Home » Dr. Jayne » Recent Articles:

EPtalk by Dr. Jayne 1/23/20

January 23, 2020 Dr. Jayne 2 Comments

IBM has proposed measures to reduce concerns of bias in the use of artificial intelligence solutions. Critics have noted that AI technologies use data that can reflect past discrimination and may not accurately reflect health factors for women, minorities, the elderly, and disabled persons. IBM is urging industry and governmental agencies to work together to create standards to measure bias and prevent potential discrimination. It also calls on companies in the AI space to appoint ethics officials and to assess whether AI systems can cause harm.

I’m eagerly awaiting the arrival of useful AI systems in my clinical practice, since we perform primary readings on all of our so-called “plain film” radiology studies. (It’s been decades since I’ve seen any film, or smelled the delightful chemicals, and I certainly don’t miss it.) It feels like we sometimes over-call findings on chest X-rays, but without truly crunching the data it’s hard to tell, since we have an inherent bias because everyone who has a film is already pretty sick. It would be great to have AI backup or pre/post screening to make our lives a little easier and a little more evidence-based, while we wait the 30-45 minutes for a radiology overread.

I enjoyed reading this op ed piece about renewed efforts to combat medical errors. I’ve worked with a handful of systems recently that still struggle with the basics, including ongoing use of so-called “do not use” abbreviations. Some vendors seem to think that just because their product isn’t certified EHR technology that they don’t have to respect the standard conventions for safety and usability. The piece does treat a couple of issues too simplistically, blaming EHRs for physician burnout (I’d argue it’s not only EHRs but the mounds of regulations and data collection requirements that EHRs were designed to satisfy). There is also a lack of citations for key data points, such as the allegation that radiologists at one organization are viewing images at a rate of one every four seconds. I wonder if that state’s Board of Healing Arts has anything to say about that.

Applications for the CMS Primary Care First program closed this week, and I’ll be interested to see how many organizations signed up and ultimately what payers end up participating in the program. The initiative didn’t excite any of my clients, despite their detailed evaluation of the program’s different tracks and comparison of it to existing programs. The application process ran so far behind that they had to shift the program by a year, so I’m not sure anyone has too high of hopes for it.

I missed this newsy tidbit last week: The US International Trade Commission will be investigating Fitbit, Garmin, and other wearable devices following a patent infringement complaint by competitor Koninklijke Philips. At least in my community, interest in fitness trackers seems to have waned – no one talks much anymore about their steps or jumps up based on a prompt to MOVE! like they used to. I still use my Garmin watch to track my runs in addition to telling me the time, but I turned off the activity prompts and the display of texts from my phone, as I found them too disruptive.

My inbox has been overstuffed for the last couple of months, so I also missed this item: Hims & Hers telehealth is partnering with Ochsner Health System for coverage of conditions not usually treated through the Hims & Hers platform. They’re fairly small as a telehealth vendor with only 200 physicians, so I’m sure broadening their network will be a benefit. I’m not a fan of their sale of nonmedical consumer products such as beauty and skincare formulas, nor their sale of various supplements and alleged sex drive boosters. I’m not a fan of those in face-to-face practice either, as I think it’s hard to remain objective about pushing products if you profit from them, and I think the evidence on some of their products is thin at best. Apparently Ochsner isn’t worried about being on the slippery slope and they plan to launch the service first in Florida.

A good friend of mine has done significant work for tobacco quit-line services, so I was glad to see this article looking at EHR-based versus fax-based referrals to the quit lines. Long study short, the availability of EHR-based referrals produced referral rates at three to four times that of the current fax-based standard of care. EHR-based referrals were also more numerous for underserved populations. The key takeaway is that the easier the process, the more likely that clinical teams will do it – and if launching referrals from screens where the staff is already working does the trick, that’s a win for patients.

image

HIMSS is hosting a webinar on Monday, February 3 that caught my eye: “Monitoring Grandma: Adoption of Connected Health Tech by Seniors.” The objectives are to explore current tech trends in the older population, along with real-world experiences from clinicians using technology with geriatric patients. They also plan to discuss attitudes toward health technology at the community level along with how it should impact design and adoption. I’ve struggled occasionally with getting my Amazon Echo to do what I want it to do – maybe it’s my accent or maybe I’m just not using the right words. Or perhaps as I head farther away from the tender age of 29, I need to embrace the mythical Amazon Echo Silver.

Informaticists are discussing the recent surge in China of a novel coronavirus that has killed 17 people with more than 540 cases confirmed. Health systems in the US, especially those in major points of entry, are debating the addition of EHR screening questions similar to past outbreaks of Severe Acute Respiratory Syndrome (SARS) and Ebola virus. The city of Wuhan, with a population of nearly 12 million people, has shuttered local transportation systems, suspended outbound flights, and is asking residents to stay home. The new flu-like virus is suspected to have jumped to the human population from illegally traded wildlife at a Wuhan market. The World Health Organization will decide this week if this outbreak qualifies as a global health emergency, although airports are already screening travelers. Meanwhile, the United States has already seen over 9.7 million cases of influenza with 87,000 flu-related hospitalizations and 4,800 deaths (including more than 30 children) this season. Just something to think about.

Has your hospital added coronavirus screening questions to the EHR yet? Leave a comment or email me.

button

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/20/20

January 20, 2020 Dr. Jayne 2 Comments

image

On occasion, I’ve done consulting for groups who are trying to drive clinical outcomes through better patient engagement. Both vendors and healthcare delivery organizations have an interest in this, as they try to help providers capture incentives with value-based payment models or try to prevent unnecessary care. I’ve seen some unique and compelling apps that they expect patients to use, some of which try to gamify the healthcare experience. Other organizations are betting their money on patient portal functionality, and some are leveraging text-based solutions.

There’s a fine line, though, between trying to converse (whether electronically, face-to-face, or virtually) with patients versus using social medial platforms to try to reach specific clinical goals. I was interested to see this article in the Journal of the American Medical Association that looks at the potential role of social media in preventive health care. The authors start by noting Centers for Disease Control and Prevention data that indicates that more than 100,000 lives could be saved annually if patients in the US received clinical preventive services. These include basic elements such as vaccinations, tobacco use counseling, cancer screening, and blood pressure screening. They note key barriers such as access, cost, and awareness as factors that lead to inadequate delivery of services.

The authors note that “social media and other digital platforms that enable connectivity have unprecedented influence,” which to me is an understatement. The rise of social media “influencers” in many facets of life is somewhat surreal to those of us who have dedicated our lives to being expert in a field and trying to use evidence to guide what we say and do. In the world of social media, you can know fairly little about something, but if you present yourself well and have something catchy to offer, you can get thousands of people to begin following your every word. Sometimes notoriety is more important than knowledge or experience, and often consumers fail to understand the difference. With that in mind, I was skeptical about how social media could positively impact healthcare delivery. Not to mention, there are obvious privacy concerns where social media and personal health information intersect.

The authors specifically discuss the Facebook Preventive Health tool, which is available only in the mobile app. The app consumes sex and age data and matches it with guideline-driven preventive health services, also offering locations where users might want to receive them. The app uses a variety of guidelines from the American Cancer Society, American College of Cardiology, American Heart Association, and the Centers for Disease Control and Prevention. In looking at the app myself, they seem to pick and choose some of their recommendations, particularly where there are discrepancies between bodies such as the CDC and ACS. It’s also not very clear who is behind choosing the recommendations, and how they decided which set of guidelines to follow for any given condition. It’s also not clear how they decided what conditions to include or exclude in the tool. The app isn’t totally benign, as Facebook gathers user data about how individuals interact with the tool. Although the company claims they’re not sharing it with third parties, I’m skeptical.

The authors note that the Facebook Preventive Health tool suggests that users can share it with their networks. Although this can theoretically raise awareness of screening measures, it’s not clear whether such sharing actually drives health behavior change. They do cite a study on voting that showed that among 15 million Facebook users, direct messages encouraging voting influenced the behavior of individuals and their networks. However, they note that “a better understanding is needed in regard to whether information about preventive health propagates across users and how new users and influencers affect dissemination.” They also note some previous research that shows that “fact checking declines when information is presented on social media compared within an individual setting.” They cite the number of anti-vaccine “influencers” online and how misinformation can impact vaccine delivery. They go on to note that “for any health intervention on a social media platform, it will be important to determine how to assess the success of an intervention that includes vetted health recommendations on the same platform as misinformation.”

The authors note that privacy is an issue. While patients easily offer their personal data to apps, fitness trackers, and other platforms, they may not be aware how that data is used or that it can be combined with other data sources to personal data profiles that are beyond what they might normally share. I had a “wow this is scary” moment with one of my clients recently when they did just this – combining publicly available data that used only a name and email address to bring in demographic data, address information, and more, and ultimately created psychosocial profiles with specific predictions of income, educational status, political leanings, and other potentially sensitive data.

They go on to discuss the challenge of engaging populations that struggle to access health services – uninsured patients and those without primary care providers. Just making these patients aware that they need screening isn’t going to make family physicians create more openings for Medicaid or uninsured patients. The retail clinics mentioned in the app don’t offer a wide variety of services and the federally qualified health centers that are recommended might not have capacity to care for these patients either.

In the end, the authors leave us with more questions than answers. They note that it has always been a struggle when technology crosses paths with healthcare and there is typically skepticism of things that are new. Miasmas versus germ theory, anyone? They note the need for careful evaluation of the use of social medial platforms in driving public health needs, and the opportunity for partnership among healthcare delivery organizations, researchers, and the social media industry. These groups need to work together to enable studies of the interventions and definitions of a successful result.

This leaves me wondering, though – what would happen if specific social media influencers teamed up with reputable healthcare organizations to promote healthy behaviors? What if the Kardashians were hawking the concept of “eat less, move more” rather than “waist trainers,” which are essentially corsets? What if Goop sold “wellness” products that were actually based in science? What if famous rappers talked about taking their lady friend to get her pap test versus taking their daughter to get a “virginity test?” (Google it if you missed it in real life.) It has to go beyond getting former Surgeon General Vivek Murthy and HHS Secretary Kathleen Sebelius on Sesame Street.

What do you think about the role of social media in health promotion? Leave a message or email me.

button

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/16/20

January 16, 2020 Dr. Jayne No Comments

Support of Windows 7 came to an end this week, and many organizations seem to be willing to take the risk that comes with not having security updates. My practice waited until the last two weeks to upgrade all the clinical workstations, resulting in countless hours being spent by end users rebuilding bookmarks, re-saving passwords and logins, and rearranging desktops as people try to get their computers to look and work “like they used to.” All of our staff rotates among a dozen or so locations, meaning they have to repeat the process multiple times because user profiles don’t sync across the organization. I think the most annoying piece was they didn’t announce they were going to do it, or which locations were going to be impacted, so every shift has been a little bit of a surprise.

The providers would have definitely preferred this be done in September or October, before the busy flu season hit. If I was wondering why I felt so beaten down after my last few clinical shifts, the month-end data explained it. My “patients per hour” metric was the highest it’s been since I’ve worked in the practice. Interestingly, even though patients had longer wait times and I had a couple of patients give me low ratings this month, my patient satisfaction score was the highest it’s ever been. I do enjoy being able to see data that explains what we’re feeling in the trenches, and being able to use it to improve how we work.

I’ve been reading reports from the recent Consumer Electronic Show. Many offerings have been over-hyped (“swim like a mermaid” had no tail) but others are kind of cool – the Mateo Smart Bathroom mat can track weight and evaluate posture while integrating with your phone, but the $179 price tag seems a bit steep. Withings has been in the health tech business for a while, and brings its clinically-tested ScanWatch, which is pending FDA approval. The cool part is its 30-day battery life. Kaiser Permanente is expanding its investment in a program using Samsung smart watches as part of a remote cardiac rehab program, with current technology showing promising results, so we’ll have to see what the next generation of tech brings.

Not all the technology that caught my eye was tech-related – the Juno Chiller can chill a bottle of wine in three minutes, but for $299 I think I’ll plan ahead instead, or just keep a bottle perpetually chilled. Other products on display are a bit much – such as Kohler’s line of Moxie showerheads, which include a magnetic Bluetooth speaker that fits in the middle. I shouldn’t be surprised, as Kohler already has a Bluetooth bathtub that features lights and vibration in addition to actual water. The LuluPet litter box uses images of feline stool and urine to monitor cat health, and can distinguish between different cats as well as weighing them. Get ready to have a discussion with Alexa about your cat’s waste, because it’s integrated.

image

Technology doesn’t always make things better and I’ve found that for many people, it has resulted in significant time-wasting as they struggle to keep up with multiple social media channels. The concept of “time affluence” being at an all-time low in the US was addressed in a recent Dropbox blog, which noted that 80% of 2.5 million people surveyed felt they did not have the time to do everything they felt they needed to do. According to the piece, people who feel like they don’t have enough time are more likely to be depressed and anxious than those who feel they have adequate free time. That’s been my experience in real life – you can tell the people who thrive on deadlines from those who feel overwhelmed.

The blog cites data from the Bureau of Labor Statistics that shows that people have more free time than they did 50 years ago, but for many people it doesn’t feel like it. It attributes this feeling to “the digitization of society,” along with information overload, and the fragmentation of time. Feeling distracted increases the perception of time stress. The blog also calls on companies to set protocols that enhance available free time, and practice them. I still see companies that don’t set appropriate rules for meetings and that fully support time-wasting practices such as double booking of meetings and not allowing people enough control over their calendars so that they can actually get work done.

Time is running out for anyone interested in the Primary Care First payment model and who hasn’t yet applied. Practices have until January 22 to apply. Modeling by the American Academy of Family Physicians “indicates that it should consistently work better than the Medicare Quality Payment Program’s Merit-based Incentive Payment System, even for those getting the maximum MIPS bonus.” They go further to say that the ideal successful practice will have at least 600 Medicare fee-for-service beneficiaries and should already be involved in value-based programs with Medicare Advantage or managed Medicaid.

Time is also short for those who are awaiting the ONC final rules on interoperability, which are expected late this month. The rules went to the Office of Management and Budget for review in September. The ONC annual meeting takes place January 27 and 28 and might be an opportune time for an announcement. CHIME recently wrote to members of Congress noting that the proposed rule doesn’t adequately address concerns about health IT security for third-party apps that are not created by organizations covered under HIPAA. They are concerned that without protections, third parties will be able to share or sell sensitive patient information.

image

From Jimmy the Greek: “I know you enjoy the outdoors, did Santa bring you one of these?” He had me at the headline: “This Floating Tent Offers You A Cool New Way To Die While Camping.” I don’t think I’ll be adding it to my arsenal, given it’s hefty $1,999 price tag or its equally hefty 75lb weight. The tent has a graphic of a campfire on its floor – although it’s the manufacturer’s logo, I hope no one gets the idea that it’s an indicator that you should build a fire on the base of the floating dome that is your home. I think I’ll stay with my standard issue REI on solid ground.

What’s the wackiest gadget you’ve seen, from CES or anywhere else? Leave a comment or email me.

button

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/13/20

January 13, 2020 Dr. Jayne 1 Comment

I’ve been thinking a lot lately about market consolidation. Mr. H always captures the movements: Teladoc Health is acquiring InTouch Health, SCI Solutions is acquiring Tonic Health, and MTBC is buying CareCloud.

Sometimes competitors buy each other, but the strategy can be somewhat murky. Are they trying to get better technology to improve their core product? Or are they trying to consolidate market share? Other times companies are buying specific pieces of technology that they lack in an attempt to stop the bleeding of customers going elsewhere for a more complete offering.

I’ve consulted for vendors during these acquisitions. My favorite type of engagement is helping the potential buyer to perform the due diligence around the potential purchase.

Usually the target company is keen on being purchased, so they are reasonably willing to get you dig around as much as needed. Sometimes, though, they may occasionally put obstacles in your way to keep you from figuring out how weak their product actually is compared to its marketing.

I worked with one vendor who thought they were getting a niche EHR that would complement their existing offerings. Unfortunately, they missed the part where that niche EHR really didn’t have a practice management system. Without the ability to bill for services, providers aren’t going to be thrilled with the fact that they’re going to have to buy a separate billing system and then try to mesh them together.

I say they “missed” the part where there was no billing system with some sarcasm. Of course they knew it was lacking, but chose to ignore it and hoped they could find enough gullible customers to come on board. Along with other members of the due diligence team, I was able to convince them they should take a pass, which hopefully saved them (and their potential customers) a good deal of heartache.

I’m interested to follow along as Teladoc Health purchases InTouch Health. I do believe that given our current culture and people’s desire for convenience, along with the need for providers to try to manage more patients more efficiently, virtual care is going to move to the forefront of healthcare.

The existing paradigms will continue to evolve. Hospitals that don’t have experts in a given subspecialty can contract with providers hundreds of miles away to provide care for their patients. Intensive care units can hire virtual teams to not only help manage patients after traditional business hours, but to review treatments and care plans as an extra set of expert eyes to make sure the best care possible is delivered. Patients can interact directly with their providers in a more efficient manner, saving the time needed to drive to an office and wait for care. Although these service lines already exist, more organizations are going to embrace them, and those that are already working in this manner will continue to evolve.

Teladoc Health already has the direct-to-consumer piece, and InTouch Health has a pretty solid institutional platform. The announcements focus on this, calling out the new company’s ability to manage patients longitudinally from the home setting to the intensive care unit. Regardless of their strengths and weaknesses, there will have to be a great deal of digging by teams on both sides to figure out exactly how their technologies might be able to work together vs. how much work will be needed to bring them together.

I worked with one vendor who had an EHR and a practice management system built on the same database platform but using different programming languages. As they tried to bring them together, they ended up halting all development on one side of the house while they rewrote the application to play nicely with the other side. The budgetary impact was significant, and it also caused the project to lose momentum. Eventually they got everything on the same page, but the product still died on the vine.

Many who have never been through the process of trying to bring disparate products together don’t realize what a long road it will be to seamless interaction between the direct-to-consumer offering and the in-hospital solutions. I love that kind of work – figuring out what can be kept, what needs to be refactored, and what might just need to be started over again from scratch in order for everything to work as intended.

In order to be successful, the various teams need to leave their egos at the door and focus on the end result, creating something new that will be greater than the sum of its parts. Sometimes, though, there isn’t enough budget allocated and the organization fails to address cultural issues, so what results is a shadow of what it might have been.

I have friends working at organizations that have struggled while trying to bring acquisitions together. One team worked for nearly two years to try to integrate the solutions, only to finally give up and demand that customers of the smaller vendor migrate to the larger vendor’s platform. Another team hurried to bring customers live on a shiny new tool they had purchased, not realizing that it wasn’t HIPAA-compliant until they started seeing unanticipated outcomes for what should have been routine workflows.

Of course, there is a negative impact on customers and their patients. These scenarios are also accompanied by declines in morale for the people doing the work. Sometimes key players will even leave because they don’t feel their opinions are being respected and they see their pride and joy being dissected during the process.

I hope that the companies involved in these acquisitions reach out to professionals to help manage the “soft” issues involved in bringing large teams together. From experience, they would likely benefit from an objective analysis and guidance in how to make everyone feel appreciated and to reduce the fear of being downsized or pushed aside. Most companies don’t do this, and they ultimately reap what they sow as the integration becomes increasingly difficult and the conversations more contentious. Some of the recent mergers and acquisitions in the healthcare IT world seem to be healthy, but others seem to be under a bit of duress.

Have you been through a merger or acquisition? Do you have advice for the impacted employees? Leave a comment or email me.

button

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/9/20

January 9, 2020 Dr. Jayne No Comments

Now that 2020 is here, CMS has opened the data submission period for the 2019 MIPS program. Eligible clinicians can submit their Quality Payment Program data until March 31, 2020. If you haven’t done this before, there are a variety of systems you have to register with to create your profile and submit your data, so be sure to visit the QPP website if you’re having difficulty. I’m exempt from individual participation and our group is opting out again this year, so that’s a relief. You can check the status of your favorite providers by using the CMS Quality Payment Program Participation Status Lookup Tool.

The new year also brings with it the California Consumer Privacy Act, with its provisions extended to the rest of us since big businesses aren’t going to have California-facing websites and others for the rest of us. It gives consumers expanded knowledge of what personal data is being collected, how it is being used, and the right to say no to its sale. It’s good for people to be more aware of how their data is being used, especially since so many people willingly give up their data without even thinking about it.

Even seemingly innocuous sharing using fitness sites can provide a wealth of information about people’s habits and movements. I’ve seen plenty of people overshare information about their children on social media, not thinking of how it might affect them when they’re older, but hadn’t thought about consumer-based genetic testing for children. A recent New York Times opinion piece addresses this, posing questions about parents sharing their children’s DNA profiles online. Apparently sending your kids’ swabs to 23andMe and sharing the results online is a thing.

I got a much-needed laugh during a clinical shift the other day. Apparently someone stuck a magnet to the inside door frame of one of our exam rooms. It wasn’t from the beach or something inspirational, but rather an ad for one of our competitors. Bold move and well played, but we did transfer it to the round file.

Less funny were the patients who came in with adverse effects of marijuana, given the recent legality of recreational purchases in Illinois. Not only did the patients get hit with nearly 25% tax, but also a hefty urgent care co-pay. As I’ve already put in several patient plans this year, lay off the weed, folks.

Amidst everything else going on in the world right now, this week the White House proposed guidelines regarding the regulation of artificial intelligence in healthcare, transportation, and other private sector industries. The general principles of “fairness, non-discrimination, openness, transparency, safety, and security” were mentioned, but in a general way. A memo from the acting director of the Office of Management and Budget warned about the perfect being the enemy of the good, stating that “Agencies must avoid a precautionary approach that holds AI systems to such an impossibly high standard that society cannot enjoy their benefits.” It remains to be seen how the principles will be specifically implemented or how much focus this will receive given other regulatory priorities.

Pet peeve of the week: use of the word “solutioning.” I’ve heard it three times this week in three venues, which makes me wonder if something is triggering increased use. Offending sentences included: “Let me work with the team to see what we can solution for you” along with “We’ll be doing some solutioning on this problem Friday and will keep you posted.” Sounds wordy and awkward to me, but I’d be interested to hear from others that think it’s a great word to use in this way.

Around the physician lounge this week: There was a study in the journal Pediatrics about the problem of “low-value care,” especially in the pediatric population. Researchers were specifically looking at whether children with public insurance (Medicaid) were more likely to receive unnecessary medical services than those with private insurance. They looked at data for over 8 million children across 12 states and found that one in nine publicly-insured patients vs. one in 11 privately-insured patients received so-called “low-value” services, meaning that they were either unneeded or unlikely to improve the patient’s situation. Either way, close to 10% of pediatric patients re receiving wasteful care.

The authors looked at a group of 20 low-value tests and treatments, many of which I see requested in practice: antibiotics for colds, unneeded x-rays, unneeded medications, etc. It’s difficult to explain to parents (and to the adults when they are the patients) that sometimes to do less is more and those explanations take precious time that providers often don’t have, so the cycle perpetuates itself. Clinical decision support rules and other technology can help us identify the low-value care, but they don’t do much to help explain why we’re saying no. Perhaps some brilliant developer could create a virtual reality game that tours through “all the bad things that can happen when providers give in to unrealistic patient request” that might make an impact. It should include a scary section where the player goes bankrupt due to wasteful spending.

Another potential game element could be the downward spiral that occurs when unneeded tests lead to a medical wild goose chase. This was mentioned in the Washington Post and I see it all the time when we order a panel of blood tests (because they all come on a convenient CLIA-waived cartridge testing system) rather than the single element we’re looking for. Something comes up out of the normal range, which doesn’t mean that it’s even abnormal, and more visits and consultations and tests are needed to work through it because everyone is worried about missing something or getting sued. The Post piece mentions unneeded testing done prior to cataract surgeries, which can lead to cascades of extra services.

I think this is one area where artificial intelligence might really be able to help – to assist us in learning what these not-normal but not necessarily concerning results truly mean across large populations, vs. us always having to go down the rabbit hole trying to figure out their significance.

The article has some gripping stories, such as the patient who had their kidney removed for what turned out to be a piece of fat, and then their remaining kidney failed. It also mentions the frustration felt by providers in these journeys. Physicians are also subject to cognitive bias (such as memories of when they previously “caught” something unusual) fed by anecdotal stories as well as personal experiences. These are exactly the elements that clinical decision support is designed to combat, but too often the physicians I spoke with are suspicious of the data behind such systems or whether use of that data would be defensible if they miss something significant and are sued.

The discussion also veered into the direct-to-consumer realm and some of the self-directed testing that is out there. Patients can now order large panels of tests, including genetic tests, without any kind of counseling or advice first. These can lead to significant anxiety along with the costs. There’s certainly variability in the services offered and the degree of physician involvement with some of these efforts. However, as long as there’s a buck to be made and patients are willing to pay for it, I don’t see them going away any time soon.

Do you think that healthcare IT can truly have an impact on the delivery of low-value services? Leave a comment or email me.

button

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/6/20

January 6, 2020 Dr. Jayne 2 Comments

An issue that is often cited as a cause of increased healthcare expenditures in the US is our fascination with technology. This is readily apparent as I see patients. They don’t want me to tell them that it’s highly unlikely that they have strep throat due to a well-validated clinical decision support rule. Instead, they demand an in-office strep test. They have been conditioned to expect technology to provide answers, even if it involves radiating a pair of totally clear lungs because the patient is concerned that they have pneumonia. The increased reliance on patient satisfaction scores as a marker of quality care certainly hasn’t done anything to improve this situation.

Earlier this week, I received a scathing review from a patient that triggered a phone call from the COO. She was upset that I suggested that she be sure to contact her primary care physician when she is ill. I had noticed that she is a member of a notoriously restrictive HMO and I wanted to spare her the denials and her physician the penalties. Instead, she took this as a statement that I “didn’t want her business” and that she was “not welcome at urgent care.”

Being interrogated by the COO about the patient encounter  — which was unusual enough at the time that I put several interesting details in the chart — was the last thing I needed during a busy clinic day when we literally had patients trying to die in the office. When I’ve talked to the emergency department charge nurse at the local Level 1 trauma center three times in the same day, that’s a bad sign for sure.

I would love to have bureaucrats and politicians in the room with me when I have to explain to a patient with a critical illness that they absolutely need to go to the hospital by ambulance and that no, you cannot go by private vehicle when you are actively having a heart attack. I had three different versions of this conversation during my last shift: one for the heart attack, one for a patient with multiple blood clots in the lung who was short of breath, and one for a patient with what appeared to be an evolving stroke. The fact that these patients were at an urgent care center and not the actual emergency department is a result of many factors.

In my anecdotal experience, the first reason is convenience. Patients want to be seen in their neighborhood by someone who can care for them quickly. They don’t want to deal with an office that can’t fit them in or a crowded clinic.

Second is cost. They don’t want a surprise bill from going to the hospital or a denial if their care isn’t deemed emergent after a hindsight review.

Third is a complicated health literacy issue. Patients often don’t understand what can be cared for at home, what needs to be at a retail clinic, what needs an urgent care center, and what needs to go to the emergency department or even a specialized emergency department. As an urgent care physician, I think sometimes we’re victims of our own successful marketing, but that doesn’t help your stress level when you’re urgently transferring a child with a coin in their airway or telling a patient they have advanced cancer that was blown off by their primary care physician.

Many forecasters thought that high-dollar deductible insurance plans would make patients savvier consumers and wiser spenders of their dollars. What we see in practice is that patients are paying so much for their insurance that regardless of the deductible, they want more and more services to get their money’s worth. I never thought I’d see patients coming in saying, “I think I’m OK, but I just want a CT scan to be sure.” They’re shocked when they say that we don’t have enough cause to order it, or that the insurance might not pay for it.

I try to use technology in some of those situations as a teaching aid, pulling up websites and providing information about why the patient is going to be just fine. Somehow it’s more believable when they see it on a website than when the doctor in front of them is saying it. I try not to take it personally.

There are also the times though that technology fails us. Recently, some patients who had undergone preventive mastectomies after concerning genetic testing results learned that the BRCA gene test may have been inaccurate. That was earth shaking for many patients, who have come to trust high-tech answers to their questions. I saw that article on the same day that I saw the Google blog piece about using artificial intelligence to improve breast cancer screening using digital mammography. Another win for technology after a stunning loss.

I was also heartened by the ultimate telemedicine encounter that occurred recently. Apparently one of the astronauts on the International Space Station developed a deep vein thrombosis (blood clot) in their neck, which was evaluated and treated remotely. The astronaut patient performed ultrasounds with guidance from an Earth-bound care team in order to monitor the clot. A pretty cool story, but difficult when you transpose it with the reality of many patients on the ground who can’t get an ultrasound for a suspected clot on two of every seven days, simply because they’re classified as “weekends” and facilities don’t have ultrasonographers readily available.

Being at the forefront of healthcare delivery is like being on a roller coaster. There are amazing highs (identifying the blood clot in the lung before it killed an otherwise healthy 25 year old) and devastating lows that are sometimes too horrific to put into words.

In my informatics practice, I work with people every single day who are committed to trying to solve the problems that we all are facing every time we, or those we care about, interact with the healthcare system. It’s a new year and hopefully a new opportunity for healthcare technology to really make a difference for patients around the world.

I’m excited to be a part of the future of healthcare. Who’s with me?

button

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/2/20

January 2, 2020 Dr. Jayne 2 Comments

Regardless of what holidays you celebrate, everyone is impacted by medical offices that are closed and healthcare facilities that are running on modified schedules this time of year.

I’m in the middle of a streak of clinical shifts that have at times reduced me to a mound of quivering jelly. Influenza is definitely on the rise and I’m starting to feel like my mask is permanently attached to my face. Our urgent care group saw nearly 2,000 patients on December 26, breaking our city-wide record. Many patients reported trying to get in touch with their primary care physician only to find the office closed, with some offices being closed until after the new year.

Seeing a 20% bump in volumes, the IT side of my brain always wonders about scalability of the solutions we use. I’m happy to report that the EHR held up like a champ, but viewing radiology images in the PACS was another story entirely. Load times were running up to two minutes, which seems like an eternity when you’ve got a full house and need to know what’s going on with your patients’ films.

One of my patients happened to be an imaging rep, who asked how we were holding up this time of year. It was nice to see someone who understands that there are many factors behind keeping an office running, although he was less than amused that we couldn’t send his records to his primary physician.

As an independent organization, the large health systems in town aren’t too keen on sharing data with us even though it would mean they receive our work product as well. Just another example of information blocking that isn’t a vendor’s fault. In the meantime, I take full advantage of the features within Epic that allow me to access patients’ charts for a short time with their permission.

My operations brain is always challenged by these high-volume days. They make me wonder what “the system” could do differently to better manage these patients. Although many of those we saw had acute conditions that needed urgent treatment, like influenza or pneumonia or lacerations, many of them could have been handled by a nurse triage line or other lower-acuity situation.

Quite a few patients hadn’t tried any self-care, not so much as a decongestant or an over-the-counter cough medication, even though they were relatively young and healthy and didn’t have any reason to be concerned about medication interactions or worsening of chronic conditions. Several had been sick for less than a day. My favorite presenting issue of the day was, “My throat started with a tickle a couple of hours ago and I just wanted to see what it was.” This shows a lack of health literacy, even in the relatively affluent area in which I was working. What could we as a healthcare system do to serve these patients better?

I’ve also been able to put my telehealth hat on this week, due to a spike in volumes in my state. I only do telehealth visits sporadically since I don’t hold a lot of different state licenses. I was pleasantly surprised by the number of patients who weren’t specifically seeking antibiotics – who just wanted to make sure they were doing everything possible to treat their condition, or wanted validation of their treatment plan because they were making slower than expected improvement.

Back in the clinic the next day, I also saw the dark side of some virtual visit care as patients came in for face-to-face visits after having been prescribed medications that seemed unrelated to their symptoms. I saw three patients from the same physician who were each a bit concerning. It sounds like her practice has recently started using functionality within Epic that allows for patients to have billable asynchronous visits, and perhaps she isn’t in the swing with the fact that just because a visit is virtual doesn’t mean you don’t have to follow the standard of care. Maybe she doesn’t know the antibiotics she is prescribing aren’t indicated for the condition being treated, but there’s no good way to try to address that professionally when we see it.

Our volumes continued throughout the weekend, with record-breaking numbers of visits at several of our locations. I encountered a couple of primary physicians and one psychiatrist whose offices were not only closed during the holiday weekend, but also who had no after-hours coverage. Even other physicians received no response when trying to reach them. In my state, that’s tantamount to patient abandonment, and I hope those patients have some difficult conversations with their physicians (or perhaps soon-to-be-former physicians) about being left hanging.

I also heard some complaints from patients who just don’t feel like their physicians listen to them. It’s not only complaints about looking at the computer instead of the patient, but also complaints about physicians pushing additional procedures that are unrelated to their care plans. One patient showed me the brochure from her pulmonologist who was offering cosmetic Botox injections. These are just a small sample of the patients who wind up in the urgent care, where they’re trying to make up for whatever they’re not receiving in their usual setting of care, if they have one.

Santa must have been very good to a couple of patients, who presented with ICD codes in the F12 series: cannabis-related disorders. Cannabis-induced palpitations was one of the conditions, and I would have loved to have simply typed “lay off the weed” in my care plan. Somehow “reduce or eliminate cannabis use until cleared by cardiology” just doesn’t seem as festive. Nor does “your risk of recurrent vomiting would be lower if you stopped using marijuana.” These are the things they don’t tell you about in medical school, that one day you might find yourself dealing with in an exam room.

On days like these, I long for the relative lack of excitement found in a good lab interface build or some of the other work I do in my informatics practice.

For those of you who worked around the holidays, what kinds of adventures did you have? Any great stories? Leave a comment or email me.

button

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/23/19

December 23, 2019 Dr. Jayne 2 Comments

A student reached out to me recently, looking for a primary care physician willing to host him for a four-week clinical clerkship. I used to be a preceptor for both of the local medical schools but haven’t hosted anyone since I stopped practicing traditional primary care more than a decade ago. A call to the primary care clerkship office revealed that a computer glitch brought me back from the virtual dead, along with a number of physicians who are no longer able to host, and we were able to get it straightened out pretty quickly.

Still, I enjoyed chatting with the student, who had never heard of clinical informatics and had no idea what a physician might do besides conducting research or seeing patients clinically.

I was a little shocked by this since the medical school he attends is affiliated with a health system that just spent nearly half a billion dollars on an EHR overhaul. He’s already in the middle of his first clinical clerkship year, so theoretically he has been exposed to the hospital and countless resident and attending physicians complaining about the EHR or how it works. I would have hoped that the orientation to the EHR might have included an outline of how to request changes in the system, which would theoretically include mention of physicians serving on committees or in leadership roles who would have input into any requested changes. Apparently none of these things happened or were ever discussed, or my potential student missed the mention.

In hindsight, I think it’s more likely the former, since the hospital (and health system) in question still does not have a functional CMIO role. They have a number of clinical VPs and other titled people who are supposed to play a role in the governance of clinical informatics, but the reality is they have a number of other things on their plates that takes them away from actual informatics work. From what I understand from my peers, they don’t have functional governance structures and part of the IT team is devoted to just building what is needed to silence the squeaky wheels. The community physicians are up in arms about changes that are put in place for the academic faculty, and there’s a lot of duplicate work going on as they build different work streams without a unified approach.

I think the student enjoyed hearing about alternative careers for primary care physicians, especially once we talked a little about healthcare finance in the US and the high level of burnout among primary care physicians. His school isn’t doing a good job educating him on that topic either, since he had little understanding of Medicare or Medicaid or commercial insurance and the pressures felt by physicians as they try to navigate our healthcare non-system on behalf of their patients.

I suppose this might be one of the key goals of the primary care clinical clerkship, to expose students to such things since they’re probably not seeing it in the halls of the ivory tower. On the other hand, especially with the new push for premedical students to already have clinical experience before they apply to medical school, I was surprised by how little he knew.

He was also unaware of the salary limitations for primary care physicians. When I asked him if he had a ballpark idea what he might make in practice, he quoted a starting salary that was more than one and a half times that of an independent primary care physician with a well-established practice and an excellent payer mix with minimal Medicare and no Medicaid.

In my heart, I don’t want students to choose their specialties based on earnings potential, but I don’t want them to be surprised, especially when they’ll be leaving school with nearly half a million dollars in student loan debt. Granted, physicians still make a very good living, but many of us now in practice didn’t graduate with anywhere near that kind of debt. I was lucky with no undergrad debt, but still had to borrow the entire amount for medical school over and above what I had saved from jobs at the golf course, the donut shop, editing people’s term papers, and substitute teaching.

We talked a lot about how I came to be in clinical informatics and how I see the role. Usually I summarize it as being a translator or mediator – being able to work with clinical teams, operations teams, and the technology teams to identify ways that we can better the mission of patient care. Sometimes it’s process improvement work, sometimes it’s deep technology design work, and sometimes it’s just handholding for providers who are at their wit’s end. There are days when it’s sheer boredom (lab interface crosswalk build – if you’ve never tried it, you’re missing out) and some days are exhilarating (go-lives gone well). The rest of the time can be a roller coaster, but I wouldn’t trade what I do for a more traditional medical career.

I’m sorry I wasn’t able to teach him how to be a family physician, or to share how enjoyable it can be to take care of patients over time and to get to know them and their families. I like to think that he did learn something over the course of our conversations, though, even if it was just that he needs to do a little more investigation before he decides on a specialty. He has a few months left before he has to start applying for residency positions, when seems relatively short when you’re deciding how you want to spend the rest of your life.

I also gave him my standard advice: learn about the business of healthcare; learn about personal finances; don’t spend “like a doctor” when you get out of school; and find some non-work-related activities that will keep you company for the rest of your life. I was lucky to have learned many of those lessons along the way, but some of my peers, and many non-physicians as well, learned those topics the hard way.

I wonder how the medical school would receive the idea of a class covering these topics. Healthcare has certainly changed in the time I’ve been out of school, and not always for the better. There are driving forces that many in the industry don’t understand, whether they’re clinical or not.

On the other hand, isolating students from the reality of what they’re getting into might be useful to maintain the physician pipeline. I know quite a few of us who wouldn’t have done it had we known then what we know now. I see some of those former colleagues in hospital administration roles, industry roles, etc. You can always tell the people who really enjoy patient care because they often fight for the ability to keep their toes in the water, even if it’s only a couple of days a month. Of course, not all employers are sympathetic, and many more are forced to give up their clinical aspirations.

What does this have to do with the larger topic of healthcare IT? It’s food for thought to help us understand the force that shape clinicians and why they might act the way they do when faced with uncomfortable or unwanted change, or when some bit of technology puts them over the edge. Maybe if they were better integrated into the healthcare IT ecosystem earlier in their training, we would be fighting fewer (or at least different) battles. Maybe they wouldd feel more empowered to demand better usability and not just go along with what their hospital says they are going to use. Maybe they would see “the IT people” as less of a threat and more of a team working towards common goals.

How does your organization onboard medical students? Do they understand what the technology teams do? Leave a comment or email me.

button

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/19/19

December 19, 2019 Dr. Jayne 2 Comments

There’s a battle raging in Colorado over the Drug Enforcement Agency’s ability to access data within the state’s prescription drug monitoring program. In the course of investigating pharmacies, the DEA requested the data via a subpoena rather than a search warrant. The state claimed that the DEA request was indiscriminate, requesting six years’ of data for over 200,000 prescriptions. They offered to provide anonymized data and to comply with more specific requests with names.

The American Civil Liberties Union has entered the fray in Colorado district court, claiming that tight standards are required to protect privacy and requesting that patients should be alerted that the data will be disclosed or that the court should require a search warrant. The prescription drug monitoring databases have been a significant benefit for clinicians – it’s much easier to identify patients who might be inappropriately using controlled substances. This can lead to earlier interventions and improved outcomes. Let’s hope the legal battles have a favorable outcome that doesn’t take away from the important

A recent JAMA Network Open research letter looked at EHR usability, finding that progress is slow and sometimes nonexistent. The authors looked at 70 vendors who had participated in the Meaningful Use program over multiple years, finding that a good number fell short in usability testing. Only 27 vendors met the inclusion criteria, which included having a computerized provider order entry system, certification according to the safety-enhanced design criteria, and a reported System Usability Scale (SUS) for 2014 and 2015 usability requirements. They found that “there was no statistical improvement in EHR SUS scores between products certified according to 2014 and 2015 standards. One-third of 2014 products and one-quarter of 2015 products fell below the average benchmark SUS score.”

Despite the implications of EHR dissatisfaction on clinician burnout and patient safety, SUS scores decreased for 44% of vendors from 2014 to 2015. The authors note that the study has limitations, including that the SUS scores were vendor-reported and may not fully reflect EHR satisfaction. They go on to conclude that, “An increased focus on clinician end users during product design and development as well as optimized certification requirements are needed to improve usability.”

My personal, albeit anecdotal experience with usability is that for many vendors, it improves in fits and spurts. When they’re under the gun with certification requirements, they focus on it less, and when there is more breathing room, they seem to make a little progress. Given the amounts of money that health systems have spent on EHRs, they’ve created captive EHR users who are basically stuck with what they have. Even if it’s a failure, there’s little money left to make a change.

I enjoyed this Forbes piece on “Why Big Tech Companies Won’t Solve Healthcare’s Biggest Challenges.” Google and Apple are trying to disrupt healthcare, and both have the potential of significant earnings in the process. Still, it remains to be seen whether they truly understand the complexities of healthcare and whether they’re going to be able to set aside profit motive for altruism when it counts. There are also concerns about companies with obvious retail and profit motives having as much access to personal data as they might have moving forward.

The piece brings up some interesting points about whether patients should share in the profit from the use of their data. They point out the situation of Henrietta Lacks, whose cancer cells were used for decades of research without appropriate compensation. If you’ve never read it, “The Immortal Life of Henrietta Lacks” is worth a read. Hopefully we can all look back in a decade or two and see that good things have happened with the tech giants, but I agree that they’re not likely to find magic solutions for all our healthcare and technology problems.

I’m working on a project with a client where I’ve been asked to cull through potential technology solutions for a new service line they hope to take on. I’ve been sifting through websites, marketing collateral, and the pedigrees of various company leaders trying to determine whether the solutions are even viable. There are a lot of cool technologies out there, but some companies don’t look like they will have much staying power in the market.

We’ve moved into demos from some of the vendors, and I was shocked today to find myself on one where the demo data was not only nonsensical, but offensive. The patient scenarios used were degrading and it left me wondering whether they actually have any physicians on staff to guide them. Even if you’re a startup, spend a little money on physician expertise to ensure you don’t look foolish to potential clinical end users. If you’re not ready for a full-time physician on staff, there are plenty of clinical informatics experts who do contract work.

Despite the overwhelming coverage of impeachment proceedings, Congress is still getting other work done. The Telemental Health Expansion Act of 2019 has been introduced and referred to the Energy and Commerce Commerce. The Act would expand Medicare coverage for mental health services delivered via telehealth, and include the patient’s home as an acceptable “originating site” for services. This is much more useful to patients than having to go to a PCP or other office to receive telehealth services from another provider. There are several similar bills already working their ways through the halls of Congress, so perhaps one of them might be successful.

clip_image001

Tis the season of giving, and many of us are looking for ideas for our friends, family, and coworkers. I thought this piece on “Thoughtful and Useful Gift Ideas for Doctors” might be helpful. The first suggestion was a book on preventing burnout, which was a turn off. Much more interesting was their list from last year, which lead off with “caffeine and booze.” Some of the other items on the list were snoozers, although giving the gift of a defensive shooting class caught my attention.

In other holiday news, there’s support for why some of us dread listening to holiday music. There’s data showing that increased repetition of songs can lead to oversaturation and negative responses. Adding this to existing holiday stress and the effects can be compounded. According to data from Consumer Reports, nearly a quarter of Americans dread holiday tunes. I certainly enjoy holiday music in live performances, but the versions typically heard while shopping can be annoying.

button

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/16/19

December 16, 2019 Dr. Jayne No Comments

clip_image003

Winter has arrived in the Midwest, and with it the end-of-year slowdown in healthcare IT news. While sales-focused teams are scurrying to complete end-of-quarter sales to bolster their final financials, marketing folks seem to be holding anything remotely interesting until we get closer to HIMSS. That leaves us with a smattering of governmental and regulatory news items.

I admit sometimes I miss these kinds of items because of the noise of all the other things going on in the industry, so maybe it’s a good thing that we’re headed into a less-frantic time (at least until March, that is).

Sneaking into the news on Friday was the FDA approval of Tandem Diabetes Care’s predictive software that bridges the gap between continuous glucose monitors and the company’s insulin pump. Why is this a big deal? It’s the first insulin dosing software approved under a new FDA interoperability pathway, which gets interesting because different companies make components of the so-called “artificial pancreas” systems that result. You could be using one company’s glucose sensor, another’s pump, and a third-party algorithm between the two.

Tandem is already working with Dexcom Inc. and Abbott Laboratories to coordinate. This is great for patients whose insurance may only cover certain brands of one device or another, and who otherwise might not be able to take advantage of the newest technology. Typically payers only cover insulin pumps every four years, so being able to update a control algorithm rather than having to obtain a completely new device is a pretty cool thing.

Also in the news this week: glitches in the Healthcare.gov system where many people have to sign up for insurance coverage. It’s possible that up to 100,000 users were impacted by technical issues on the first day of open enrollment. CMS had to add a “waiting room” to the site to help manage traffic flow, and as of December 7, there have been 6 percent fewer enrollments compared to last year.

Patient advocates were concerned about the typical last-minute surge of enrollments and whether the site would be able to handle the traffic before the deadline. I haven’t seen any updated numbers this morning, but I’m sure there will be a lot of spin placed on whatever data becomes available this week.

A recent approval by the Federal Communications Commission is raising concerns. The group voted last week to create 988 as a nationwide suicide prevention hotline telephone number, much like 911 for emergency services. It would replace the existing number for the National Suicide Prevention Lifeline. The thought is that a shorter number would enable more people to call, but there are anticipated downsides: an increased number of callers would also increase the costs for crisis centers staffing those phones and many centers are struggling to make ends meet as it is.

The hotline is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA). Theoretically more people would be calling 988 rather than 911, so that’s a cost savings since fire and emergency services won’t be dispatched for a potential suicide attempt. It could also lead to significant societal savings by preventing loss of life, but those savings aren’t immediately passed to those institutions bearing the cost, based on the calculus of healthcare math. Another example that healthcare is complicated, y’all.

Other government news includes the impending release of millions of dollars in disputed Medicare hospital payments that were withheld due to a payment policy that was struck down in court. The American Hospital Association estimates that $380 million will begin flowing as Medicare Administrative Contractors start reprocessing claims that were paid at reduced rates. Reprocessing begins January 1, so get your data and claims engines running!

Just when I thought I was out of government news, I came across news about the recent report by the US Department of Health and Human Services, Office of the Inspector General, regarding concerns around chart reviews looking at Medicare Advantage payments. Not surprisingly since billing is such a game, claims were reflecting sicker patients and more comorbid conditions than patients might actually have. Apparently payers are adding diagnosis codes for conditions that aren’t documented in physician or hospital records and this occurred in 99.3% of chart reviews.

Medicare Advantage is a big piece of the Medicare spending pie — approximately $210 billion of the $711 billion spent last year went to Medicare Advantage plans. There are concerns not only about overbilling, but that plans are functioning like the HMOs of the past to deny care as a means of increasing profits. There are also concerns that if the patients actually have the conditions added by payers (which aren’t reflected in the medical records) that patients aren’t receiving adequate care.

The audit looked at data from 2016 to assess the financial impact in 2017. As payers get more creative, it’s possible the problem could be even more rampant now. A particularly damning sentence from the report: “Although limited to a small number of beneficiaries, almost half of all Medicare Advantage organizations reviewed had payments from unlinked chart reviews where there was not a single record of a service being provided to the beneficiary in all of 2016.” At least fee-for-service payment models require the patient to be in front of you before you bill for services.

HHS recommends that CMS provide oversight of organizations that had payments resulting from chart reviews where beneficiaries received no services; conduct audits to validate diagnoses; and reassess the practice of allowing unlinked chart reviews being used as a source of diagnoses for determining risk. CMS accepted these recommendations.

There’s one piece of governmental news that’s front and center right now, although patients aren’t talking about it. Influenza is on the rise, with 2.6 million illnesses, 23,000 hospitalizations, and 1,300 deaths so far. I can’t count the number of patients who said “I never get the flu shot” a couple of months ago who are now showing up at the office sick and miserable. There’s not a lot we can do for influenza, other than providing supportive care and symptomatic relief. For small children, there’s even less we can do. Please do your part – wash those hands and stay home if you are sick. And next year, consider a flu shot.

button

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/12/19

December 12, 2019 Dr. Jayne No Comments

My bedtime routine includes checking HIStalk for comments and doing some light Web surfing on my phone, so my attention was captured by yesterday’s JAMA article entitled “Matters of the Mind – Bedtime Procrastination, Relation-Induced Anxiety, Lonely Tweeters.” No surprise, studies linked smartphone use with bedtime procrastination. The piece also looks at how relaxation can be stressful for individuals with anxiety and depression, as well as how Twitter posts could help identify loneliness. These are areas of research many of us wouldn’t have dreamed of a decade ago. I’ve thought frequently about consumer technology (particularly smartphones) and how it’s collectively one huge experiment, albeit one without an Institutional Review Board to make sure the participants aren’t harmed. I think we’re just scratching the surface at learning what technology does (or doesn’t) do for or to us.

image

Jenn clued me in to this article about startups focusing on nurses as a target audience. There are 3.8 million nurses in the US, so it makes sense that companies would start designing around their needs. Clove is one of them, and their name is an inside joke as well – the C with a line over it is medical shorthand for “with” so their products are “with love.” The name is subtle but the medically-inspired design of its shoes aren’t – although they’re a running style, they have a solid smooth surface over the toe area which is great to protect from the spills and goo of the job. Ventilation holes are relocated to the sides, where splashes and drips are less likely.

The company is savvy in other ways, showing that they understand healthcare folks by shipping a three-pack of pens with every pair of shoes. The pens are marked “For Borrowing Only.” Anyone who keeps a spare (and usually crummy) pen in their pocket to deal with people who ask to use your pen and who are unlikely to give it back knows what I’m talking about. Nike also recently launched a healthcare shoe, but it’s not nearly as cool. I was a little put off by their unisex sizing as well as their use of the “star of life” logo most commonly used by emergency medical services. In contrast, Clove has both women’s and men’s sizing as well as color names that make clinicians smile: Grey Matter, Night Shift, and Pink Up.

Public health informatics is a big part of clinical informatics, and I was shocked to learn about a measles outbreak on Samoa, where measles is running rampant. The country has a population of around 200,000 and nearly 4,900 people have become ill with 71 dying. Similar outbreaks are also occurring in Tonga, Fiji, and American Samoa. Several of the Pacific island nations have vaccine rates below World Health Organization recommendations. There are numerous reasons for the low vaccination rates, but my thoughts go out to those who are sickened and their caretakers. Hopefully the outbreak is a brief one.

In other news, analytics folks must be cheering at the possibility that flu season could peak early this year. The Centers for Disease Control and Prevention’s FluSight Forecasting initiative gives it a 40% chance of peaking this month, as flu levels have been at or above the national baseline for several weeks. The chance it will peak in January is 30% and February is 20%. I’ve significantly reduced my clinical work for January and February because I loathe driving in icy conditions, so we’ll see if I played the odds right or not.

image

Intelligent Medical Objects has launched IMO Precision Sets, which are designed to allow clients to quickly define various value sets needed for quality work and value-based care. Based on IMO’s solid terminology and maintained by their dedicated clinical terminologists, they are available in various sets – Oncology, Reporting, Behavioral Health, Chronic Conditions, Perioperative, and Acute Conditions. I spent way too much time in a past life trying to maintain those groupings for reporting, through ICD codes and SNOMED codes. IMO’s original Problem IT product was the only solution I ever deployed as a CMIO where my providers proactively reached out to say thank you, so I’m a big fan of their work.

Congress is looking for feedback on a new bill nicknamed “Cures 2.0,” which is designed to go beyond the content of the original 21st Century Cures Act to address topics like digital and connected health platforms. They also plan to focus on real-world evidence in the FDA’s approval process, and to speed up coverage of FDA-approved drugs by payers. Feedback is requested by December 16 at cures2@mail.house.gov if you’re interested in sharing your thoughts.

As we approach the end of the year, it’s a time for many to reflect on the months that have passed and our hopes for the coming year. Since we work in healthcare technology, we’re not immune to the influence of various trends and fads, especially where health-related tech is concerned. Like many, I’ve had my adventures with wearable tech, startups, and various apps that proposed to make my life better. Lots of people have stories to tell about how we can live our “best lives,” from tech gurus to TV personalities. In a fit of decluttering I had my Marie Kondo moment, so I giggled when I came across this article about “The life-changing magic of making do.” I’m a frugal person (as evidenced by writing this wearing 20-year old pajamas on a 20-year old sofa, watching Netflix on a TV smaller than some computer monitors), but was shocked by some of the statistics in the article as far as sheer consumption in North America.

The piece’s comments on the lack of fixability with technology resonated with me – it’s one of the reasons I hope my geriatric washer and dryer never fully give up the ghost – I don’t need something with a motherboard to control how my clothes are cleaned. (I’ve had enough of that drama with the refrigerator to last a lifetime). I’ve rehabilitated both the washer and the dryer courtesy of Repair Clinic and its videos. (Have you ever seen inside a gas dryer? It’s pretty crazy in there.) It gives me hope for what I want to do professionally in the next year – to help healthcare organizations get the most out of the resources they’ve already paid good money for and that they might not be using to the fullest. It’s a good goal, but difficult for some organizations because it often involves hard work. It’s much easier to throw out a “problem” technology when the real problem is the people or processes that govern its use. We’ll see how that plays in the New Year.

What are your reflections on the past year and hopes for the coming one? Leave a comment or email me.

button

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/9/19

December 9, 2019 Dr. Jayne No Comments

As part of the Maintenance of Certification process for my clinical informatics board certification, I have to complete a quality improvement project related to practice. Although there is quite a bit of flexibility in these projects, it’s been challenging for me to come up with something because I don’t have what many would consider a “typical” informatics practice. Many of my peers are either part of academic institutions where they have clear roles and/or titles. Others are part of healthcare delivery organizations where they have the ability to use data and processes for quality improvement. As an independent CMIO for hire, I often have a seemingly random mix of employers, ranging from startup technology vendors to large healthcare systems.

In these situations, I have contractor status. It’s a strange limbo where often you are treated like an employee but you’re actually not – you have many of the same responsibilities and are subject to the same rules as employees, but at the end of the day you don’t have the ability to direct your own work or propose new initiatives that would make sense for a straightforward project for board certification. My clinical situation is unique in that I’m employed, but very much part time and with no formal informatics role these days. My informatics influence is limited to cranky emails to our IT team asking why the system is suddenly allowing us to e-prescribe controlled substances when we do not have legitimate EPCS technology in place. My employer is reluctant to allow me to do anything with our data, since I’m essentially just an hourly physician.

I have another year or two before I have to finish this project, but I still feel somewhat adrift with it. Still, I am always on the lookout for ideas. One recently came across my desk, and I wonder if the practice would be willing to let me use their data if I could find some “what’s in it for me” for them. As an urgent care, we certainly see our fair share of trauma. Recently, JAMA Otolaryngology-Head & Neck Surgery published a study investigating a surge in cellphone-related facial trauma. Reported injuries range from being injured by a dropped or thrown phone to distraction-related falls.

The authors looked at 20 years of data from the US Consumer Product Safety Commission database looking at ER visits. They found 2,500 patients with phone-related head and neck injuries between 1998 and 2017, with a surge beginning in 2007, coinciding with the advent of smartphones. Approximately 40% of the subjects were between the ages of 13 and 29, and they were generally injured while walking, driving, or texting. Although cell phone use has also been linked to repetitive motion injuries, these were excluded from the study. The most common injuries were facial and head lacerations, followed by contusions, abrasions, and injuries to internal organs. The majority of patients were treated and released. Apparently there are more than six million patients treated for lacerations every year, with an estimated cost of $3 billion.

I’d be curious to find out how cell phones compare with other sources of trauma in our urgent care practice. We see over 300,000 patients a year so there should be a reasonable amount of data. Anecdotally, I think that sports-related injuries likely make up the lion’s share of our head trauma, followed by motor vehicle accidents, and falls. I’m betting that the causes would have to be determined by a chart audit, because many of my partners aren’t as specific with their coding as they could be. My quality intervention could be to assess whether visits were documented more accurately when physicians or scribes were doing the work, and to develop a curriculum to try to increase the specificity of coding. It’s kind of a soft project, but it at least addresses something that is clinically relevant in my practice. Still, it’s unlikely that I could talk my employers into it, since there’s not a clear return on investment for the time that would need to be spent educating clinicians and staff.

Another option for the quality project is for informaticists to conduct a 360-degree evaluation project. We did a 360-degree evaluation in residency and I’ve done it with a previous employer, and also with one of the community service organizations I work with. All three times I found it to be useful, although the episodic nature of some of my work might make this challenging. Some of my projects only last a month or two, which makes it hard for someone to get to know how you work, critique it, and then re-evaluate after you’ve completed some kind of intervention or change in how you work.

These are all part of the hoops that we have to jump through to maintain our board certification status. It’s particularly challenging in clinical informatics, since there can be such breadth in the type of work that we do. Our practice environments can be very different, and we may spend anywhere between 1% and 100% of our time doing informatics work depending on how much our employer wants to fund. I am glad that the American Board of Preventive Medicine, which is my certification body, recently approved a proposed Longitudinal Assessment Pilot as an alternative to the one-day board certification exam. It is supposed to launch in early 2021 and run for 24 months. Participants will answer 24 questions a year. This differs significantly from the longitudinal assessment pilot in my primary board, where we have to answer 100 questions a year for four years in order to replace the exam. It’s hard to imagine how the scope of clinical informatics can be distilled down to 24 questions a year, but unlike my primary board, it doesn’t seem that we have the opportunity to opt-out of this pilot.

I’m curious whether non-physicians are aware of the clinical informatics quality projects and whether your board-certified colleagues have pulled you in to help them get across the finish line. How are the projects perceived? Have there been positive outcomes? Or are they just a nuisance? On the physician side, is anyone else dreading their project? Leave a comment or email me.

button

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/5/19

December 5, 2019 Dr. Jayne 1 Comment

A recent NEJM Catalyst piece looks at the role of physician gender when looking at EHR usability and clinician burnout. Researchers at the University of California San Francisco found that female physicians created longer notes, addressed a higher percentage of patient contacts within 24 hours, and spent more after-hours time using the EHR than their male counterparts. Female users were also more likely to use copy/paste and other tools to make documentation more efficient, but spent more time in the EHR. These factors may explain a higher rate of female physician burnout when looking specifically at EHR use. The study was fairly broad, looking at over 1,300 physicians across nearly 90 specialties. It looked at various six-week time periods over the course of a year.

The authors suggested that healthcare organizations could do a better job reducing EHR burden overall, including creating clear expectations for EHR use and timeliness of patient contacts. I’d go further to suggest that they look at the FTE support staff in various practices and whether the physician to staff ratios are equal.

I’ve seen several practices in my recent travels that relatively understaffed some physicians (both male and female) despite equal productivity. Staffing ratios there depended more on physician personality and the fact that some providers demanded more support staff, where others were more likely to pitch in and do staff-level work or didn’t want to rock the boat asking for more help. Although the study controlled for staffing, my experience in non-research environments is that staffing can be highly variable.

Other teams have also looked at this issue. A recent JAMIA article looked at usability and gender, along with age, professional role, and years of experience. Among intensive care physicians, they identified “significant gender-based differences in perceived EHR workload stress, satisfaction, and usability – corresponding to objective patterns in EHR efficiency.” Drawing conclusions based on gender can often create friction among clinicians, but I’m glad they’re looking at the problem.

clip_image001

I’ve been on several vendor webinars this week and have experienced sessions spanning the range of good, bad, and downright ugly. For those of you who have to deliver webinars, I have some tips.

First, make sure you have your content fleshed out ahead of time. You don’t have to write a full word-by-word script, but you need to know what you are planning to say. On the other hand, if you struggle with impromptu speaking or have a tendency to go off track, write a script. Whatever you do, please do not simply read the slides to the audience. You’ll lose them in a flash. If you use a script, practice reading it in a conversational way, not like a robot.

Second, check your slides for visual appeal. Text should not be too bulky in content or too small in font. Use visuals to convey your ideas along with your word track and it will be more memorable to the audience. If you’re including polls for the audience, please show the results as you go – don’t just grab the data for your own marketing purposes. Attendees often want to understand how they compare to others on the call – whether they’re ahead of the game or trending the same as other organizations.

Last, make sure any photos used during introductions are professional or appropriate to the audience. Your hair should be combed, at a minimum, and it would be nice if the background was uncluttered and the lighting was good. Under no circumstances should you crop yourself out of a group wedding photo (yes, I saw this).

Mr. H already mentioned this article about physicians and tech staff clashing at digital health companies. Having been a physician working in digital health including with vendors, I wanted to add my two cents.

The article makes the point that clinical and product teams are “at odds,” which I have definitely seen. I’ve also seen teams where everyone works well together and drives the solution forward because they have a mutual understanding of each other’s experience, goals, and priorities. One of the biggest barriers to successful collaboration is the presence of preconceived notions about the members of the team. If tech team members have had previous negative experiences with physicians, they’re likely to make assumptions based on those experiences. Similarly, physicians may not understand the roles and processes of various tech team members or how an agile process works. Getting everyone in the same room to learn about each other and how they need to work together is a start.

Another barrier I’ve seen is lack of structure – inconsistent sign-off processes that may not fully explain how requirements or other work product should be flowing through the organization and lack of defined processes for clinical and other subject matter experts to provide their feedback. That can result in unpleasant shocks at the end of the process when clinical folks are presented with workflows that aren’t going to work, but could have been better engineered if the clinician input was at a better place in the process.

Physicians also need to have a common framework for how they’re going to make decisions around clinical content. Is the company striving to be evidence-based, or is customer satisfaction or sales the lead driving factor? These elements aren’t mutually exclusive, but there has to be a common goal or physicians may be in conflict with each other. This goes back to governance, including team charters and product charters that make sure everyone is working towards common goals and there is clarity about how decisions need to be made, or how to handle when physicians or other clinical SMEs are not in agreement.

This isn’t just a clinical issue. I’ve seen the same problems in other areas of the healthcare IT industry, whether it’s revenue cycle, billing, patient engagement, etc. Everyone needs to understand the role that team members play and needs to respect the roles and knowledge of others on the team or there is going to be conflict. This goes back to leadership. If the individuals in charge don’t buy into this concept of mutual respect, and either team feels like it’s being marginalized or attacked, the effort is not going to be successful.

Do you have clinicians who are part of your development organization? What advice can you offer? Leave a comment or email me.

button

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/2/19

December 2, 2019 Dr. Jayne No Comments

clip_image003 

I’m happy to report that I’ve survived the Thanksgiving holiday despite the intersection of bizarre karmic forces that had me working in the clinic most of the week as well as hosting Thanksgiving Dinner. I worked Black Friday and the weekend as well, so I haven’t fully recovered. Next, I’ll have nearly two weeks free of clinical care, then some scattered shifts before the scheduling gods smack me down again with a five day streak of 12+ hour days before we head into 2020.

I don’t know what our schedulers are thinking at times, but I suspect they’re scheduling around the day-off requests of the full time and higher-ranking physicians. I’ve asked for fewer shifts in the new year, so hopefully I can regain my sanity.

Truthfully, I don’t mind working Black Friday and it’s become a bit of a tradition for me. I’m not much of a shopper and value my sleep too much to be getting up at the crack of dawn to hunt for bargains. Most of the patients who come in are actually sick and it’s a privilege to help them. Many of them put off care because of holiday preparations and having family in town and now they’re in bad shape.

Most of the primary care offices in the area were closed, so their choices were limited. One cardiology office I called had a message that they would be closed until January 2, so either something funny is going on with the practice or they accidentally recycled their Christmas out-of-office message from last year.

We started the day with more than a little trepidation. The team that was on for Thanksgiving noted they had issues with our EHR communicating with our drug dispensing system. They were not able to get it resolved due to lack of holiday support from the tech teams. Fortunately for us it was working, and by noon, we had seen more than twice our usual volume of patients. As soon as we would empty the waiting room, another batch of patients would arrive. It was well after 3 p.m. before any of us were able to sneak off to the kitchen to eat the previous day’s catered leftovers.

I have to say that our leadership understands that well-fueled staffers are happy staffers. They had pizza delivered the day prior to Thanksgiving, a full holiday spread on the day itself, and the random arrival of dozens of tacos and burritos on Black Friday.

The holiday patient mix is always an interesting one. We had several hospital transfers for influenza, pneumonia, and out-of-control diabetes. We saw kidney stones, raging urinary tract infections, and a couple of lacerations that should have been taken care of the day before, except people didn’t know we were open. There were even a couple of people who had a little too much holiday merriment and came in for IV hydration. Strep throat, sinus infections, and plenty of lingering colds rounded out the day.

I was glad to see the severity of illness dropping as the day went on since we were all getting pretty worn out by dinner time. We had a brief surge of people who came in after their shopping was done, which always makes me a little aggravated since they were out spreading germs when they should have been at home with some soup and a vaporizer. The rest of the weekend was a different story, with moments of calm punctuated by anxiety-provoking stroke symptoms, head trauma, and a myocardial infarction that was smoothly transferred to the hospital.

On days like these, I’m grateful for the EHR and the ability to have default documentation that works for patients with similar symptoms. We tweak them as we need to, but it’s still fast, and as long as you’ve personalized your defaults, the notes are of good quality.

Of course, there are always providers who don’t personalize their options, which is how you wind up with visit notes that have exam findings that you’re sure the physician in question didn’t do. Or they don’t use the defaults at all, which leads to slow documentation and plenty of physician frustration. I definitely couldn’t document this fast on paper, even when I worked in an emergency department that used paper templates designed for rapid documentation based on the patient’s presenting issue.

People often ask me why I continue to do as much clinical work as I do. The real answer is that I enjoy it. I enjoy the people I work with and the organization I work for. We have an outstanding workplace culture. Frankly, compared to being a CMIO, it’s like being on vacation. Everyone knows their roles and responsibilities and how to work together as a team, despite the fact that we work with different combinations of people and at different locations all the time.

It’s a fail-fast environment. People who can’t get it done don’t last very long. They give people the tools they need to be successful, and if it’s not a good fit, they’re not going to subject the rest of the team to poor performance. I never played on a select sports team, but I imagine it might feel a bit similar. I’m willing to put up with wacky scheduling in order to stay on a high-performing team.

We no longer have an annual company holiday part  since it has been moved to the spring after flu season is over. But this year, the staff has organized their own get-together. Sometimes people just want to get away from their co-workers at the end of the day, so it’s great being at a place where people like each other enough to want to spend time together. We’ll be bowling the night away along with a “rob your neighbor” gift exchange, which based on the sense of humor held by many of my co-workers, should be highly entertaining.

I was honored to be invited since I don’t think all of the physicians were on the guest list. At least we know that if anyone has too much holiday cheer or sprains something during the “crazy bowl” part of the evening, we’ll be well cared for in the morning.

What does your company do to celebrate the holidays or thank the team for its hard work? Leave a comment or email me.

button

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/25/19

November 25, 2019 Dr. Jayne 3 Comments

Clinician burnout continues to be a hot topic, so this American Academy of Family Physicians article caught my eye. It looks at the possibility that being able to better address the social needs of patients might reduce the possibility of burnout. I’m not surprised by this – physicians and other clinicians are trained to do their best to address all their patients’ issues, whether they are purely biological, psychosocial, or somewhere in between.

In many residency programs, we have all kinds of ancillary providers that help us do these things. My training program had PhD pharmacists, social workers, diabetic educators, dieticians, and psychologists to which we could refer our patients for a variety of services. Need a patient to receive education on anticoagulant drugs, their long-term monitoring, and the need for dietary changes? Check. Want to enroll a patient in smoking cessation clinic? Check. Newly diabetic patient who needs supplies and training? You got it. Patient who needs help navigating Medicaid enrollment or applying for supplemental nutrition assistance? Done.

When I headed out into practice, however, I was on my own to try to deliver many of these services. Even referring to subspecialists often became a battle that was made worse depending on the patient’s insurance coverage, ultimately resulting in the patient not receiving needed services.

At one point in time early in my career, only one of the city’s practices was taking new neurology patients who had Medicaid, which made the wait to see a consultant nearly a year long. This led to primary care physicians trying to do what they could to manage complex neurological issues that they weren’t trained to handle. You don’t have to ponder to hard to see where that could cause stress and burnout.

Not much has changed in the last couple of decades, although at times it’s a little easier to get patients in to see subspecialists, or maybe I’ve just built up enough friendships to be able to call in more favors. There are other more complex issues that we can’t solve through a phone call to a friend or classmate. Maybe it’s housing issues, transportation issues, or food insecurity. These are the types of issues that the study mentioned was looking at, along with whether inability to address patients’ social needs was a contributing factor to primary care clinician burnout. The authors went on to note that increasing services in the practice to address social needs tended to reduce burnout and improve clinician morale.

The study noted that participating physicians were concerned about how addressing social needs would impact their workflow. I’m curious about how those physicians went about adding services or training staff to address social needs and how that impacted not only the workflow, but the practice bottom line. Theoretically, some of the new care models, such as Comprehensive Primary Care Plus or Primary Care First, should provide additional funds to cover these additional services. However, it’s still not going to be enough.

A friend’s EHR has the ability to link out to transportation resources for patients, such as Uber. However, the practice has to pay for the transportation, leading to an ongoing internal conflict about which patients should receive those services. Independent physicians can make these decisions locally, but employed physicians are often subject to the whims of their owners, and productivity and case mix determines which physicians (and therefore patients) receive additional support and which don’t.

On the technology side of healthcare, we face similar difficult decisions. We have limited budgets and requests for more projects than we could possibly fund or staff. At one of my large health system clients, decisions often impact broad swaths of patients. Are we going to focus on systems to improve labor and delivery workflows this year, or fund the initiatives that the heart failure program has requested? How many patients would benefit from either approach? What about the community diabetes screening initiative, or the dental care mobile van? Should we look just at patient count, or go further to see how interventions would impact people over time?

At one point, money earmarked for optimization of frontline nursing workflows was diverted to cover consulting services needed to complete a required regulatory upgrade. This led to a relative revolt by some of the staff involved in advocating for projects that didn’t get the nod.

The emotions felt by some of the IT staff were no different than what was probably felt by the physicians in the study. In particular, those whose projects weren’t taken forward felt disenfranchised and often had a profound sense of loss. Some of those whose projects succeeded had something akin to survivor’s guilt as they watched other worthy initiatives wither. It also engendered a sense of fear and concern, with people wondering whether their project would be the next one to be defunded or otherwise not fully implemented. Sure, projects get canceled in every industry, but I think my colleagues in healthcare IT feel it more acutely because they know their work has the direct ability to impact patients’ lives.

The emotions become even more acute when you are working for organizations that are sitting on billions of dollars of resources, but may not be spending as much on patient care as they should. The marble lobby of the tertiary referral hospital is particularly luxurious (and the fountain is pretty darned impressive), but neither of those see patients. They don’t make up for the negative emotions felt by the clinical staff that empties the exam room trash cans every other day because the housekeeping budget was cut and services are only provided on even days. The luxury boxes at the ballpark and the over-the-top billboards are also a visible reminder of the money the health system is willing to spend on non-patient-care activities.

As the old adage goes, you have to spend money to make money, but somehow that spending is becoming less palatable when healthcare is on the line and patients are literally dying due to lack of basic interventions.

It’s easy to see why people in healthcare are burned out, no matter where you work or what your role is. Our inability to meet our patients’ needs is only a proximal cause, with many root causes beneath. I’m cautiously optimistic about new models of care that might help alleviate suffering or reduce gaps in care, but it may take years to determine how successful they really are. In the meantime, we need to support each other and continue to try to come up with innovative ideas to solve some of the most difficult problems humanity faces.

What would make you feel less burned out? Leave a comment or email me.

button

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/21/19

November 21, 2019 Dr. Jayne 1 Comment

I wrote a few weeks ago about my adventures with flu vaccines and how the charges are handled by my insurance. Kaiser Health News dug into the phenomenon this week, going farther in noting the differences in costs among one payer’s own employees. The payments ranged from $32 in Washington, DC to $85 in Sacramento.

This illustrates the results of negotiations between payers and providers, the madness of which leads to the need for entire segments of the healthcare IT industry to keep up with it. Anyone who has worked with practice management or revenue cycle systems has experienced the phenomenon and the layers of code needed to wrangle it, and I salute you. It remains to be seen whether the government will be successful in forcing providers and payers to disclose this information publicly. Efforts to do so will likely be in the courts for some time.

I’ve been doing some behind-the-scenes work on clinical guidelines, and recently tried to track down data on a drug that is supposed to be available as a generic that we couldn’t find. The Wall Street Journal made note of the problem this week as well, observing that multiple factors keep those drugs from making their way into patients’ hands. It’s a disappointing phenomenon, but an interesting read.

In other drug news, a serious outbreak in pigs is likely to cause a shortage of the critically necessary blood-thinning drug heparin. African swine fever is on the march, killing nearly 25% of the world’s pig population, particularly in China, where the majority of heparin is produced. The World Health Organization is recommending that governments stockpile heparin, so be on the lookout for extra alerts and clinical decision support needs in EHRs.

Mr. H already reported on the AMA’s call for inclusive EHRs for transgender patients, but I want to throw in my two cents. Several years ago, I worked on some focus groups with a vendor who was trying to get this done. It can be complex, because there are many variables to document, including legal status, legal name, preferred name, surgical status, hormonal status, anatomical status, genetic status, etc. The vendor was focused and had several physician advocates who would continually explain to business analysts and developers why this was important. They ultimately they got the job done.

I’ve heard rumblings from other sources that this is a big lift for a small number of patients. But without the ability to document key clinical data and use it at the point of care, it results in a subpopulation being treated differently and in ways that might actually be counter to good clinical care.

The AMA also adopted a policy to promote education on health issues related to sexual orientation and gender identity for medical students and residents. I didn’t know much about the transgender population until medical school, where I had a professor who was public about their transition. It was a tremendous opportunity for learning and understanding and made a great impact on me, ultimately leading to me having a good number of transgender patients in my practice. I’m fully supportive of efforts to make EHRs inclusive for everyone, whether it’s based on differences in gender, age, race, ethnicity, or any other characteristic that may influence health. To be the most effective, we need to be able to meet our patients “where they are” and this is one way to work towards that goal.

Measure-palooza: The American Heart Association (AHA) and the American College of Cardiology (ACC) have released updated Clinical Performance and Quality Measures for adult patients with hypertension. The new report includes 22 new measures and expands focus from blood pressure measurement to care delivery systems and approaches. Their goal is to look beyond individual provider performance.

That’s great in theory, but it’s not how most other clinical quality measures programs work. It may also add workflows to EHRs, resulting in poor usability that will be blamed on the EHR rather than an explosion of guidelines and measures. There are also mismatches in the quality numbers used by AHA/ACC, CMS, and the National Committee for Quality Assurance. I’m sure EHR requirements writers are wringing their hands at this point. The report also includes a focus on digital health, including remote monitoring for hypertensive patients.

Maybe the EHR isn’t so bad: A recent study conducted at the University of Pennsylvania Health System showed an increase in orders for certain cancer screening tests when a “nudge” alerted users from the EHR. The alerts were targeted to medical assistants who created the orders for licensed clinicians to review and hopefully discuss with their patients. Despite the increased orders, there were not significant changes in the number of patients who completed the recommended screenings within a year-long time frame.

I recently worked with a practice that raffled off a big-screen television to patients who completed home colorectal cancer screening kits within a specified time frame. I’m not sure how legal it was, but it was certainly effective at motivating patients to submit a sample.

Kudos to the clinical informatics team at Oregon Health & Sciences University, who recently implemented a drug pricing comparison tool within Epic. It factors in data points such as co-pays, deductibles, and the need for prior authorization. The information has been available to dispensing pharmacists for a long time, but moving it to the point of care is key. It doesn’t matter how effective a drug is when it’s never going to be taken because the patient can’t afford it.

My clinical practice offers cash-only prescriptions at the point of care, which simplifies things for patients who know what their co-pays are (most of our drugs are either $15 or $30). However, many of our patients have no idea what their co-pay might be and are unable to make an informed decision. Having a tool like this at the bedside would be a benefit for the rare cases when we have to prescribe more costly drugs.

clip_image002

Flu season is getting well underway, particularly in the South. My practice is running low on vaccine and expects to be out by the end of the month. If you’re thinking about getting vaccinated but haven’t done it yet, time is of the essence. Three children have already died this season. If you still have plenty of vaccine, maybe an outreach campaign using those expensive population health tools is a good idea.

button

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/18/19

November 18, 2019 Dr. Jayne 3 Comments

A former colleague of mine reached out recently, frustrated by a physician in his organization who is demanding that clinical decision support features in some applications be turned off. He was asking for tips to help counter the argument.

It turns out that the physician in question believes that if the application presents you with guidelines that you ignore, you are liable. Fortunately, it’s a pretty easy counterargument. If a guideline exists and you ignore it, regardless of whether it’s in your application, you are liable. In many cases, if a guideline exists and you don’t know about it but a physician would be reasonably expected to know about it, you are liable.

The whole point of clinical decision support is to bring those guidelines  — which you may or may not be familiar with or incorporating into your practice — to the point of care so you can react to them. Of course, this assumes that the clinical decision support in question is accurate and appropriate.

Since crossing into the realm of clinical informatics more than a decade ago, my clinical activities have been limited. This is partly by choice (realizing that I can’t do justice to the traditional primary care paradigm when practicing on a very limited schedule) and partly due to workforce economics. Unless you’re a physician administrator at an academic institution or your CMIO situation includes a specific carve-out for clinical care, it’s unlikely that someone wants to hire you to see patients one day a week.

Since the scope of my practice is relatively limited, one might think it would be easier to keep up with the knowledge base, but it’s still very challenging. I remember a couple of years ago when one widely-used antibiotic fell out of favor for a particular condition. It was a good six months before one of my go-to journals reviewed the primary article and another three months before I actually read it, meaning that I was prescribing a less-than effective medication for a good nine months before I knew any better. What if there could have been clinical decision support at the point of care, which would have alerted me to the fact that the antibiotic selected was no longer recommended for the diagnosis I had entered?

Conventional wisdom is that medical knowledge doubles approximately every eight years. Physicians graduate from medical school and are then trained in residency by physicians who might have been in practice anywhere between one and 60 years. One would expect great variability in those teaching physicians’ knowledge bases as well, which is another plus for clinical decision support.

There are a number of pros and cons around whether clinical decision support should be regulated and how that might impact shifting liability. Others voice concerns about whether this will lead to so-called cookbook medicine or encourage mental laziness among physicians. Regardless of the strength of decision support or whether it’s regulated, physicians still have a duty to determine whether the recommended course of care makes sense or if there are any concerns about the recommendations.

Physicians need to understand where the recommendations found in clinical decision support systems originate. Are they from well-known guideline producers, such as the US Preventive Services Task Force, the Centers for Disease Control and Prevention, the American Cancer Society, or the American College of Obstetricians and Gynecologists? Are they just automated and exposed guidelines that are doing simple checks against diagnosis codes, SNOMED codes, LOINC codes, and medication codes, or are they using artificial intelligence or machine learning?

Rand Corporation blogged about this issue way back in 2012, and the thoughts around it haven’t changed significantly. Straightforward clinical decision support, such as drug-drug interaction checking is great, but alerts have to be at the right level for a physician to highlight the most critical cases while preventing alert fatigue. Users who click through alerts without reading or digesting them will continue to be at risk for increased liability in the case of a poor outcome.

Oregon Health & Sciences University’s Clinical Informatics Wiki covers this issue as well. It notes that, “As long as 25 years ago it was realized that availability of computerized medical databases would likely erode the local or community standard of care.”

Changes to the community standard of care might not be a bad thing. Many of us believe patients should be treated the same whether they live in the city versus rural areas and regardless of differences in income or demographics. However, there have been pockets of the country where physicians were held to a different standard for a variety of reasons.

Take the PSA test for prostate cancer risk. At a time when the US Preventive Services Task Force was specifically recommending against testing (in part because of the number of false positive tests leading to unnecessary biopsies and other downstream consequences) my community performed them across the board because a leading urology researcher at a local academic institution drove expert opinion that they should be done. If you didn’t do a PSA and a patient turned out to have cancer, you were in for a bumpy ride.

OHSU notes correctly that state laws have lagged behind current technology and that the scope of the legal medical record varies from state to state. I’ve worked in organizations that swear that the final signed chart note in the EHR is the legal record, and others who said, “everything in the database is the legal record.” I’ve worked with attorneys going down SQL rabbit holes trying to figure out what a physician knew and when based on various timestamps, user IDs, and other metadata.

The wiki authors also note the need to better understand how clinical decision support systems influence clinician judgment and how their use might impact those who are “not adept at system-user interfaces.” They also note the relative lack of case law in the area, but go on to say that, “Physicians are likely to be held responsible for the appropriate use and application of clinical decision support systems and should have a working knowledge of the purpose, design, and decision rules of the specific decision support systems they use.”

For some EHRs and related systems, this is easier than others. I’ve seen systems where you can quickly drill down to the specific recommendations and understand why a flag was thrown. I’ve also seen systems where alerts don’t seem to make sense and searches of well-known physician resources fail to shed light on the subject (nor do simple Google searches, so a double dead end). The bottom line remains, however, that regardless of the volume of information out there, physicians are expected to know the answers and do the right thing for their patients.

How does your organization address liability for clinical decisions, whether human-created or prompted by technology? Leave a comment or email me.

button

Email Dr. Jayne.

Subscribe to Updates

Search


Loading

Text Ads


Report News and Rumors

No title

Anonymous online form
E-mail
Rumor line: 801.HIT.NEWS

Tweets

Archives

Vince Ciotti’s HIS-tory of Healthcare IT

Founding Sponsors


 

Platinum Sponsors


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gold Sponsors


 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reader Comments

  • Awe and admiration: Epic and the executives of their leading hospital customers should be up for some special shared Nobel Prize... Their se...
  • Stinky: Re: Epic's Information Blocking: No one passionate about patients and their care opposes interoperability. The only care...
  • JudyHuh?: I like Judy a lot, but am befuddled by her letter. If she's concerned about patient privacy, I think that would up to t...
  • Frank Poggio: Topol goes overboard just as much as Epic, just the other side of the boat. 1. Epic doesn't 'make' over $3billion. Th...
  • Epic Adjacent: Talk about not knowing your audience. If anything Epic's customers want _more_ access to their own data for their own pu...
  • Elizabeth H. H. Holmes: Re: Tom Jackson comment - do you have a Facebook account? Curious as to why you think the security concerns are not legi...
  • AC: " once the barriers to system switching come down" If you think the main barrier to switching is the open API, you're...
  • Epic_0_ONC_100: Even if we were to attribute the best intentions (privacy, VCs making hay from data etc.) to Epic's lack of enthusiasm t...
  • Eddie T. Head: Is Eric Topol so desperate as to publicly make provably false claims? I know that my MyChart account has a "Share my Rec...
  • DNA is DNA: That's probably true but it could just be a matter of market saturation. How many people are left who want to use the se...

Sponsor Quick Links