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EPtalk by Dr. Jayne 7/20/23

July 20, 2023 Dr. Jayne Comments Off on EPtalk by Dr. Jayne 7/20/23

There’s not a day that goes by that I don’t see an article or hear commentary about how AI is going to somehow cause the end of the world. Earlier this month, it caused plenty of chaos at Gizmodo, when an AI-created story about Star Wars hit the virtual presses.

The author, “Gizmodo Bot,” created a work about the chronological order of various installments in the Star Wars franchise. A deputy editor who performed an initial review found 18 issues with the story, including elements being out of order, missing, or incorrectly formatted. He also took issue with the fact that the story didn’t include a disclaimer that it was AI-generated except for the byline. I found it interesting that the story was written using both ChatGPT and Google Bard.

Gizmodo staff commented: “I have never had to deal with this basic level of incompetence with any of the colleagues that I have ever worked with… If these AI [chatbots] can’t even do something as basic as put a Star Wars movie in order one after the other, I don’t think you can trust it to [report] any kind of accurate information.”

As much as many of us share concerns about using AI in healthcare, using it in news might be even more worrisome. Although this certainly wasn’t a hard-hitting news article, it deals with subject matter about which there are a number of authoritative resources and its chronology is undebated. When you consider other subject matter where things might not be so clear (such as when there are consensus recommendations, expert opinion, and data from clinical research that might not always agree), the stakes are higher.

Still, I got a chuckle out of a description of employee feedback that was delivered in a Gizmodo Slack channel. A company comment about future use of AI received “16 thumbs down emoji, 11 wastebasket emoji, six clown emoji, two face palm emoji, and two poop emoji,” according to screenshots provided to media. Here’s to employees who feel comfortable speaking their mind.

Following a recent change to Utah law which allows pharmacists to prescribe birth control, Intermountain Health has launched a virtual care program to serve the state’s women. After a virtual visit, patients can receive prescriptions for contraceptive pills, patches, or rings. Medications can be mailed directly to patients. The $20 virtual visit fee makes it an economical care option for many. Utah joins 24 other states plus the District of Columbia in allowing pharmacists to have prescriptive authority for birth control.

The hot topic around the virtual water cooler this week was the Freed AI-driven virtual scribe service. They must have done a major marketing push because several people had heard of it and a couple were checking it out. They advertise 20 free visits with no credit card required for signup, and an ongoing price of $99 per month for unlimited visits with no lead time for cancellation. They also offer discounts if you are an “in-debt resident or facing financial challenges.” The solution says it will place all the documentation — including notes, pended orders, and after-visit summaries – into “your favorite EHR” for review and signature.

I’ve seen enough virtual scribe services to be at least a little skeptical, especially given the pricing. If you know more about Freed, or if you’ve given it a test drive, let me know. I’ll be happy to run your anonymous thoughts and impressions.

CMS has opened a call for public comments on MACRO cost measures. The 12 measures have been part of the Merit-based Incentive Payment System since the 2020 performance year and CMS is considering a comprehensive reevaluation. The survey  is open until July 21 at 11:59 p.m. Eastern and is divided into two sections covering cross-cutting questions and measure-specific questions. All questions are optional, which is nice for those of us who might not have the time to go through the entire thing or for those who just want to give specific feedback about a particular measure that applies to their specialty or subspecialty. CMS is using a survey partner to make recommendations on whether there should be changes, although the ultimate decision belongs to CMS.

I was intrigued to learn about the Alcohol Capture app that is designed for patients to capture 14 days of alcohol consumption data for research purposes. It’s been found to be valid and reliable, and includes the drinks and sizes commonly available in its development site of Australia. I enjoyed learning that there’s a drink size called a schooner (425 mL) and also one called a middy (285 mL). Users can report their alcohol intake in real time or by responding to twice-daily notifications. Although users can see a history of their data entry dates and times, they can’t look back at the alcohol data.

Pet peeve of the week: I attend webinars for professional organizations, vendors, and educational companies. There is nothing worse than hustling around to make it to a call on time and to find an idle “welcome” screen that says, “We’ll start in 5 minutes to allow everyone time to join.” That does a disservice to those people who worked hard to be there on time. We should honor the people who are doing the right thing. Those who arrive late can wait until the recording or transcript is distributed and can catch up on their own time.

Severe weather seems increasingly common these days, and on Wednesday a tornado struck a Pfizer pharmaceutical facility in Nash County, North Carolina with reports of “50,000 pallets of medicine that are strewn across the facility.” According to the Pfizer website, the facility is one of the largest in the world for manufacturing sterile injectables, with nearly 25% of all such medications used in US hospitals being manufactured at the site. I’m sure we’ll all be on the lookout for what are likely to be shortages of anesthesia, pain management, and anti-infective medications in the coming months.

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Over the weekend, I had the chance to help teach the Radio Merit Badge at a local scout camp. It’s always good to see young people showing interest in activities where they are not traditionally represented. Watching them learn that radio is the force behind a lot of the technologies they use every day was rewarding. My co-instructors included a computer science expert, an electrical engineer, and an enterprise software architect.

They had lots of questions about what exactly a physician does in the technology space. It was great helping them understand what happens behind the scenes when they seek healthcare. Our students were engaged, and although they were initially nervous about using the radio, they quickly became confident in their skills. It’s always good to help people learn new things and maybe have the chance to inspire them in a career.

What do you do in your spare time that brings you joy or makes you hopeful for the future? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/17/23

July 17, 2023 Dr. Jayne 3 Comments

Although my friends and family don’t exactly understand what I do at work, they know that I’m generally aware of cutting-edge technology. I can’t count the number of times in the last six months that people have asked me what I think about ChatGPT or artificial intelligence taking over the world. Although I enjoy reading the scholarly articles that people are publishing in informatics literature about the use of large language models, I’ve made it a point to try to keep up with the lay media so that I understand what my friends and family are reading. It’s also a good proxy to understand what my physician colleagues understand about the technology, given the fact that if they’re reading scholarly literature, it’s most likely in their professional specialty or subspecialty fields.

I was intrigued to see this article in the New York Times this week covering the Federal Trade Commission’s investigation into the potential harms of ChatGPT. Regulators sent a letter to OpenAI to inquire about its security policies and procedures, as well as to learn if consumers have suffered damages related to how the chatbot collects data. They’re also interested in the ability of the technology to generate and publish false information on individuals. The NYT reported that the letter was 20 pages long and included pages of questions, including those seeking information on how the company trains its AI models. It also requested documents related to the inquiry. A question is whether the company “engaged in unfair or deceptive privacy or data security practices or engaged in unfair or deceptive practices relating to the risks of harm to consumers.”

Most of the people I talk to act like ChatGPT is no big deal and we should be excited about using it. Although I’m optimistic about its ability to provide value in a variety of different industries and situations, it’s a complex technology and there needs to be thoughtful consideration about how we do or do not use it for patient care. I see a lot of people using it to generate patient-facing correspondence without much review. One physician boasted about how she was able to create lab results letters for her patients, sending a full day’s worth of letters in under three minutes. The ability to create and proofread those letters in the cited timeframe is questionable at best. Based on the looks on the faces of some of the colleagues she was speaking to, I wonder if they were questioning her professional judgement.

Many of the large health systems and EHR vendors that some of my colleagues work at are reported to have been on point with messaging to their physicians and other clinicians about not including protected health information in prompts that are used to access the systems, especially when users are considering using publicly available tools rather than institutional or research tools. However, many of my independent physician colleagues haven’t received the same level of education and didn’t understand that information they’re feeding into the prompts can be used in various ways once a technology company has control of it. Some of the physicians I’ve interacted with on social media still aren’t savvy enough to not post protected health information in their posts or images, and someone is always calling out a group member for posting unredacted content. The majority of physician users I interact with also don’t know that systems also might not have been updated with current data, which makes them unreliable when you’re asking for the latest medication or regulatory information. Without receiving education on the technology, they’re also often unaware about the potential of AI-driven systems to hallucinate or create completely inaccurate information based on patterns presented to it in the past.

It’s also important to understand how AI technologies might impact our economy and those that are doing the jobs that people have proposed for it. For example, earlier this year there was a lot of buzz about AI-generated art and particularly AI-generated head shots. I felt like I was one of the only people in my physician social media circles who didn’t join the scores of people getting new headshots. A handful of people voiced privacy concerns, especially about the need to upload a bunch of pictures for the technology to work, and the potential that the company might be collecting facial recognition data for nefarious purposes. But those were in the minority – and most people were going along with it until the algorithm started going sideways, spitting out images that didn’t look remotely like them. The worst examples included pictures of people in superhero costumes or in situations that weren’t remotely appropriate for a professional headshot. One of my family members is a professional photographer, so I brought up the point that crafting a professional portrait is both an art and a skill – and that AI-generated images compete directly with those professional people who are earning a living and contributing to their communities.

Economic factors are certainly concerning, but the risk of technology creating disinformation raises significant concerns. OpenAI leadership has admitted that there needs to be regulation in the industry. Following the announcement of the letter, its leader said that he’s confident that the company is following the law and that they will be cooperative with the investigation. Other countries have already been more critical of the company than US regulators, with Italy banning ChatGPT in March over concerns about inappropriate collection of personal data from users and lack of age verification for minors trying to use the system. The company addressed the issues and access to the technology was restored the following month. Advocacy groups have been pressing the FTC and other regulatory agencies to address the risks of ChatGPT. The article notes one organization, the Center for AI and Digital Policy, which has asked the FTC to block Open AI from releasing new versions to the public. About a week ago, it updated its complaint with additional supporting materials on the ways that chatbots might cause harm.

Federal agencies often move at a snail’s pace, and it’s unlikely that the FTC’s investigation into ChatGPT will proceed swiftly. The article notes that the FTC “may not have the knowledge to fully vet answers from OpenAI and that they don’t have the staff with technical expertise to evaluate the responses they will get and to see how OpenAI may try to shade the truth.”

Even after the investigation concludes, there’s a possibility that no action will be taken. Outcomes of investigations are often not widely distributed and it will be interesting to see if the FTC decides to err on the side of availability or whether it will take Freedom of Information Act requests to find out the results. Only time will tell whether we’ll see increased regulation or a more wait-and-see approach.

What do you think about the need to regulate AI-powered technologies? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/13/23

July 13, 2023 Dr. Jayne Comments Off on EPtalk by Dr. Jayne 7/13/23

I’ve been surprised by how much conversation I’ve heard about this Epic study in the virtual physician lounge. One of the key purposes of the study was to look at trends in documentation over the time period since CMS made updates to the way physicians can code their office visits. I’ve been surprised to learn how few physicians understand that changes happened – and those that understood that something changed are often unable to articulate how those changes have impacted their documentation. The majority of physicians discussing it share the “nobody told me” narrative, which I struggle to believe is as common as people say.

The largest physician specialty organizations ran article after article about these changes when they happened, as did national multispecialty organizations like the American Medical Association. The health system where I was working at the time had a major educational campaign around this, in part because they hypothesized that physicians would be able to bill higher codes under the new paradigm. There was a lot of chatter about it, but of course this conversation was during the height of the COVID pandemic and I’m sure a lot of us failed to fully understand a lot of things that came across our desks and inboxes during that time frame. For those of you who haven’t seen the study, here’s the highlight reel: Although the time to create clinical notes has decreased, the average length of those notes continues to increase.

While it’s great that notes have taken less time to document, the persistence of longer notes continues to contribute to the problem. It still takes time for recipients to read those lengthier notes, and the impact is compounded the larger the size of the care team. Another interesting factor called out in the study’s key findings is the fact that, “while overall average note length increased, around 40% of providers reduced their average note length.” That means that 60% of providers had the same notes, with some of them having longer, so that the math for the average works out. In my clinical work, I still see plenty of bloated communications from other providers and wish they had the personal drive or institutional support to streamline their documentation.

A reader alerted me to this article that falls squarely in the column of “physicians behaving badly.” A North Carolina otolaryngologist was sentenced to 25 years in prison for committing Medicare fraud by reusing single-use surgical devices. Although she performed more than 1,400 sinus surgeries over a seven-year period, she was only able to provide records of having purchased 36 of those devices. She billed Medicare more than $46 million for the procedures, which most certainly would have raised red flags. Patients impacted by the fraud will have 90 days to present claims for damages. This kind of behavior is horrific and egregious and contributes to the rising distrust of patients felt by many physicians these days. I hope she spends the next couple of decades reflecting on the situation.

Last week, I commemorated the passing of July 1, which is the traditional day in the US that medical students start their internships and other medical trainees advance in their residency programs. I asked for people to share their best or worst memories of internship, and our readers did not disappoint. Dr. Nick van Terheyden shared a blog about his first days as a junior doctor. I was surprised to learn that there was little difference between his experiences in the UK during the 1980s and my experiences in the US in the 1990s. He also reminisced about some notes he came across when a hospital in London was being relocated. The notes were written during The Blitz and as much as we found practicing medicine stressful during the COVID pandemic, I can’t imagine trying to practice in the middle of an air raid.

One of my favorite correspondents shared the story of a July 4 night on call at a big city hospital. They were working in the emergency department but weren’t seeing a lot of patient volume, so their attending physician invited them to take a break to watch fireworks. The savvy attending had brought lawn chairs and led them up the secret stairs to the roof, where they had a great view of the city’s fireworks show.

Still, nothing beats the story of “interoperability” as it occurred in a hospital where the interns figured out how to liberate patient charts from the dialysis clinic when patients needed to be admitted to the hospital. Apparently the clinic had a divided “Dutch door” entrance and an enterprising intern figured out how to get the top half open without a key so they could consult the patient charts, write their notes, and return them before morning. It’s a good reminder of what life was like before electronic health records. I never had to climb into an office to grab a chart but I did spend a lot of hours in the medical records area digging through month-old, half-documented charts to try to make sense of them while I was in the process of readmitting recently discharged patients.

I’m a big fan of celebrating milestones, and today marks the 1,300th post I’ve written for HIStalk. It’s been a bit of a long, strange, trip. I started writing during the incentive-hungry boom created by the Meaningful Use program. Since then, the world of healthcare information technology has been through numerous ups and downs, including periods of wild growth and unbelievable scarcity. Still, I’m impressed every day by the physicians that continue to put their scrubs on one leg at a time and care for patients despite the frustration and hardships found in the practice of medicine today. I’m continually grateful for the IT professionals that support them and make sure the servers are humming, the desktops are cooperative, and that they have the access they need to take care of people. And to all the others who support patient care – be it housekeeping, nutrition, engineering, or the dozens of other departments – we salute you.

How do you like to celebrate milestones? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/10/23

July 10, 2023 Dr. Jayne 2 Comments

In my past life, I did a fair amount of medicolegal consulting. Although I don’t regularly work in that space anymore, I’m mentoring a young clinical informaticist that finds himself thrown into that space without much warning. When you’re a front-line physician, you know that there is always a chance that a patient complication or a poor outcome could lead to a legal claim. Even when you’re not primarily responsible for the situation, if you’ve participated in the care of a patient, you might be contacted to serve as a fact witness. Regardless of the situation, depositions can be nerve wracking. No matter the industry you work in, generally people don’t really look forward to being dragged into a legal situation. Most informaticists don’t expect to be drawn into legal issues, but when complex systems are involved in documenting the care that was rendered, it’s becoming increasingly more common.

In the past, fulfilling legal requests meant that the health information management department would pull hundreds of pages of paper records and photocopy them to send to the requesting attorney. When we started transitioning to EHRs, sometimes the records requests were fulfilled in a hybrid manner depending on where the hospital was in its EHR journey. There might have been a mix of documents, with some being photocopied and others being printed from the EHR. When I first started seeing these kinds of records, it amazed me how different the EHR output was from different hospitals. Some had better formatted notes than others; others were sometimes downright confusing. The transition of electronic flowsheets to paper output is particularly problematic at times, and when I used to work legal cases regularly, I’d sometimes have to put all the paper representations of formerly electronic flowsheets across the living room floor to try to make sense of them.

Now that the majority of care delivery sites are fully documented using electronic records, the size of documentation on a per-note basis has grown dramatically. Hospital daily progress notes that typically would have been a page or a page and a half in the paper world are now three to five pages long. Despite efforts to the contrary, they often exemplify the concept of “note bloat” with lots of copy and paste and more carry-forward documentation than most of us want. Even a short hospital stay, when converted from an EHR chart to a paper record, can generate thousands of pages of records. Wading through them can be challenging, even when you’re experienced in looking at EHR output. Lately, I’ve seen some notes from hospitals that are exposing metadata within the notes themselves. For example, tagging every sentence with its author in a superscript, or tagging sentences to identify whether the content was generated from a template or through manual entry.

My young colleague has been working in clinical informatics for a couple of years, but mostly spending his time as a super user and helping support his specialty colleagues at the point of care. He only recently started getting into more strategic areas of EHR management. He served on a couple of EHR committees, one of which was depicted last year in a glowing article in the health system’s public-facing newsletter. That particular article was about work that the informatics team had been doing to revisit procedure documentation in a particular specialty area as part of a preventable harms project. It was intended as a feel-good piece, describing how the hospital was using information systems to promote patient safety. Various people were quoted in the article, including my friend, who talked about how the committee was reviewing procedure note templates and order sets to ensure they were being kept up with current evidence and represented the highest standards of care.

Unfortunately, the quotation in the article also ended up tagging my colleague as a potential expert in how the hospital decided to redo its clinical content. Apparently, there was a potential legal claim after a procedure that resulted in a poor outcome, and there’s a hypothesis that an outdated order set contributed to the situation. Since the article appeared on the hospital’s website, it’s easily found in an Internet search, leading to a request for deposition from some enterprising attorneys. He’s now second-guessing the EHR Quality Committee’s strategy in deciding which documentation pathways to review now versus those that were marked for later analysis. Like all of us, his organization was struggling with the idea of having so much to do and so little time, so hard decisions had to be made.

In learning more about the case, it’s not clear how much influence the EHR really had on the situation, even if its documentation was outdated. Ultimately the clinician at the bedside is responsible for placing the right orders for the right patient and for ensuring that they meet the standard of care. Unfortunately, many of us have become so dependent on the EHR as our mechanism for ensuring we’re ordering what we should be ordering. I’ve seen plenty of physicians who have let their critical thinking skills slide and who don’t question what they’re seeing even when they know it’s not right. They’ve come to rely on the prompts and reminders given by the EHR, sometimes to the detriment of the patient when the EHR either doesn’t have any care pathways for a particular situation or when there’s a technology outage.

Plenty of us are speculating as to how artificial intelligence can help us be better doctors – whether it be through helping us write notes that make more sense than what humans are currently generating or whether we’re using it to suggest alternative diagnoses or treatments that might not be top of mind. However, such technology is only going to take us further down the proverbial rabbit hole of reliance on tech. Some of the most harrowing moments I’ve had in clinical practice have been during an EHR downtime and I don’t wish that experience on anyone. Particularly, I feel for those clinicians who work at hospitals that have been hit by ransomware and who have to resort to downtime procedures for extended periods of time. Technology may be making us dumber, in a way.

In the meantime, I’m helping my colleague through the legal process as much as I can, recommending additional training about how his system presents data and educating him on what it will be like to be deposed. He’s incredibly nervous and he never dreamed that EHR governance was going to be on his mind as much as it is now. No one ever said being a clinical informaticist was dull, but I hope for his sake that the next couple of weeks are fairly boring, including the deposition. Being in his position is certainly something they didn’t teach us about in medical school or residency, and definitely not in clinical informatics training. Fortunately, though, in those educational environments they do teach us critical thinking skills, logic, and the need for ongoing learning, so I hope my friend can use those skills to weather the current storm.

Has your IT department ever been cited as party to a legal action? Was it juicy enough to be the subject of a courtroom drama? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/6/23

July 6, 2023 Dr. Jayne 1 Comment

I mentioned recently that July marks the traditional start of the new training year for medical education in the US. Those interns are approaching the end of their first week on the job and are likely to be using a variety of coping strategies to figure out how they’re going to make it through the next three to 10 years of their lives. Figuring out when and what you’re going to eat when you have little time is usually a big part of that survival strategy. Jenn clued me in to this cooking contest for vegan hospital food. The District of Columbia Hospital Association recently held its third annual Healthy Hospitals Initiative Cooking competition with a “secret ingredient” this year of carrots. The event is also sponsored by the Physicians Committee for Responsible Medicine and winners included MedStar National Rehabilitation Hospital with its purple carrot ravioli and carrot halwa pistachio trifle.

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I read with interest this piece about Cleveland Clinic opening a new telehealth hub at one of its hospitals. The facility’s 57 rooms are equipped with technology to allow patients to have consultations with physicians who are at other locations. Knowing that they plan to staff cases remotely, it will be interesting to see what kinds of providers and staff are actually in place at the facility. I’m guessing they’ll go with a minimum staffing approach, and as far as licensed providers, probably will leverage nurse practitioners and/or physician assistants more than you might at a facility with traditional staffing. I hope someone is doing outcomes research and looking at how these patients fare compared to those being cared for under usual care models. If research proves this approach is equivalent but less costly, or drives better outcomes with the same cost, it will truly be a game changer.

Speaking of telehealth, it’s often cited as being key to solving the access problem for patients in need of mental health services. Author Health, which has a platform for seniors on Medicare Advantage, just announced a $115 million funding round with Humana as a payer partner in south Florida. The platform also addresses substance use disorders. Author Health delivers care both virtually and in-person with a cross-functional team including physicians, therapists, nurses, and community health workers. All of the resources are virtual except the community health workers. They’re hoping to manage workforce issues by recruiting providers first and getting them licensed in target states, rather than trying to recruit those who already have specific licensure. That’s easy in some states but harder in others, so I’m sure it will drive their expansion plans.

In reading more about the Author Health arrangement with Humana, it appears to be based on a fee-for-service model with a goal of transformation to a value-based model in the future. They also hope to be able to demonstrate improved outcomes for patients’ comorbid medical conditions, such as diabetes. It will be interesting to see how the platform grows over time and whether or not the partnership with Humana helps it yield results faster than competitors. I enjoyed learning a little about their branding – the name Author Health is drawn from the idea that patients should be writing their own life story and defining how they want the next chapters to unfold. I’ve got the company on my tracking list, so we’ll see how it fares over the coming months to years.

Mental health apps are also a big topic of conversation as a way of solving the access issue. I ran across this article looking at the pros and cons of direct-to-consumer virtual mental health apps. Before reading the article, my major concern with these offerings was the protection of patient data. Most patients don’t realize that the majority of apps aren’t required to protect the privacy of patient data nor do they know that some app developers are actually selling their personal data. I’m sure the number of consumers that actually reads the full Terms and Conditions when downloading an app is very small. According to the article, there may be between 10,000 and 20,000 mental health apps out there. Although the sheer number might be a good thing, the article brings up additional pitfalls beyond privacy and security concerns. It notes that we don’t know for sure whether apps can deliver the same quality of care as existing treatments do, and that traditional healthcare providers and payers need to play a role in making sure that quality is assessed.

Given the fact that digital therapeutics companies who have the proof of their outcomes have struggled to make a go of it, I’m not optimistic about the ability of front-line care providers to participate in the process to prove whether an app meets the standard of care. The boom in app use in other disciplines has contributed to provider frustration, as many have to spend already scarce clinical time explaining why some apps might be a bad idea. Many of my colleagues in women’s health have spent a lot more time counseling patients on the risks of using period tracking apps because patient privacy cannot be guaranteed, especially for patients in states that have restricted abortion care. I used to occasionally have to counsel patients about the validity of various home blood pressure cuffs and the data they generated, and with current technology patients can send me hundreds of data points at the click of a button that I now have to figure out how to reconcile. There can be a lot of effort needed for physicians to figure out what to do with all this information, and given the conversation in the physician lounge, people may be less than enthusiastic about rising to this particular challenge.

Bad news for those of us who like our downtime: There may be a link between napping and esophageal cancer. Researchers at Washington University School of Medicine in St. Louis have identified prolonged sleep as a risk factor for esophageal adenocarcinoma, with those sleeping nine hours per night having double the risk of individuals sleeping seven hours per night. They also found increased risk in patients who slept less than six hours per night. In looking at patients who slept or napped during the day, they also identified increased risks. Researchers think that the link to increased cancer risk might be due to disruption of sleep/wake cycles that leads to reflux of stomach acid, or to immune dysfunction that might cause increased cancer risk. Thinking as an average person, it sounds like this isn’t terribly conclusive. There may be other factors involved such as obesity, although the researchers did adjust their data for sex, smoking status, body mass index, and whether or not patients engaged in shift work. I consulted my favorite otolaryngologist and we both agreed that a good afternoon nap is probably worth the risk.

When is the last time you had to do an all-night upgrade or IT work that made you want to nap the next day? If you’re a napper, are you willing to give it up to lower your cancer risk? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/3/23

July 3, 2023 Dr. Jayne 1 Comment

In advance of the holiday, the HHS Office of Inspector General dropped this sweet hundred-plus page final rule on information blocking. It includes the details of the civil monetary penalties that health IT developers will be subject to if they’re caught and OIG determines that information blocking did indeed occur. The document won’t be fully official until it is published in the Federal Register, and the majority of it will go into effect 30 days after that publication date.

I like the OIG’s clear description of the problem that it is trying to address: “Information blocking poses a threat to patient safety and undermines efforts by providers, payers, and others to make the health system more efficient and effective. Information blocking may also constitute an element of a fraud scheme, such as by forcing unnecessary tests or conditioning information exchange on referrals.” The fact that the mention of patient safety is the first thing on the list is important. Often, in the technology space, I see organizations that forget that none of the things that we’re trying to do mean anything if there’s not a patient at the center. Personally, I know I can give better care when I have full access to all of the patient’s information, but I often don’t have it.

This final rule specifically addresses civil monetary penalties for practices that are “likely to interfere with, prevent, or materially discourage access, exchange, or use of electronic health information (EHI) if the practice is conducted by an entity that is: a developer of certified health information technology (IT); offering certified health IT; a health information exchange (HIE); or a health information network (HIN) and the entity knows or should know that the practice is likely to interfere with, prevent, or materially discourage the access, exchange, or use of EHI. Most of the information blocking that I see as a physician isn’t being done by healthcare IT developers. I’ve been behind the scenes with the development teams of multiple EHRs over the last two decades and I’ve seen a tremendous amount of effort around data sharing. One of those vendors helped me stand up the first HIE in my state “way back when” and was as shocked as I was when we couldn’t get healthcare delivery organizations to play nicely with us.

On the flip side, the HIE in a neighboring state was charging what I thought was an exorbitant fee for providers to connect. In digging deeper, their entire pricing model was built around the idea of connecting large health systems to the HIE, with little consideration for independent providers. I was working as a locum tenens physician at the time, providing coverage across a number of organizations in the state and was trying to get my own credentials to access the system so that I could have the most data at my fingertips regardless of where I was seeing patients. They had no way of accommodating anything like that at the time and said they could only do a direct EHR connection. Even if a smaller practice (most of the ones I was working with had five physicians or less) wanted to connect, the price tag was daunting. They definitely wouldn’t be going to the expense and time commitment of a project like that just because I asked for it, so I was never able to get connectivity to better serve my patients.

In reality though, the majority of information-blocking activities that I see in real life are directly related to behaviors by health systems and care delivery organizations. The hoops that patients go through to try to make sure that consulting physicians receive the records needed to render service are unreal. And sometimes, the physicians themselves don’t even understand what needs to happen or how to help make the system effective even when organizations are freely sharing data. I’m a member of a number of online physician forums, and questions about this come up frequently. Just this past week, there was a complaint from a primary care physician that a consulting physician sent back a “snarky” letter about a patient’s condition, suggesting that the primary care physician hadn’t taken appropriate steps to address the patient’s condition before sending a referral.

In digging deeper, the relatively inexperienced primary care physician assumed that since they and the consultant were on the same enterprise EHR, that the consultant would have full access to the chart. It didn’t occur to them that the consultant might not want to (or have the time to) wade through the dozens of encounters that were present trying to figure out what was going on, especially if those encounters contained a lot of confusing cut-and-paste documentation. Since the EHR’s referral module was largely about handling insurance referrals and ensuring payment for the consultant versus conveying useful clinical information, there wasn’t clear communication about the nature of the consultation request. Several more senior physicians chimed in with stories of “back in my day” before we could easily share records, where we’d draft a one-page letter to the consultant, summarizing what had already been done, our thoughts, and what questions we had for them. It sounds like the primary care physician didn’t do anything like this, and ultimately the patient’s time was wasted (not only at the appointment but the multi-month wait leading up to it) as well as the consultant’s time.

Unfortunately, this is all too often the kind of care we see now that everyone is operating under great pressure – whether it’s time pressures created by administrative teams, or whether it’s due to the scarcity of certain kinds of consultants, or whether it’s due to physician burnout, patient care ultimately suffers. Information-blocking rules aren’t going to fix that. The current information-blocking rules also aren’t going to fix the problem of health systems dragging their feet releasing records or images to competing health systems, although many of us are hopeful that a proposed rule for provider penalties will help with that particular problem. As a patient who watched organizations argue with each other about some pathology slides a couple of years ago, I’m supportive of most anything that will make things easier for the patients.

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Over the weekend, we slipped from June into July. For many of us who are physicians, July 1 has a special place in our memories because it’s traditionally the date that newly minted physicians become interns at training hospitals. For other residents, it’s the day you move up in the hierarchy, becoming a supervisor of the brand-new interns who just started. For those just using their medical degrees for the first time, it can be terrifying, especially when you’re called in the middle of the night to look at a STAT x-ray or to give orders in response to lab results for patients you’ve never met. I was fortunate to be part of an amazing intern class that you could always count on to have your back. Even decades later, we know we can call each other for things big or small. Honestly, I would hop on a plane with a moment’s notice if one of them needed me, because those are the kinds of relationships that are forged when you go through those kinds of circumstances with a team like that. A toast to my class, and a salute to all the new interns who are on Day 3 of the rest of their lives.

If you’re a physician, what’s your best or worse memory of internship? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/29/23

June 29, 2023 Dr. Jayne Comments Off on EPtalk by Dr. Jayne 6/29/23

Telehealth is here to stay, and the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act has been reintroduced in the US Senate, this time by a bipartisan group of 60 Senators. A companion bill was also introduced in the US House of Representatives. The bill was first introduced in 2016 and aims to expand coverage of telehealth services through the Medicare program. It would amend the Social Security Act and includes provisions to: expand the range of health professionals who can deliver telehealth services; remove requirements for in-person visits in tele-mental health programs; expand telehealth in rural health clinics and health centers; remove geographic restrictions on telehealth services; and require research on the impact of telehealth on quality of care.

Broadening the reach of telehealth is part of the overall solution package needed to deal with the physician shortage, disparate distribution of physicians between urban and rural areas, and lack of access for many in the US. It’s naturally complimentary to other strategies such as team-based care, nontraditional appointment times, and the ability for patients to be seen at a location that is convenient to them. In speaking with members of my community, a large number of people aren’t aware of the care options available to them, including after-hours clinics and telehealth. In addition to legislation, health systems and care delivery organizations need to do a better job informing patients of their options for care beyond the traditional doctor’s office. It seems like payers and employers are doing a better job pushing telehealth (most likely because they see it as a lower-cost alternative to in-person visits), but depending on where they’re steering patients, it might be contributing to fragmented care. We’ll have to see how this bill makes it way through Congress or if it will just sit there on Capitol Hill like so many other bills.

I’ve been following some public health informatics issues, and was surprised to see a recent write up describing the transmission of malaria in the US. A handful of cases have been detected in Florida and Texas, after being eliminated from the US in 1951. (An eight-person cluster of cases was identified in Florida in 2003 without further spread.) Although the risk of being infected with the disease is low in the US, there are plenty of other reasons to either use insect repellent or wear long pants and long sleeves during outdoor activities. Malaria is a serious medical condition and most physicians in the US don’t think about it when they’re seeing patients who haven’t traveled to areas in the world where transmission is more common. I’ve seen a couple of professional organizations issue bulletins to their members, so hopefully this will help get the word out as well. Maybe some of us in the CMIO trenches can consider clinical decision support interventions to help our clinicians think of diseases that might not yet be on their radar. Symptoms include fever, chills, headache, and fatigue. Although patients typically get sick within a few weeks, there can be a lag of up to a year after the initial infection, which adds to the difficulty in diagnosis.

In other public health news, healthcare expenditures due to pickleball are on the rise. UnitedHealth Group has detected an increase in healthcare utilization due to pickleball-related injuries. The game is increasingly popular among the senior set and may be contributing in the neighborhood of $377 million to healthcare costs for procedures such as emergency department visits, outpatient visits, knee surgeries, and hip replacements. It would be interesting to see if the increase in costs is similarly associated with paddle tennis, which is a similar concept but “not remotely the same” according to my racquet-wielding friends who can cite the differences like they’re defending a dissertation. Pickleball growth continues with estimates that the number of players will reach 22.3 million this year, with seniors accounting for nearly a third of the pickleball regulars.

Complaining about the EHR is a common activity for many physicians, especially those whose organizations haven’t taken steps to tame the inbox or provide adequate support staff to manage the rising numbers of patient-generated messages and requests. A recent study in JAMA Network Open notes that part-time primary care physicians spend more time using the EHR per hour of clinic than their full-time colleagues, and also spend more time outside scheduled appointments. Data from the University of Wisconsin-Madison looked at 11 months between May 2021 and March 2022. EHR measures were normalized per week and per eight hours of scheduled patient time. The authors found that panel size, visit volume, or message volumes didn’t explain the additional time spent by part-time physicians.

They did find that the part-timers spent more time in their inboxes but were unable to fully draw conclusions from that finding, hypothesizing that “more EHR work outside scheduled hours … may allow them to feel caught up or allocate more time for panel management work ….” The study is limited by the fact that it was done at only one center and had a relatively small number of participants. It also included non-patient-care EHR administrative work that part-timers (such as your friendly neighborhood CMIO, super user, or practice champion) might do. Understanding exactly what is going on in the EHR with various providers is the key to improving their efficiency. I continue to see physicians who refuse to take advantage of EHR features that are designed to make their lives easier, and who would rather type the same phrase 20 times each day than spend the seconds it takes to create it as a favorite for future use. It’s baffling, and I struggle to get into the user psychology that supports it, but I’ll continue to advocate to get physicians on the happy path.

On a recent trip, my inbound aircraft was carrying the remains of a fallen soldier. I was impressed by the level of respect shown by those waiting at the gate as well as the airport staff. Resources from the airport fire department and security offices were lined up on the tarmac in tribute alongside what appeared to be family members. The flight crew held all passengers on the plane while an honor guard transferred the flag-draped coffin from the aircraft to a waiting hearse. For that moment in time everything stopped – a fitting tribute to someone willing to give his or her life in service of our country. Well done, MKE, well done.

For those of you preparing for the Independence Day holiday and the potential family gatherings this weekend – be safe, enjoy the time with family, celebrate our nation’s birth, and don’t forget the insect repellent.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/26/23

June 26, 2023 Dr. Jayne 2 Comments

The clinical informatics community is buzzing with the news that ChatGPT was used to “pass” a simulated clinical informatics board exam. A recent article in the Journal of the American Medical Informatics Association describes the process used to evaluate the tool and goes further to question whether or not the general availability of AI tools is signaling the end of the “open book” maintenance of certification programs that many board certified physicians, including clinical informaticists, have come to enjoy.

Many of the medical specialty boards have moved to the ongoing maintenance of certification process, shifting away from the high-stakes exams that they used to require diplomates to take every seven to 10 years. My primary specialty board, the American Board of Family Medicine, began to pilot the maintenance of certification process in 2019. Since it had been a while since I practiced full-scope family medicine (which includes obstetrics), I was eager to try the new format, which delivered questions every quarter that could be answered using available resources such as textbooks, journal articles, or online references. This approach is a lot closer to how we actually practice medicine – which involves being able to investigate to find answers when we’re not able to pull the information from memory. High-stakes exams such as the ones we used to have aren’t reflective of our ability to deliver good care and such exams have been shown to negatively impact a variety of demographic groups.

The authors of the article tested ChatGPT 3.5 with more than 250 multiple choice questions drawn from a well-known clinical informatics board review book. ChatGPT correctly answered 74% of the questions, which leads to questions about whether or not it might be misused in the certification process. It was noted that ChatGPT performed differently across various areas within the clinical informatics curriculum, doing the best on fundamental knowledge, leadership and professionalism, and data governance. It did the worst on improving care delivery and outcomes, although statistical analysis didn’t find the differences across the categories to be statistically significant. The authors hypothesize that ChatGPT does better in areas where the questions are recall-based as opposed to those that emphasize application and reasoning.

They go on to propose that “since ChatGPT is able to answer multiple-choice questions accurately, permitting candidates to use artificial intelligence (AI) systems for exams will compromise the credibility and validity of at-home assessments and undermine public trust.” Based on some of the conversations I’ve had with patients over the last three years, I’m not sure patients are too impressed with the idea of board certification in the first place. It feels like some patients put more trust in what they see on TikTok and from various health influencers than in what I’ve learned over the last 25 years in family medicine. The phenomenon has definitely gotten worse since the COVID-19 pandemic turned healthcare delivery systems upside down.

The initial certification exams for specialties are still of the high-stakes format, and some specialties also require an oral examination. Those exams are proctored in order to ensure the integrity of the testing process. When I sat for the initial certification exam in Clinical Informatics nearly a decade ago, it was administered at a corporate testing center, and I took it alongside people taking the real estate licensing exam and other standardized tests. At least at the facility where I took it, I found the process to be nerve-wracking since there was a lot of waiting around and dealing with proctors who were trying to apply different standards to the different types of test takers. For example, my particular exam protocol required me to turn out my pockets and prove that there was nothing in them, but others didn’t have to go through the same steps. It created a feeling of overall uncertainty and was even worse when I needed a tissue due to a runny nose during the exam, when I was treated like I was trying to cheat somehow. Needless to say, I was happy when the maintenance of certification approach was brought to both of my specialty certifications.

One of my colleagues had asked why the use of ChatGPT was a problem since the process already allowed the use of external resources to answer the questions. (Examinees are prohibited from speaking with other people, however.) The authors addressed this in the article, noting that the current process requires examinees “to process and assimilate the information found online to determine the correct answer to the exam questions” where “when using LLMs like ChatGPT, exam takers can simply manually enter or automatically scrape the question into the freely available web interface and be given an instantaneous result. This transaction requires no prior knowledge of theory or application and eliminates the need for reflection, reasoning, and understanding but can still result in a passing score.”

The authors do note some limitations of their study, including the fact that they drew all the questions used from a single board review book. That approach may not be representative of the full range of questions used or content delivered on the actual board certification exam. Additionally, ChatGPT couldn’t be used to address questions that contained images. They go on to say that given the situation, certification bodies need “to explore new approaches to evaluating and measuring mastery.” They suggest that testing may need to include more complicated or novel question types, or may need to include images or graphics that can’t be easily interpreted by current AI technologies. They do suggest that “in some situations, there may be a need to consider reverting to proctored, in-person exams,” although I think there would be a general revolt of diplomates if the board actually considered this approach.

It should be noted that the maintenance of certification process currently includes an honor code attestation, where diplomates certify that they’re following the rules on the use of reference materials and that they aren’t consulting other people for help with the questions. It would be easy enough to broaden that statement and ask diplomates to agree to avoid using AI assistants or other similar technologies when completing their maintenance of certification processes. Personally, I’m glad to be at a point in my career where I might only have to recertify each of my specialty boards one more time. I don’t envy those in earlier phases of their careers who will have to tiptoe through the veritable minefields that new technologies are creating.

What do you think about ongoing proficiency exams, whether for physicians or other industry professionals? Are they useful for demonstrating competency and ability or just a way for certification bodies to generate cash? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/22/23

June 22, 2023 Dr. Jayne 1 Comment

I continue to receive emails from multiple vendors addressing me as “Hey Jayne” and demanding that I schedule a call, or alternatively, respond to the email to tell the sender I’m not interested. I can guarantee I’m not going to respond to an email with that salutation, nor am I going to respond to bullying.

I keep trying to block the senders, but they’re somehow still getting through from at least two organizations. You might think that continued non-response would also be a ticket to be taken off of their marketing list. I’m also getting hit with solicitations for speaking engagements at dubious “conferences” that sound decidedly pay-to-play, but those seem to be a little easier to block.

In his recent Healthcare AI News roundup, Mr. H mentioned the inclusion of skin conditions in the Google Lens visual search tool. I decided to give it a whirl and ran three pictures of known dermatological findings through it. The tool scored zero out of three, so I think there’s still some opportunity for improvement. Granted, one of the conditions isn’t super common and it suggested a condition that is often confused with the actual diagnosis, but the other two submissions were very common, and I was surprised it didn’t do a better job with those.

When technology companies are marketing directly to consumers, it’s hard for primary care physicians and others who have the patient’s interests at heart to get ahead of the messaging and explain how these tools might or might not be used. It’s one more thing that overburdened clinicians need to add to their list of anticipatory guidance for upcoming patient visits.

AI continues to be a hot topic both within the US and around the globe. Various European consumer protection organizations are calling for investigation of AI systems in the interim before European Union regulations on the systems go into effect. Concerns range from the risks involved when AI generates content that mimics human work to the risk that AI could manipulate humans into doing things that will harm them. The European Union is creating rules for technology use, but they won’t go into effect for a couple of years.

Other countries are addressing the issue on a case-by-case basis, with Italy ordering OpenAI to stop processing user information during the investigation of a data incident. Nations such as France, Spain, and Canada are also looking into the technology. The next few months will be interesting as far as the continued discussion of AI and how it can best be used for the greater good.

I started doing some clinical work with a new organization and they’re eager to get my informaticist opinion on their EHR and how they might improve it. The first thing I recommended was some optimization to improve usability by putting the most commonly selected items on various menus in positions where they will be the easiest to select for the greatest number of patient visits. The EHR analyst couldn’t figure out how to do it, so he had to open a ticket with their vendor. It turns out that the EHR doesn’t allow this level of configuration, but rather forces items on the menu to be displayed in the order in which the menu items were built in the system’s back-end utility.

I remember seeing that kind of nonsense on a system I implemented back in 2009, but I thought that vendors had moved beyond that. It’s no wonder that physicians are complaining about scrolling since they are having to do more of it than they should.

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Registration is open for the LOINC conference being held October 17-20 in Atlanta. Sessions will focus on health data interoperability issues. Attendees include providers, patients, laboratory organizations, government entities, software vendors, device manufacturers, researchers, and students. The first day will be “devoted to LOINC learning,” with educational sessions to support newer users of LOINC and grow expertise in advanced users. Subsequent days will include public meetings of the LOINC committee as well as presentations from the LOINC community. Proposals are still being accepted, and for those unable to attend in person, there is an option for online participation.

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Speaking of conferences, one of my favorite readers is attending a meeting this week and sent some musings about his experiences. The meeting is the Multidisciplinary Association for Psychedelic Studies annual Psychedelic Science conference,  being held in Denver. Organizers estimated the potential attendance at 10,000 and continuing medical education credits are being offered. The conference agenda is fascinating, and my reporter has found it to be “wildly informative” and full of information about topics he had not previously been aware of.

Based on his reports, it feels like the event was pretty mellow and lower key than some other conferences. There was at least one EHR vendor was exhibiting although I didn’t catch which one it was. I imagine the vendor has to have either some highly specialized content, or alternatively, a fairly significant ability for clients to customize to meet their needs.

Other interesting offerings included sessions on the convergence of wearables, neuroscience, and psychedelics; a history of the discipline; discussion of rituals; practical techniques for prayer practice; the use of psychedelics in alcohol use disorder; and a stomp class.

The use of drugs like ketamine and psilocybin also features prominently in the agenda. I have worked with a handful of patients who have had life-changing experiences with ketamine treatment, so I hope people are open minded when considering some of these non-mainstream treatments. The website’s chatbot told me the conference was sold out except for single-day passes for Friday, so it sounds like plenty of people are interested in learning more.

I don’t have any conference travel planned for a while, so I’ll just have to live vicariously through my readers. If you’re attending a meeting we haven’t historically reported on, feel free to send your thoughts and observations. Or if you have ideas of meetings that you think HIStalk should be covering, please pass those along as well. As I put together my conference plan for the rest of 2023 and the first half of 2024, nothing is off the table.

Do you have any work-related travel that you’re looking forward to? What makes it unique or appealing? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/19/23

June 19, 2023 Dr. Jayne Comments Off on Curbside Consult with Dr. Jayne 6/19/23

I mentioned a few weeks ago that I have been having issues with my health system’s online billing functions. I was receiving paper statements before I received the online bills and couldn’t figure out how to adjust it so that I didn’t get paper statements.

At a recent visit, I asked the staff to see if they could adjust it on their side, and they said they would try. Interestingly, they also refused to accept my co-pay at the time of service, which is a big negative as far as revenue cycle management, so I wasn’t hopeful that they’d be able to get my account set up in a best practice fashion.

It looks like the “turn off paper statements” piece worked because I received an online invoice today. It included the co-pay (no surprise there) but also an unexpected co-insurance amount that doesn’t match how my insurance works. I haven’t even received the Explanation of Benefits document yet, so I’m not about to pay it. We will have to see how this cycle continues to unfold.

We had some family adventures in healthcare this weekend, with an unexpected injury that required attention beyond what I could manage with my first aid kit. Of the urgent care facilities in the area, some had spots available for online check-in, but others didn’t. Since we wanted a minimal wait, we opted for the one that was displaying available capacity, which is also an organization that I know fairly well.

As expected, walking in with a bleeding injury of the head puts one at the front of the line whether you have an appointment or not. Unfortunately, the provider wasn’t a great communicator and was mentioning how busy she was and how many other patients she was tending to rather than making the patient feel at ease.

She tried to downplay the injury a little, but fortunately the patient followed my advice and advocated for the treatment that is actually standard of care – they only knew that because I had prompted them after evaluating the injury and referring them to in-person care. The alternative treatment offered is typically less time-intensive for the provider, but results in poorer outcomes for this specific patient scenario. Most patients don’t know the difference, and it’s sad when our healthcare system is repeatedly putting time pressures ahead of patients.

After resolving the situation, we headed out for some Father’s Day celebrations, and then I came home to catch up on some work. It was timely that Mr. H called out this New York Times story on the level of moral crisis that physicians in the US are facing. Not a day goes by that I don’t hear a story from a colleague about this issue.

I’ve worked for organizations whose relentless focus on profits led to inappropriate prescribing behaviors as well as excessive ordering of tests. In one urgent care position, management justified these actions by saying, “we’re still only one-sixth the cost of a visit to the emergency department” and regularly presented me with reports that illustrated how much of an outlier I was to my peers when looking at the sheer number of prescriptions ordered. It should be noted that this organization had its own in-house pharmacy for which it didn’t submit insurance claims, so all prescriptions generated revenue.

From a conscience standpoint, by the time I worked for this organization, my prescribing habits were well established. I didn’t fall into the trap of trying to keep up with my peers in a way that didn’t make sense for clinical quality. Due to my training and prior experience, I also tended to make more clinical diagnoses using decision support tools and algorithms rather than tests and imaging studies, so of course that was an issue as well.

Eventually the organization figured out that my clinical skills and procedural abilities allowed me to see patients at a pace and volume that still made them money, so they left me alone, and eventually, the reports stopped coming my way. At the same organization, I also had to deal with some occasional patient safety issues as they encouraged me to practice outside my comfort zone with certain procedures, forcing me to have difficult conversations about my refusal to treat patient care like the Wild West.

Once they transitioned from being physician-owned to being owned by non-clinical investors, I knew my time there was limited. Others saw the writing on the wall as well, and now the organization can’t even keep its locations staffed. Not because there’s a shortage of clinicians, but because there’s a shortage of those who want to work there.

The article details many of the issues I’ve run across while in practice or in talking with my colleagues. Physicians are reluctant to speak out when they find themselves in these situations, because it’s been reinforced that they need to be team players, or they have experienced that reporting their concerns can lead to retaliation.

Former physician peers have lied on exit interviews because they were afraid that what they said would make the rounds in the physician lounge and come to haunt them in their new positions. Even in large cities, the physician community can be small. Powerful physicians on a given hospital’s medical staff can make things difficult for physicians who are younger, newer, or who otherwise have less political clout.

When I initially entered practice, I was once called out by a senior physician who felt I wasn’t giving him enough referrals and demanded to know why. I’m not sure who I could have complained to about that since he was not only chair of his department, but president of the medical staff.

That situation is relatively mild compared to some of the pressures that physicians experience today, especially those who work in segments that are largely controlled by private equity organizations or who are under strict productivity models for their compensation. Many physician contracts have clauses that would be problematic for other classes of employees.

I was recently presented with a contract that specified compensation based on the concept of a 12-hour shift, with no extra pay for additional time spent. When I asked for the language to be changed, I was told no, that all the other physicians already working had agreed to it and they weren’t willing to alter it. Needless to say, I won’t be working for that organization. Whether they’re lying about what other physicians have agreed to or just being difficult, it’s a decent indicator that they don’t value their physicians’ time. I guarantee they wouldn’t offer that contract to a nurse.

When physicians don’t feel valued, it creates psychological challenges that make it difficult to deliver good patient care. Whether consciously or subconsciously, decisions are made in the heat of the moment that can impact patient care but are based on the provider’s current situation.

I suspect that’s what my family member experienced today, when they were offered two different but non-equivalent management plans with a comment that it was up to the patient to decide. The difference in the clinician’s time was about 10 minutes, but sometimes that 10 minutes is what keeps you from going to the bathroom, eating lunch, or taking care of two more patients waiting for care. It’s a sad commentary on what many of us are facing every single day with patients caught in the middle.

If you’re in a non-clinical role, do you consult clinical colleagues for advice prior to seeking care for yourself or a loved one? Have you had to advocate for yourself or someone else for medical care in the last year? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/15/23

June 15, 2023 Dr. Jayne Comments Off on EPtalk by Dr. Jayne 6/15/23

I recently took a smaller version of The Great American Road Trip and made it a point to visit some historical roadside attractions. In the 1950s, it was all about seeing the USA in your Chevrolet (or equivalent) and families might have stopped at various quirky museums or points of interest.

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One of the places I visited had a collection of antique cars. I was struck by the idea of this 1960s era Amphicar. In some ways it’s a solution in search of a problem, which is something we see often in the world of healthcare IT. I have so many vendor emails hit my box each week promising to solve problems that I didn’t even know I had that I can’t keep track of them all.

The Amphicar was innovative, but didn’t make it big, ceasing production only four years after it began. Sounds like a lot of the products I see out there.

A group of organizations including AstraZeneca, Elevance Health, Geisinger, and UCSF have come together to publish a framework for evaluating digital health products. The goal is for care delivery organizations, health insurers, and trade groups to use it to determine whether digital health products are evidence based. The authors examined 70 frameworks that were created to assess the evidence around digital health intervention, determining that the existing frameworks lacked the specificity needed by healthcare organizations.

Sometimes people forget that digital health interventions can be as important and useful to patients as medications and surgeries. For example, an appropriate intervention to help patients stop smoking can prevent lung cancer. Digital coaching to manage body weight can lead to reductions in heart disease and stroke. The authors identified certain requirements as being potentially non-negotiable for organizations depending on their needs: HIPAA compliance, FDA clearance, and ability to be understood by patients with a fifth-grade reading level were examples.

Organizations are instructed next to use existing evidence assessment frameworks that have been defined for non-digital interventions. Following that, they should apply the new framework’s 21-item supplementary checklist for considerations specific to digital health. These may include elements such as assessing an intervention for selection biases, looking at data gaps, or ensuring that underserved patients were included in the product’s clinical trials.

According to the article, there are 300,000 health apps and 300 wearables in the marketplace, so being able to determine quality of an intervention is key. I wonder how much traction this approach will get, especially when we’re already struggling to make use of evidence quality in non-digital interventions. One of the hottest topics among physicians in my area is the surge in providers offering non-evidence-based hydration and vitamin infusion services. Comments such as “the patients want it, and I don’t see the harm” win the day, along with the potential for revenue. I’ll be watching closely to see how the world of evidence for digital interventions plays out.

Mayo Clinic is planning a $1 billion expansion and its new clinical spaces will incorporate data from patient wearables. Clinicians will have the opportunity interact with patient data elements such as pulse, steps, and sleep. I got a chuckle out of the fact that the article specifically called out Mayo’s “marble-filled lobby” since so many hospitals are overly proud of their non-patient-care spaces while patients may struggle to have basic needs met.

I also found it interesting that it mentioned the tension between Mayo’s lobbyist and Governor Tim Walz over the potential for penalties against hospitals that have excessive cost growth. The project is part of Mayo’s plans to transform the city into an international medical hub. The system has pitched the state, county, and city for $500 million in public funding for campus-serving infrastructure improvements. The new expansion will impact several blocks in downtown Rochester and is intended to make the campus more streamlined and modern, eliminating wayfinding confusion and harmonizing the patient experience. Construction is slated to begin in 2024.

Northwell Direct has inked a deal with the US State Department to offer telehealth consultations to patients seeing Department of State medical professionals around the world. The offering will apply to US government employees and their families posted outside the US. Consultations will be available 24 hours a day, seven days a week and requests will be triaged for assignment to the appropriate Northwell provider staff in more than 100 specialties and subspecialties. Those providers will also provide medical clearance services before employees are sent outside the US, as well as clinical case reviews. Northwell Health also partners within the US with Teladoc for additional virtual care delivery services, so it’s not entirely clear how this will all fit together.

Speaking of government, the Surgeon General of the United States has issued an advisory about the impacts of social media on adolescent and child mental health. The report notes that social media use is nearly universal in those ages 13 to 17 with nearly two-thirds reporting daily social media use and one-third reporting use of platforms “almost constantly.” It goes on to conclude that “social media presents a meaningful risk of harm to youth” with those spending more than three hours daily facing double the risk of mental health problems as others who spend less time on social media.

The long and short of it is that “we cannot conclude social media is sufficiently safe for children and adolescents” and lists steps that can be taken to reduce the risk of harm in those groups. These include: reaching out for help for those negatively impacted by social media; creating boundaries to balance media use; being selective about what is posted and shared online; and addressing cyberbullying. A short summary is available or you can view the full advisory.

Many of my family physician colleagues are still trying to figure out how to balance their use of telehealth within the context of traditional primary care practice. A recent report from the University of Washington Center for Health and Workforce Studies showed that while there was limited data about how medical assistants participate in the telehealth setting, those staffers can transition to virtual roles following additional education and training. Unfortunately, I think a lot of organizations just try to throw people in a role without fully thinking it through. We saw this a decade ago, when practices decided they would just turn their medical assistants into scribes but didn’t think through how to create an appropriate training program or how that role transition might otherwise impact office dynamics.

More on the topic of transitioning historically in-person tasks to virtual caregivers. I was talking with some CMIOs earlier this week about whether they think virtual nursing is going to solve some of their staffing issues. Systems such as Washington-based Providence and Arkansas-based Mercy have already rolled out programs and labeled them as successful, preparing for expansion. Among the group, several were enthusiastic about the idea, and one said their system was in the process of rolling it out using internal resources. However, another said her system was about to sunset the concept because it hadn’t yielded the savings it anticipated. Although that organization’s efforts did dramatically reduce its dependence on travel nurses, those savings were countered by expenditures for hardware and third-party staff management.

Has your organization dipped its toes into the waters of virtual nursing? How is it going? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/12/23

June 12, 2023 Dr. Jayne 3 Comments

I was intrigued by a recent study published in in JNCI Cancer Spectrum that looked at how capable ChatGPT is when asked questions about common cancer myths and misconceptions. The study, performed with the Huntsman Cancer Institute, compared ChatGPT output against social media.

I understand the premise. Many patients are getting their information from social media, friends, family, and people they know on a personal basis rather than being able to learn key information from their care teams. Sometimes this happens because people may be receiving cancer diagnoses via their patient portal accounts due to immediate-release results policies stemming from governmental regulations. Other times it happens because patients are unable to reach their care teams when they have questions or they don’t feel that their team is listening to them.

Cancer is also a condition that leads people to leave no stone unturned as far as investigating treatment options and potential outcomes. It’s one of the scariest diagnoses you can receive, and even as healthcare professionals, we are rarely prepared for it. There can be a lot of uncertainty about treatment plans and sometimes even about diagnoses, and patients often seek additional information or alternative treatments as a way of trying to maintain control of their own health and lives.

Generally, physicians appreciate working with engaged and involved patients who want to understand the pros and cons of various treatment options. But a number of industry forces create pressure on that scenario, including time pressures, insurance limitations of treatment options, and availability of options in a particular geographical area.

In fairness, the study was performed shortly after ChatGPT became widely available, so it may not be entirely applicable today. Researchers used a list of frequently asked questions that they sourced from the National Cancer Institute’s “Common Cancer Myths and Misconceptions” website. They found that 97% of the time, the answers from ChatGPT were in agreement with the responses provided by the National Cancer Institute.

In contrast, approximately one-third of social media articles contain misinformation. Distrust of medical institutions and medical professionals has grown exponentially since the beginning of the COVID pandemic, and patients may decide not to pursue standard treatments based on information they’ve heard from friends or family or might have found online. This can lead to negative outcomes for patients, who may expose themselves to increased mortality rates when selecting unproven treatments.

Even when considering medical professionals as a source of information, I’ve seen instances where misinformation can be spread. Sometimes patients consult neighbors or friends who might be physicians, but who are in specialties nowhere near the patient’s area of need. I’m not even an old timer, but I know that the treatments for various cancers have progressed exponentially since I last cared for patients with those diagnoses. I’m always careful to refer patients back to their oncologists, hematologists, or surgeons, but not everyone does that. I’m part of several Facebook groups that have exclusive physician membership, but we still see bad answers circulating when physicians who are patients themselves pose certain questions.

For physicians who are actively caring for cancer patients, knowing that patients might receive medical misinformation can increase their feeling of burden in delivering care. One of my colleagues feels she can never disconnect from managing patient portal messages because she feels that if she doesn’t answer the patient’s questions promptly, they will be more likely to go down the proverbial internet rabbit hole, leading to greater stress for the patients and their families. When we discussed having boundaries around these kinds of interactions so my colleague can have a break, she said she’s thought about it, but feels that correcting the misinformation later actually requires more work and emotional effort than just being continuously available to field questions. It’s a difficult spot for clinicians to be in when they feel called to serve their patients so broadly.

The study involved a blinded review of the answers to the questions, grading them not only for accuracy , but looking at word count and Flesch-Kincaid readability grade level factors. Answers from both sources were less readable than recommended by most health literacy advocates, but the responses from ChatGPT tended to use more words that led to a perception of hedging or uncertainty. The questions evaluated were striking, and included items such as:

  • Is cancer a death sentence?
  • Will eating sugar make my cancer worse?
  • Do artificial sweeteners cause cancer?
  • Is cancer contagious?
  • Do cell phones cause cancer?
  • Do power lines cause cancer?
  • Are there herbal products that can cure cancer?
  • Do antiperspirants or deodorants cause breast cancer?

I have to say that I have heard at least four of these questions from friends and family members in the last month or so,  and I am not surprised that they made the question set. The issue of antiperspirants and breast cancer risk comes up often in some of my social media channels, as to the questions about eating sugar and using herbal remedies.

Full documentation of both the National Cancer Institute answers and the ChatGPT answers are included in the article, in case you’re curious.

In addition to the question of accuracy, there’s also the question of specificity. Researchers noted that while the ChatGPT answers were accurate, they were also more vague than the comparison answers from the National Cancer Institute. This could lead to patients not thinking the answers were valid, or to them asking additional questions in clarification.

There was also concern about patients who might ask ChatGPT questions about cancer that are less commonly asked, and which might not have a large body of knowledge to form a training database. The study was also limited to the use of English, which has an impact on its applicability to broad swaths of the US and the world. As a patient and knowing what I know about the propensity for ChatGPT to hallucinate, I don’t think I’d want to go there for my medical information.

Given the newness of the technology when the study was performed, it would be interesting to see how newer versions would perform in the same circumstances. There are a couple of possibilities. It could become more accurate, or it could go completely off the rails as we’ve seen it do with some queries. Additionally, the content used for the models typically only runs through 2021, so current data might influence the results. I hope researchers continue to look at how ChatGPT might be useful as a healthcare adjunct, and where it might serve patients best.

What do you think about ChatGPT as a debunker of medical misinformation? Will it tell patients to inject bleach to kill viruses, or declare it to be an insane strategy? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/8/23

June 8, 2023 Dr. Jayne 3 Comments

When I certified, one of the major components of the clinical informatics board exam curriculum was public health informatics. As a family physician, I understand the value of public health, and especially after the pandemic, most of us understand how underfunded it is in the US.

Various studies show that a dollar spent on public health has the power to reduce future healthcare spending by anywhere from $11 to $80 depending on the nature of the intervention, yet it’s still not where we prioritize our spending. The reality is that prevention isn’t sexy and doesn’t make money for the people who pay for lobbying, but a girl can hope that eventually policies will shift in a way that makes better funding a reality. A recent article in the American Journal of Public Health looked at the US life expectancy compared to that of other nations over the better part of the last century.

The author found that the US life expectancy began falling in the 1950s and continued to worsen over the last four decades. He also noted regional variation across different parts of the US, finding that the Midwest and south-central states fared worse than other regions. Almost a third of the US states have 60% or fewer of their children vaccinated, and that’s a basic public health intervention that is proven to save lives and reduce days missed at work and school. When people don’t see the value in that, it’s hard to get them on board with funding more “exotic” interventions like community gardens, food pantries, nutrition and cooking classes, and healthy environments for exercise and community activities.

As a clinician, it’s difficult to watch the decisions that health systems continue to make as they prioritize high-earning surgical subspecialties and cutting-edge interventions while they refuse to fund staff expansions in primary care. I’d love to see more research looking at the long-term cost savings and quality of life improvements when preventive care is prioritized.

I had that on my mind when I came across an article about how Regenstrief Institute is working with the National Association for Chronic Disease Directors on a project that will use EHR data to estimate chronic disease burdens at the national and local levels. I wasn’t aware that there was a project in the works for a Multi-State EHR-Based Network for Disease Surveillance (MENDS) or that local public health organizations will be able to tap into it.

The goal is for the EHR-derived data to replace more manual efforts, such as health department workers having to canvas at the community level. There are barriers to the data sharing, however, including the lack of a mandate for hospitals and provider organizations to share their data with public health agencies. Other potential issues include lack of accuracy in diagnosis coding and lack of staffing at public health agencies.

The Office of the National Coordinator for Health IT is looking for feedback on expanding the US Core Data for Interoperability classes and elements. The list of data elements was expanded to better reflect the clinical quality measures that are in use with Centers for Medicare & Medicaid Services quality reporting programs and also to incorporate greater use of FHIR-based reporting. The draft list of data elements for USCDI Version 4 will be open for public comment until June 30.

I had the chance to help a colleague out today when they were working on a specific formatting issue for a scholarly work. It’s been a long time since I’ve published anything, and as I was digging into the details, I was impressed by the number of resources available on the internet. Back in the day when I was a regular on the presentation circuit, you had to have a stack of reference manuals to make sure you got everything right before submitting your paper, which had to be sent in a box since it was typed, double spaced, and printed with multiple copies. As we think about standards in healthcare and standards in the digital universe, it’s intriguing to remember that some of the first usability standards were set for written scholarly works. When papers were all written with the same stylistic features, it made it easier to understand the content and less likely for the reader to have to wade through a confusing format. Usability principles have evolved over time, but still adhere to a common core of thinking, and it was nice to be pulled in as an “expert” on the topic.

I’ve been back on the road recently and summer travel is in full swing. Unfortunately, I started today’s leg of the trip at an airport that decided it would be good to shut down 50% of the women’s restrooms for maintenance at a time when they had 20 arrivals and departures in the hour surrounding my flight. Needless to say, it created some bottlenecks.

I always wonder if people exhibit the behaviors that I see in the airport during their “regular” lives. At least where I live, I never see people ordering hard liquor with their breakfast, but you see it a lot at the airport. In the boarding line today, I had two guys behind me chugging beers after they had been told they couldn’t take them down the jetway. There was also a group of high schoolers, the majority of whom had full-size bed blankets for their trip and were juggling all their gear while trying to figure out how to repack to try to get it all on board. I felt bad for their chaperone, who had largely lost control of the group. I’ve chaperoned groups of teens before and we always had strict rules about what they could bring or not bring so that we could avoid issues at the gate like I saw today.

On the plane, one of the students in front of me spent the majority of the flight kneeling backwards in her seat, talking to the person in the row next to me. Their chaperone, who was in the same row, just ignored it. Although it was annoying, I remember what it was like to be a teenager, so I decided to just tune it out. There have been so many changes to the typical US teen experience during the last couple of years that this might the only trip these kids have taken (or might ever take), and it’s good to see schools who are encouraging their students to see the world. I also learned today that you can’t take a bowling ball through the TSA checkpoint at this particular airport even though the TSA app says it’s permitted.

What’s the most interesting thing you’ve seen during travel this year? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/5/23

June 5, 2023 Dr. Jayne Comments Off on Curbside Consult with Dr. Jayne 6/5/23

I spent the weekend largely unplugged, catching up on some household projects and indulging my need for quality time in the kitchen. My last-minute run for pickling and baking supplies created an interesting assortment of items at the grocery checkout, but when you like to do things old school, sometimes you really do need three kinds of vinegar and a jar of bay leaves.

My pickling efforts were slightly more successful than the baking one, which resulted in the first time I’ve ever had to admit that it’s possible to have too much sugar in a cake. When I finally reconnected this weekend, my inbox seemed to be forming a theme around the topic of healthcare IT gone bad.

First, there was the story of the National Eating Disorder Association chatbot being decommissioned after it recommended harmful behaviors, including dieting and calorie restriction. The organization at least owned the problem, stating that the advice being given was “against our policies and core beliefs.” Apparently the chatbot, called Tessa, was created around proven cognitive behavioral tools that have been shown to reduce eating disorders. However, it appears that programmers may have tried to make it work more like ChatGPT and ended up running off the rails. The original tool used pre-programmed responses and was not intended to be adaptive or to use AI features.

It’s been interesting to watch chatbots evolve over the last couple of years. Quite a few vendors claim to have created AI-enabled chatbots, but when you look behind the scenes, they end up being sophisticated (or sometimes not so sophisticated) decision trees. I’ve seen some alleged healthcare chatbots that are constructed by teams that don’t even have clinicians on them, which is truly worrisome. It’s always surprising to see the logos of organizations who have bought into the hype and probably never asked to speak to the clinical person behind the proverbial curtain.

When ChatGPT came to the forefront in recent months, I saw several companies try to leapfrog good design and development principles in an effort to be able to say that their product was using the technology. I’ve worked with enough technology organizations and on enough different projects to know that trying to cut steps out of the software development lifecycle is never a good idea.

The steps that organizations typically try to cut are the ones that are the most critical in my book: planning, analysis, and testing. They forget that the whole point of the process is to be efficient from both time and cost perspectives. When you rush to market, you usually end up paying for it on the back end with broken functionality and unhappy users. The piece that it feels like people forget though is that when you’re in healthcare IT, that can translate to patient harm. Developers always need to remember that regardless of whether you call them users, consumers, or patients, the person on the other side of the code is someone’s parent, child, friend, or loved one.

The next story wasn’t about AI run amok, but was about more than 400 Grail patients receiving notices that they may have cancer. The company immediately pointed fingers at its third-party telemedicine vendor, PWNHealth. In digging into the details of the issue, more than half of those receiving the erroneous letters hadn’t even had their blood drawn.

The test in question is Galleri, which can screen for 50 kinds of cancer through a single blood draw. Large healthcare organizations like Mercy have jumped on board with it, offering the tests on a cash-pay basis even though they aren’t part of guidelines-based recommendations. The test costs $950, and if I had paid that kind of money, I would be doubly aggravated to receive an erroneous letter before I even had my sample collected. I had heard of the test when Mercy first started advertising it, but didn’t realize until I read the articles this weekend that it has not completed human clinical trials. There’s a study in the UK that’s at the halfway point, though. Despite that, more than 85,000 patients have spent the money to have the test performed, with only a handful of insurers providing coverage.

I’ve been on the other side of an erroneous medical testing result and it’s a horrific experience, leading you to wonder even if your corrected result is valid. In my case I had my pathology slides re-read by an outside pathologist because I didn’t know which reading to trust. Not every patient has the knowledge to ask for that or the resources to pay for it. Also in my case, the test orders were placed by a local physician who knew me well and with whom I had a relationship, which was a great support as we worked through the issue. Grail, whose owner is DNA-sequencing equipment Illumina is already under fire from regulators in both the US and Europe due to monopoly concerns. It will be interesting to see how this unfolds.

The third story wasn’t about healthcare IT as much as about AI in general, looking at specifically how AI would compare to humans on judging whether rules have been broken. A study done by Massachusetts Institute of Technology examined how AI would handle such things as a post violating a site’s rules or a dog being in violation of apartment rules. Researchers concluded that since AI can be trained on data sets that don’t include human validation, results may skew more harshly. A researcher in the field, Professor Marzyeh Ghassemi, is quoted as saying, “Humans would label the features of images and text differently if they knew those features would be used for a judgment. This has huge ramifications for machine learning systems in human processes.” Definitely something to think about when it feels like everyone is clamoring for more AI.

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I would be remiss if I didn’t say happy birthday to the HIStalk team as the healthcare IT universe celebrates its 20th anniversary. One of my vendor executive friends recommended it to me when I first started my healthcare IT journey, and I never dreamed I would be part of the team. It’s been quite a ride with a lot of ups and downs in the industry, and I still remember sending my application to join the team by way of my trusty BlackBerry. Looking through old posts and revisiting what we thought was wild and crazy at the time, some of those news items pale in comparison to the issues of today. Here’s to the future of HIStalk as it continues to chronicle our topsy-turvy industry and to be everyone’s favorite source of healthcare news, opinion, rumors, and gossip.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/1/23

June 1, 2023 Dr. Jayne 1 Comment

Midwestern health systems BJC Healthcare and Saint Luke’s (Kansas City) have announced plans to join through a $10 billion merger. They have been previously connected through participation in the BJC Collaborative, which Saint Luke’s joined in 2012 as the organizations sought to share resources and cut costs.

Announcements from the organizations note plans to operate under their existing brands and operate from headquarters in both St. Louis and Kansas City. Detailed plans for the merger are slated to unfold through the rest of the year, with a goal of closing the deal by the end of the year. I reached out to some Midwestern friends who know both organizations well and it sounds like there may be some significant cultural differences that come into play. It should be an interesting one to watch.

I receive dozens of cold call emails every day despite my best efforts to filter them into junk mail or spam folders. My favorite of the week was one that gave three different stylistic treatments to the healthcare entitlement program for seniors: MediCare, MediCARE, and ultimately Medicare. Maybe their marketing team will eventually create a style guide so that they can remain consistent, but since I made use of the block sender functionality, I hopefully won’t be seeing it again.

I don’t practice as often as I used to, but when I do, there’s always a patient who asks about something they saw on the internet and how it might relate to their reason for seeking medical care. A recent Forbes article discusses data that more than a third of members of Generation Z trust TikTok more than doctors. It’s not the only player in the equation – another 44% of adults surveyed visit YouTube before contacting their physician. One in five respondents trust health influencers more than they trust medical professionals, citing access, cost, and avoiding judgment from medical professionals.

The article goes on to emphasize the need for care providers to meet patients where they are. I agree with that approach. I’ve not seen many mainstream health organizations fine tuning their social media sites to go after that demographic, but I’ll keep an eye out. There is plenty of medical misinformation out there that needs to be countered, but competing against influencers might be an uphill battle.

For health systems and other organizations that are trying to build their brands (and often renaming themselves in the process), they might want to target older demographics. A recent article notes that members of Generation X and Baby Boomers are twice as likely to trust brands than members of Generation Z. Topping that brand list and possibly providing inspiration for marketers: Band-Aid, UPS, Amazon, Lysol, and Kleenex followed by Cheerios, Visa, Dove, The Weather Channel, and FedEx. The survey noted that Generation Z doesn’t trust many brands to do the right thing – non-profit brands were the only category to which it responded well. I tried to poll a couple of the members of Generation Z about the topic, but hit a dead end because they were heads-down on their phones.

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I have a visit later this week with a new physician who is part of the medical group where I’m already established. I was relieved to receive an electronic check-in notice through the patient portal. My previous physician left the practice for health reasons, but I’ve been a patient in both the practice and its database since 2019 (and in its precursor, which was converted, for a decade prior) so it should have been smooth sailing.

I completed the electronic check-in and was met with a notice that “you might be asked to complete additional paperwork in the office,” which jogged my memory that indeed they had mailed me a packet six months prior. I found it in the file sorter on my desk and was dismayed to find that it contained four pages of materials that are redundant to my existing chart, including the pharmacy information and medication list that I just confirmed during the electronic check-in process. When I scheduled the appointment, I made it clear that I was transferring from her former partner. Since I’ve been seen within the past three years by a physician of the same subspecialty who bills under the same tax ID, I’m technically an established patient even though I’m new to her. I assume they send the “new patient” paperwork to everyone, but it’s still disheartening.

No one wants to arrive at the office and be turned away because they don’t have the (totally unnecessary) paperwork, so here I sit filling out information when I’m 100% confident that it’s all in the chart already, because I’ve seen it in my past visit notes. The real kicker was when I arrived at page four and found the “physical examination do not write below this line” section, where presumably the physician (who has a multi-million-dollar EHR) will not be documenting my exam because her contract requires her to use said EHR if she wants to get her annual bonus. I helped institute those contracts in a past life, and according to my former colleagues, they are still in place, so that should make for a fun conversation when I get to my appointment. The photocopies themselves are no longer crisp and are marked by smears from repeated copying, which is just sad.

Getting to the end of the paperwork, I realized that it didn’t even ask for some of the key elements of my history that are important to the topic of the upcoming visit, as well as being critically important for a physician in that subspecialty regardless of whether they’re a topic of this specific visit or not. As a physician, I know this is a big deal, but many patients might not volunteer that information if the physician doesn’t specifically ask for it.

Based on the paperwork and the pre-visit experience, I’m not confident of what to expect from this visit. For an organization that is worried about patient experience and their patient satisfaction ratings, I’ll be sure to give appropriate feedback when the inevitable survey arrives in my inbox. If they’re interested in some management consulting and EHR optimization, I might just know someone.

What’s the most frustrating healthcare IT-related issue you encounter as a patient? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/25/23

May 25, 2023 Dr. Jayne 2 Comments

A recent article in the American Academy of Family Physicians’ journal FPM summarized “Clinical Workflow Efficiencies to Alleviate Physician Burnout and Reduce Work After Clinic.” The first of their four suggestions was for EHR users to make use of macros and defaults in their systems so that they can easily insert content into their visit notes.

I continue to see physicians who won’t take advantage of basic system personalization. When I was in traditional primary care practice, my goal was to be able to do visits using as few clicks as possible and there’s no way I could have been as fast as I was without defaults for common physical exams and orders. It’s still difficult for me to understand the psychology where a user will waste time visit after visit, day after day, week after week, but won’t spend 90 seconds to create a default. The article even includes a link to a blog with a starter list of EHR macros for those who might have users who are reluctant to take steps to make their lives easier.

One of their other recommendations was to “consider cutting note bloat by writing in short phrases rather than full sentences and including only what is essential.” My first EHR made it easy to create notes in a format that was more akin to a bulleted list than beautiful, flowing prose. For many, reading a list like that is easier than reading a block of text, so I agree that it’s a valid strategy.

They also go on to mention that the EHR should be used as a database and not as a way to recreate the paper chart. Providers are encouraged to ask for help and to take advantage of organizational resources such as clinical informaticists, or even to get help from more efficient colleagues.

Even as a CMIO, I’m always willing to sit down with our clinicians to coach them through more efficient workflows. One of my early clinical informaticist roles involved implementing some challenging users. I miss the days when I could work with them and watch the proverbial light bulb go on when they had figured out how to breeze through their visits.

Many of the organizations I work with are big on telehealth, and I hope all organizations are making their plans to move to HIPAA-compliant telehealth technologies now that the public health emergency has ended. Organizations have had three years to move to compliant tools, but there are always going to be groups that wait until the bitter regulatory end before they do the right thing for patient privacy. The Office for Civil Rights is providing a 90-day grace period, but penalties for HIPAA violations will resume on August 10.

In the interim, organizations should look at their telehealth programs and technology, conduct a risk assessment, and confirm that they are using HIPAA-compliant tools. I suspect some purchases may be on the horizon and can imagine some vendors salivating at the organizations that left their transitions until the bitter end.

From Jimmy the Greek: “Re: marketing. Check out some of the language on this corporate website. ‘We create value by making sustainability an integral part of our vectors of superiority.’ There’s also ‘Improving lives for generations to come with irresistible superiority that is sustainable.’” Wow.” Any time I see the word “vectors,” my infectious disease brain immediately thinks of rats, flea bites, ticks, and other disease vectors. These linguistic gymnastics are found on the Procter & Gamble investor site, which is an otherwise interesting read if you’re so inclined. Given their product lines, I suggest that P&G might be better served by a tagline such as, “Assimilation through personal care, one buzzword at a time.”

Speaking of buzzwords, I’m currently disliking this one the most: omnichannel. The way I keep seeing it used, it falls squarely into the “I do not think it means what you think it means” category more often than not. I’ve also recently run into a resurgence of “circle back,” which I think should be eradicated from the business lexicon, along with “synergy,” “new normal,” and “out of the box.”

I had a visit at my primary care physician’s office this week. I scheduled it online and had my choice of a next-day visit that didn’t work for my schedule or one the following week, which I booked. Online check-in was a breeze, and the patient questionnaire related to my issue was easy to navigate.

The only blemish in the workflow was when the medical assistant had to free text every field when documenting my vaccine administration. At a minimum, I would have hoped the EHR would have had a vaccine inventory management system that would have presented things like the lot numbers and expiration dates as dropdowns or pick lists to help reduce errors and manage inventory. Even the site had to be free texted despite the fact that there are generally only six places on the human body where intramuscular injections are administered. She also had some kind of paper sheet that she was performing dual entry on, so I’m not sure what was going on with that and was afraid to ask.

When I arrived home, I was pleased to see that my patient-visible note contained an accurate History of Present Illness and that the exam matched what was actually performed, which is a big contrast to a visit I had with a specialist in the group last year. However, as I was reading my note, I realized that they never asked to collect my co-pay. Since they’re owned by my former employer, I know that collecting the co-pay at the time of service is a requirement. It’s also an industry best practice that everyone should know about. It helps avoid statement costs as well as the risk of never receiving the co-pay.

This means that I’ll get an annoying statement in the mail (I haven’t been able to turn off paper statements despite trying) and then have to go online and make a payment. Usually, I don’t receive an electronic statement notification until after the paper one has arrived, which seems to be a less than optimal way to configure your revenue cycle.

What makes you cringe when you visit a healthcare facility and see that best practices aren’t being used? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/22/23

May 22, 2023 Dr. Jayne 1 Comment

I’m a big fan of experiential learning, especially after having just finished teaching some Outdoor Classroom sessions for a local youth organization. It’s great to see people use the skills you’re teaching as they interact with each other and try to solve problems. It works best, however, when you have a good blend of instructional time with practical or application time.

Having hands-on time can be great if you at least understand the concepts that are being presented and the goal is to either learn them at a deeper level or become more capable in performing them. I liken it to a surgical skills lab. First, you learn about wound repair, and make sure you understand how skin will heal depending on the repair technique and how different types of sutures will work in different ways. Then, you actually practice either with a simulator, or back in the dark ages, we practiced with pigs’ feet. You don’t just start throwing stitches into live patients without understanding the fundamentals.

I have a couple of certifications on EHR products that I rarely use, but for which I like to stay up to speed. One of the vendors rolled out a new product that I’ve not been certified on. Given my past work with the application, they offered me the opportunity to take the certification classes for the new product.

I was excited about the opportunity and ready to prepare for the classes. Unfortunately, there wasn’t any kind of preparatory work – no pre-class readings or training videos. There was a PDF for the class, but what was in there looked mostly like exercises without any foundational content. I wasn’t sure if I was missing materials or whether it was intentional, but I decided to head to class with an open mind.

I have to say that it was one of the most frustrating classes I’ve ever taken. The entire thing was taught in a hands-on fashion, with no structured presentations or materials that summarized the functionality. Each module was a situational vignette, and after reading it, we were expected to go into the application and figure out how to take the necessary steps.

It was completely frustrating. I knew the general layout of the application and the main menus, but I didn’t know all the shortcuts that this class apparently expected us to not only know, but use. It was made worse by the fact that many of the desired tasks had more than one way for them to be accomplished, but you only deduced this after working through the scenario a couple of times. At no time did the instructor explain why one might want to embrace one workflow over another.

Not having any kind of initial summary or teaching also made it difficult to figure out what the various options were. I felt like I was more focused on writing things down in my notes so I could try to put it together in a cohesive manner rather than trying to understand how to manipulate the different scenarios. Because of that, I found myself missing key information because I was still trying to figure out something that happened a minute or two earlier in the simulation scenario.

Even if I would have been given a one-page summary that listed the different workflow possibilities and explained why a user would select one compared to another, it would have been a significant step up. A handout of the system’s keyboard shortcuts would have been helpful as well. After completing the class, I ended up spending several hours in the system’s demo environment running through common scenarios and seeing if I could figure out how to execute them on the platform.

At the end of the course, there was an evaluation that contained a couple of the question formats I hate the most. The first was what my medical school used to call “multiple-multiple choice” questions, which typically had four answer options (A, B, C, D) but then would have additional options like “A and B” or “A and B and C” and other combinations. Inevitable you’d find more than one thing on the list that was likely to be correct, but you spent excess time trying to psych yourself out about which items to exclude.

The other most hated question format (which unfortunately continues to also be present on my medical specialty board certification platform) is the “choose the best answer” type question. “Best” is really a subjective question, especially when you’re talking about patients and how they might take or not take a medicine. There have been campaigns for many years to get those kinds of questions off the recertification exams, so I’m used to seeing them more rarely. However, those questions were all over this software training, with the problem being that finding the “best” solution depends on many more factors other than just the test taker.

For patient care, the best solution might be one that balances clinical effectiveness with cost and makes it easier for patients to take their medications they way they intended. Best could also mean the treatment that will give a patient the most longevity, or the highest quality of life. But it can also represent treatments that might save your life, but that also might cause horrific side effects and deterioration in your quality of life at the same time.

This can also be true in the healthcare IT side of the house. The term “best” might represent the solution that has the most bang for the buyer’s buck. It could also be the solution that has the lowest risk of patient care errors. Or perhaps the one that takes the least amount of time for nurses to complete their workflows. When you put on your client hat while reading test items like that, one can’t help but overthink them or overanalyze similar decisions you’ve made in the past.

After feeling like I had been led astray but the hands-on training and then burned by the confusing test questions, I was ready to give up. Sure, I could follow the instructor to perform a bunch of different tasks, but I had no idea how the application would help my daily work or benefit my organization. I’m a pretty decent test-taker, so I ended up passing the evaluation step, but I still don’t feel like I know anything as far as being able to operationalize the functionality.

One of my co-presenters at Outdoor Classroom has dyslexia, and working with him made me think about how others would perceive the class. Similarly, people who learn best from reading rather than watching an instructor perform tasks and then try to emulate them might be out of luck. Organizations need to do more thought around different learning styles and need to spend time crafting strategies that will work for the diverse groups of users that their products will certainly encounter.

What are the best and worst types of software training you’ve experienced? Any advice that you’d give those who create the strategies? Leave a comment or email me.

Email Dr. Jayne.

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