I’m not waiting on someone else to show up on their schedule.”

I appreciate the need for patient convenience, but I think it’s important for patients to acknowledge that the vast majority of the time, physicians are not on schedule because they’re caring for other patients, whether in-person or asynchronously, because they are managing refills or completing paperwork. When my patients are frustrated because it’s taking 30 minutes for me to reach their exam room in my walk-in clinic, it’s usually because someone with a more acute need has arrived at the same time or before them. Although healthcare delays can be due to inefficiency or operational issues, they can also be due to me arranging a transfer to the emergency department or counseling a patient on a devastating diagnosis, such as a miscarriage.

In the case of Saturday night, the delay of care might have been due to the fact that our entire staff was busy performing cardiopulmonary resuscitation on a patient, trying to bring him back from the dead in the interval before the ambulance arrived. If you’re the patient in distress, you certainly don’t want me cutting you short because I have someone else who is waiting.

I struggle with understanding how they plan to balance the promised levels of convenience with the offered continuity, because they’re often in conflict. Team-based care can certainly help with this, but patients have to understand what that really means. As healthcare has become more transactional, I find that many patients don’t care who they see. While a brick-and-mortar practice can’t staff an unlimited number of physicians, online practices can certainly have a deeper bench. But we can only deliver face-to-face care (whether virtual or in person) to one person at a time, even if we’re running back and forth between exam rooms. The demand for instantaneous care has definitely impacted the relationships that we are trying to build with our patients, and at least anecdotally among my local peers, is one of the reasons some of them have changed jobs.

The devil will be in the details, but I can’t wait to see how this unfolds. Get your popcorn, folks. How do you think Amazon Care will play out nationwide? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/18/21

March 18, 2021 Dr. Jayne No Comments

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I completed my HIMSS21 rollover registration, so we can finally get some return on the money Mr. H fronted back in the fall of 2019. HIMSS is pre-managing any future refund requests by noting that it’s not a true rollover of the registration fees – it’s a “complimentary registration” for 2021 due to the cancellation of HIMSS20, and as such is non-cancellable, non-refundable, and not subject to the documented cancellation and substitution policies. If you’re going to do the rollover, you have to follow a specific link you receive via email. Interestingly, the link arrived in my inbox shortly after another one from HIMSS announcing a decrease in individual membership prices, so my previous membership is now good for an additional six months.

I’m not thrilled about the campus-style venue, which means traipsing or shuttling from the Venetian-Sands Expo Center to the Caesars Forum Conference Center and the meeting space at Wynn. I’m sure they’re doing it so that events can allow for social distancing, so I get it from a public health standpoint. When I’ve been to conferences that did the campus approach, the experience ranged from successful to downright painful. Hopefully, they’ll keep similar programs or tracks together to make it more likely to achieve the former.

HIMSS is not announcing its specific health and safety protocols at this time, but promises to deliver the info as it gets closer. I expect a fat waiver absolving HIMSS of any and all responsibility should attendees be exposed or infected during the conference. Since the badges are going to have headshots on them this year, I’m going to bring some stickers and put a mask on my badge so my photo matches the in-person version. There were some issues with the photo upload process where my picture was clear at the time of upload but grainy when I came back to the screen later, so who knows what it will look like in reality. I also got a kick out of the registration page’s recap of demographics, which due to the magic of formatting, displayed my professional title as something that evokes Pinocchio:

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Since HIMSS will also have a digital track this year, it will be interesting to see what post-event surveys reveal about attendee satisfaction and perception of value. The boom in videoconferencing has created plenty of psychological research around its impact on users. Researchers at Washington University in St. Louis are looking at perceptions of self-image from those who are having increased video interactions. The findings were published in the International Journal of Eating Disorders and found that most women have not had a change in their satisfaction with personal appearance despite increased time spent on Zoom. They noted that people spend 40% of their time on Zoom looking at their own image, with some reporting 100% self-gaze.

I’m glad I ran across the article because it introduced me to Zoom’s “touch up my appearance” feature, which I had not been aware of. The researchers plan to follow up with a study to look at the same factors for male users. They note limitations of the study in that the research began in May 2020, and as the year has progressed, we all have spent more time on video chat, with the lead researcher noting that, “What it means to us now might be very different than what it meant to us then.”

The American Medical Association ran a recent piece that is targeted at helping physicians adjust to the new reality of patients seeing their visit notes. For many physicians, the idea of patients seeing their own documentation is terrifying, with physicians wondering if they are going to have to completely change their documentation style to avoid creating anger, confusion, or resentment in their patient population. The idea of open notes is not new for many organizations, and I’ve watched several physicians who come from institutions where this is practiced coaching those who are afraid.

The AMA encourages physicians to think about how greater transparency can benefit patients or help them have more buy-in with their care plans. Still, I think there will be opportunity for physician consultants to coach individual providers through the process of creating notes that adequately paint the clinical picture while avoiding potentially inflammatory content. I’ve done this a couple of times in the past and am always happy to put my literature background to work.

Best Buy Health has partnered with Apple to offer remote monitoring services via Apple Watch. Users can access the Lively app to contact Urgent Response Agents to assist with everything from medical emergencies to roadside assistance. Best Buy is also credited for working with Apple to create an upcoming fall detection features that “make it easier for older adults to stay safe, healthy, and connected.” Consumers who agree to a two-year Preferred Health & Safety contract will receive a discount off a watch purchase at Best Buy.

An article in the Journal of the American Medical Informatics Association caught my eye this week. It looks at how technology can be used to detect if people in video streams are wearing masks. Being able to pick up if people are wearing masks is a good thing, but even better would be to identify those who are not wearing them properly and perform some kind of remediation. It still amazes me that people are unwilling to wear masks properly now that we’re a year into this adventure. My state recently opened the vaccination tier that includes teachers, and my hometown newspaper prominently featured a photo of a teacher being vaccinated who had her entire nose exposed out the top of her mask. If the teachers can’t model correct mask-wearing, I’m not sure how they’re supposed to make sure students are doing the right thing.

By this point in the game, those of us who want to wear masks full time or those of us who have to wear them for work should have figured out what mask style works best for us and how to keep it from moving around. I have a handful of go-to styles depending on what kind of activities I’m doing and how long I have to wear it. What have you found as the most comfortable and practical mask, or just the one that makes you smile? Leave a comment or email me.

Email Dr. Jayne.

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Reader Comments

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  • Brian Too: I dunno. Seeking an answer in AI for America's healthcare woes seems a little desperate. LIke, adding one magic new in...
  • meltoots: You forgot that politics will have to be programmed in your AI. On both sides of the aisle, misinformation, doing things...
  • IANAL: So what should Cerner do though? They have some market issues because the largest potential or current customers have at...
  • Ghost of Andromeda: That's exactly the opportunity here! Cerner is struggling and could really use someone who knows how to execute with dis...

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