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Curbside Consult with Dr. Jayne 8/31/20

August 31, 2020 Dr. Jayne 1 Comment

Over the last few years, I’ve done quite a bit of work with healthcare IT startups. There are hundreds of people out there who think they have the next big thing and jump headlong into the journey of trying to make it a reality. It’s a difficult road from having an idea to going live in production, and an even more challenging one taking a product from go-live to profitability. We’ve all seen the startup failures and even those that make it to the big time seem to struggle becoming profitable.

The biggest issue I’ve seen with some of the startups I’ve worked with is that they fail to determine how they’re going to govern themselves and their application. I’m a huge fan of governance, not only because good fences make good neighbors, but because being able to make decisions effectively also helps prevent wasted effort and rework when it turns out something was built that doesn’t make sense.

There are numerous governance questions that need to be addressed. First, there are issues about how the organization will be formed. Is it a partnership, a limited liability company, or something else? Does everyone have an equal share in the profits and liabilities? Is the company based somewhere with favorable laws? I was recently approached by a startup that had no corporate structure. While I’m comfortable contracting with individuals, I wasn’t comfortable having one partner hire me to fix what sounded like a problem with one of the other partners.

Next, there are issues around contracting and spending money. Who has signatory authority for contracts? Who has the ability to spend money? Can everyone spend money up to a certain threshold, but do expenditures above a certain point require a greater decision-making authority? What kinds of expenses qualify as business expenses? Do various functions have budgets and are expenditures regularly reviewed to ensure things are not getting out of hand? Are the appropriate checks and balances in place?

There are certainly more “business-y” things that have to be done when you’re contemplating a startup, but operational and product governance also needs to be in place if an effort is going to be successful. On the operational side, is there a mission and a vision for the company? Do the involved parties have a common understanding of what they are trying to build and sell? Or are there simmering disagreements about whether the effort is more technology-based or service-focused, or a bit of both? Who is the target audience, and does the group understand their needs? I’ve seen plenty of great ideas fall flat because no one involved in the visioning process understands the target audience, or even the target industry. Cue the music for all the big tech companies that thought they could “do healthcare” and exited after spending a lot of money and not accomplishing much.

There also needs to be some level of product governance figured out before the first line of code is even written. Who makes decisions on what the product is going to do? In a startup, people may wear multiple hats, but who owns the functions of product management, clinical oversight, development/dev ops, testing, marketing, and sales? If there are competing priorities, how will decisions be made? Who determines minimum viable product? Who will represent the voice of the customer? Who will keep up with regulations, if applicable? I once worked in a startup that had a brilliant development mind who didn’t play well with others. He’d stay up all night writing code, without running anything past the clinical advisors (and often without running it past others who were writing conflicting features). When his ideas were shot down, not only did we have to untangle the content from the application, but it took days and sometimes weeks to get him back to his happy place where he could be productive again.

Another sticking point I see people get in trouble with is the management of contractual requirements for customers or prospects. This goes back to the mission and vision part. If a client or prospect asks for a feature to be built as part of a contractual requirement, who makes the decision? Is it more important to land the customer, even if it means delaying other planned features or moving away from the product’s comfort zone? If a contractual requirement is agreed upon, does the agreement contain enough detail to make the feature a reality, or will there be room for the client to claim that it wasn’t properly delivered because the contract was vague? I see a lot of startups that try to be everything to everyone and move well outside their comfort zone and often into the danger zone because they lack governance.

One of the most important things that startups need to develop is the ability to say no. Sometimes a prospect just isn’t a good fit or has needs that are beyond where the company is in its development. It can be more important to walk away from a deal rather than saddle the team with an unwinnable situation, or unreasonable product demands. I recently worked with a group that had a truly cool offering that was just coming into its own when COVID hit. A large health system approached them about modifying it a little and trying to scale it up to fill a COVID-related need. Fortunately, the managing partners said no, because trying to get the health system live would have been a huge distraction from all their other priorities for the year. Although some argued that it was a missed opportunity, the reality is that saying no gave the company additional opportunities to be true to their core mission and their existing clients.

Seeing a cool idea become reality is incredibly exhilarating. It’s also exhausting, and I’ve seen it weigh heavily on individuals, their families, and their careers. Playing in that part of the industry isn’t for the faint of heart, although it’s a relatively great place if you’re an adrenaline junkie or if you enjoy staying awake at night sweating all kinds of things which might go wrong. It’s fun to wake up wondering what adventures each new day might bring, but it’s even more fun when you get to do it within the confines of a leadership team that’s done the legwork needed to increase the odds for success.

What’s your best (or worst) startup story? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/27/20

August 27, 2020 Dr. Jayne 2 Comments

Telemedicine provider Avera ECARE creates the American Board of Telehealth, positioning it as a national body to develop best practices and standards for telehealth education. The new board plans to focus on telehealth quality and education across the scope of individuals involved in telehealth, from administrators to physicians and everywhere in between. The ABT’s advisory board includes leadership from industry players such as Amwell and the American Telemedicine Association (ATA), along with a couple of academic faculty.

Avera received a $4.3 million grant from the Leona M. and Harry B. Helmsley Charitable Trust last year, which funded a telehealth education center along with a certificate program. The new ABT program will launch online September 7 with a CORE (Clinical, Operational, Regulatory, and Ethics) Concepts in Telehealth Certificate Program. Validated guidelines will be supplied through the Harvard medical Physician Faculty Group and the curriculum will be delivered using seven online modules. I’ve been underwhelmed by previous educational opportunities from the ATA and telehealth vendors, so my curiosity sent me to check out the website. There’s a $400 fee for the program and it sounds like they will mail you a handsome certificate, since they note that there is a $150 fee for a replacement.

My wacky clinical story of the week comes courtesy of our broken healthcare system, because if it was functional, the visit would never have happened. A patient presented to a direct-to-consumer telehealth service after seeing her primary care physician, who referred her to a subspecialist, who recommended a course of treatment that the patient didn’t feel was working. She was unable to reach the subspecialist due to limited office hours, so she called telehealth for a “second opinion.” It never occurred to her to reach back out to her primary physician to further discuss it. She ended up on the phone with an emergency medicine physician who wasn’t able to assist due to both limitations of knowledge and the constraints of his scope of service. Operations people take note: technology is not the answer here (but it can help).

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Doing what I do for HIStalk is a great excuse to spend time every week checking out new companies. Sometimes a friend clues me in on an interesting thing they’ve seen, or mentions a need that gets me questioning whether a solution exists. Such was the case this week with SS&C’s Vidado platform, which was formerly under the Captricity moniker. Apparently they are a player in the insurance and financial services sector, with clients such as MetLife and Guardian. They have a track record with OCR and data extraction of insurance history and medical forms, which gives support to their entry into the world of healthcare. They processed over 300 million pages last year and obviously can play at scale.

It looks like their healthcare focus includes drug prior authorizations and specialty pharmacy orders, along with common documents such as claims forms. It sounds like they have a short-term proof of accuracy offer that allows clients to see how the solution would handle their forms before signing on the dotted line. If I was looking for a vendor in the space, that would certainly be compelling. I’ll certainly be keeping my eye on them to see how they fare in the wacky world of healthcare.

There are still plenty of paper forms out there, as I learned at the imaging center last week. They are now two years into their Epic implementation and are still handing patients a paper form to complete that looks like a downtime document – it doesn’t even have the patient’s name or demographics on it. Forms that make you fill out your address when it’s already in the registration system, EHR, and RCM system are just annoying.

One of my favorite techies has been out of work for a while and reached out today to share his acceptance of a new position. He’s been to hell and back in his job search and we caught up about some of the strange behaviors he’s seen among recruiters and hiring managers. One disheartening tale involved a recruiter who reached out twice for the same position, missing the fact that she had previously told him he wasn’t selected to move to the next step. Another involved a manager who noted that he was the first to interview for the position, but they planned to conduct interviews for the better part of a month, so he shouldn’t expect a decision any time soon. Nothing says “we don’t know what we’re looking for” like an admission that you haven’t narrowed your candidate pool.

My friend noted that multiple people asked questions like “why have you been out of work for so long” as if they were unaware of major layoffs in the healthcare IT industry or a global pandemic that has eliminated hiring in many sectors for the last six months. Not to mention that people may have been impacted by COVID personally or with the illness or loss of a family member, so it’s just not that great of a question. I’ve always found it better to focus on what the candidate is bringing to the table rather than the circumstances that led them there.

Regardless, I’m glad he found a position that seems like a good fit and that happens to be in his favorite industry. The fact that it’s work-from-home well into 2021 is a bonus, too. I know there are millions of good people looking for work right now and I wish them productive interviews with companies that have their acts together.

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Everyone falls victim to clickbait headlines. I have to admit I was pulled into this viewpoint article in Nature Reviews Urology. “Making love in the time of corona – considering relationships in lockdown” looks at impact of societal lockdowns on intimacy. Topics range from the practical to the philosophical, so if you’re looking for an interesting read, it certainly fits the bill.

What’s the worst clickbait headline you’ve ever fallen for? Leave a message or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/24/20

August 24, 2020 Dr. Jayne 2 Comments

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There’s a lot of talk in the healthcare industry about “wellness.” Everyone is trying to cash in on it, and it seems like there are as many different definitions of wellness as there are companies trying to figure out how to make it part of their portfolio.

As a physician who strives to practice evidence-based medicine, I find many of the elements that are rolled up under the wellness umbrella to be questionable.

I ran across an insurance company last week that is encouraging its members to have “wellness labs” performed. This sounds like a good idea until you look at the contents of the lab panels, which include multiple tests that aren’t recognized as screening tests and aren’t recommended unless patients are experiencing symptoms. We all know that when tests are ordered that aren’t needed, we not only increase the healthcare cost burden, but also place patients at risk, as additional tests may have to be performed to further evaluate the results of a test that shouldn’t have been performed in the first place. I find it shocking that payers would want to spend money on unproven evaluations. I don’t fully understand what they hope to accomplish.

When various groups try to define wellness, they include anywhere from five to eight dimensions of wellness, including emotional, environmental, financial, intellectual, occupational, physical, social, and spiritual aspects. All of these certainly impact the ability of individuals to achieve their ideal state of health, but it’s difficult to quantify the complex interactions and how modifying one dimension might lead to changes in the others.

Many of the companies that are trying to get into the wellness space seem to be playing on people’s insecurities as a means of generating profits rather than being truly interested in the science as we understand it. Gwyneth Paltrow and her Goop brand has made millions of dollars selling wellness products ranging from nutritional supplements to sex toys. Wellness is the place to be, but that doesn’t change the fact that I tend to think twice about organizations that make it a central focus.

This really hit me the other day as I drove by a shop that had a “find wellness here” banner to promote their sales of CBD oil. Even though there is a small body of evidence looking at it, many of the shops promoting it aren’t selling medical-grade product and are certainly hyping it well beyond what the evidence shows.

Especially with confusion around the proven effectiveness of various products, patients have an extremely difficult time determining which wellness interventions they should most vigorously pursue. Does a mammogram or a pap test carry the same weight from a wellness perspective as trying to eat healthier to reduce cardiovascular risk? How do those interventions compare to improving emotional and spiritual health? Should EHR vendors be branching out to gather more data about the dimensions of wellness in addition to gathering all the usual discrete data about recommended screening tests? Or should we recognize that the jury is still out on many of the aspects of wellness and stick with trying to manage the conditions and interventions for which we have the best data?

I have a potential client who would like me to help them build a dedicated wellness practice. I’m struggling with the idea. I know how to help them accomplish what they’re trying to do and can help them with both the operational and technical pieces. They plan to staff the practice with their usual physicians, who will take turns seeing the wellness patients. If they find something that requires more in-depth follow up, they will refer the patients back to the traditional practice.

The client doesn’t seem to care whether the physicians have much buy-in to the concepts of wellness, or whether they are prepared to address all the different dimensions of wellness. In talking with them about their goals, it feels like they’re just trying to catch a ride on a popular concept while making some money along the way. One partner specifically mentioned wanting to keep patients away from telehealth practices that offer wellness services.

On one hand, it would be easy to just take the engagement and get the work done. However, part of me will still have doubts about the validity of the plan since it seems more about the money than offering a comprehensive portfolio of services that would help support their patients in the pursuit of better health.

This situation underscores the issues with healthcare in the US today. We have a mismatch of incentives that leads providers to look for ways to bolster the bottom line at the expense of initiatives that are designed to shift to a value-based approach. Organizations cite the idea of “no margin, no mission” as a way to justify some of the choices they make. Given the financial beating that many practices have taken this year, you can’t blame them.

The decision might be out of my hands, as I’m not sure they’re going to be willing to spend the amount of money that will be needed to build the whole wellness concept from start to finish, including marketing, staffing, and changes to their EHR and other technical systems. I bid on several projects like this each year, where people think they are going to be able to do major projects on the cheap, and then seem shocked when someone fully spells it out for them. I can’t imagine that any of the larger consulting companies can do it more economically unless they’ve dramatically slashed their rates due to slowdowns from the pandemic.

Plus, the practice need to be ready to handle the losses they will incur over the next year or so until they know whether it’s going to turn out the way they hope. Given the uncertainty of the pandemic and the upcoming flu season, I’m surprised they are willing to even consider taking the plunge.

What do you think of the idea of wellness? Do you think it’s a good time to take the plunge on new service lines? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/20/20

August 20, 2020 Dr. Jayne 3 Comments

There’s been so many notices from CMS in my inbox lately that I missed a biggie, and that was the recent release of the 2021 Medicare Physician Fee Schedule. CMS is planning to shuffle some of the telehealth codes, eliminating 70 or so codes from the 80-ish that were created to cover services during the pandemic. They are adding more than a dozen new codes, though, and some advocates are hopeful that the public comment period will lead them to add even more. They’re going to have an uphill battle since CMS isn’t convinced that the services are beneficial outside the context of a public health emergency. The organization will be looking for data to make a decision, and in reality, none of us know how long the declared emergency will last. Flu season will soon be upon us – I’ve already had patients trying to get vaccinated – and only time will tell.

The Physician Fee Schedule noticed was tucked in between about 10 emails about new resources and strategies and collaboration spaces for eCQM projects. In my previous life with a large health system, the clinical quality measures fell under my purview. I’m fairly certain that dealing with all the calculations and making sure our EHR was handling them properly killed more than a couple of my brain cells. I have tremendous respect for the IT and clinical teams that live in that world all the time, and just wish there could be an easier way to go about gathering the data needed to drive value-based care.

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The American Academy of Family Physicians launched their new redesigned website today. Although it’s much cleaner than the old one, virtually no information is available from the home screen without going through menus. The entire first page is sucked up by a big graphical tile and the concept repeats down the screen, offering little value. They also changed the login scheme from one using the member number to one using an email address, forcing every single user to change their password.

A blurb they sent out about the update mentions the addition of new “mega-menus” for users to find their content, and I’m definitely not impressed. The menus are so long you have to scroll through them, and they completely cover the rest of the screen even though a good chunk of the menu popup is blank. Seems like perhaps it’s supposed to be optimized to some other form factor than the PC I was using it on. The menus are so big though I can’t imagine them on a phone screen. It took me four clicks to access content I used to find with one, so I give the update a grade of C at best.

A better website was the one for the COVID-19 Prevention Network, which I visited to volunteer for a potential vaccine trial. Based on the questions, I’m not sure what their ideal candidate looks like, but if they are seeking people who are constantly exposed to unmasked sick people, I might know a couple.

My clinical employer sent out a notice from a local medical testing place that is also doing vaccine trials, but I’d much rather participate in one that is part of a university study versus the commercial lab that was offering cash to participants. Not to mention that I have no desire to be part of a safety trial, but would be happy to be a guinea pig for one that determines whether the vaccine is effective in the real world.

I’ve read several articles in the last couple of weeks about so-called toxic positivity and its negative impact on people as they try to cope through the pandemic. Although experts agree that having a positive mindset can help with coping, when overdone, it can make it seem like the only way to deal with a negative situation is to put a happy face on it.

I’m a huge fan of Fred Rogers. As an adult reading about his life, one of the things I came to appreciate about him is that he told children that it was OK to feel mad, or sad, or bad. One of his goals was to help his viewers learn to process those emotions in a productive way. One study from 2018 looked at “The psychological health benefits of accepting negative emotions and thoughts” and found that those who don’t manage difficult emotions don’t do as well as individuals who manage them effectively.

I used to have someone in my life who told was constantly telling me to smile, which I loathed. Trust me, there is nothing to smile about when you’ve been on call in the critical care unit for over 24 hours, have had to pronounce patients dead overnight, or have had to do any of a number of difficult things that healthcare professionals do all the time. Years later, I understand that the real reason I hated the comment was that it was an attempt (conscious or not) to minimize or invalidate my experiences or to try to mold them into something that the other person was more comfortable with. As we learn more about the trauma that healthcare providers experience and other concepts such as moral injury, it becomes even more important to give ourselves permission to be less than OK.

Getting through this pandemic and whatever other economic and societal crises go along with it will be a long, hard slog across the globe. I saw a figure the other day that some 20% of first line healthcare workers had contemplated suicide in the last 90 days, which should be setting off alarm bells. As someone who has been personally touched by physician suicide this year, I encourage everyone to try to find moments to check on your co-workers and to care for each other.

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This week provided another crazy day at the urgent care, where I was completely understaffed and “over-patiented.” We have some newer-ish staffers who are still a little freaked out about COVID, unlike the rest of us who are just used to it by now. Mask, double mask, face shield, let’s go. We were trading stories about whether we’re still doing the whole “strip in the garage and run to the shower” track and field event when we get home from work. 

The paramedic I was working with had me literally laughing out loud. His wife won’t let him in the house until he strips in the garage, sprays a cloud of Lysol, and walks through it to the shower. He refers to it as “the fog of war,” which was just the right degree of hilarious coming from a guy who served his country in both Iraq and Afghanistan and who could probably kill me three different ways with chewing gum and a popsicle stick. Somehow the camaraderie made up for the 68 patients I saw by myself, and I’m actually looking forward to my next shift.

What’s the funniest thing you’ve heard in the time of COVID? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/17/20

August 17, 2020 Dr. Jayne 1 Comment

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Sunday was National Rum Day. Alas, I spent it treating patients rather than enjoying fuzzy drinks in the sun somewhere.

Today was a case study on how broken the healthcare industry is. Given the economy, over the last few weeks we’ve seen a surge in people questioning their deductibles and trying to figure out what the cost of care might be prior to checking in to be seen. Of course we haven’t done anything remotely close to installing real-time eligibility checking and usually don’t have a clue what their benefits might be due to convoluted payer contracts, so they stand at the front desk and debate whether they want to be seen or not. I feel for them because most of them need care, but are feeling like they’re stuck between a rock and a hard place in deciding what to do.

We’re seeing a mix of patients who are terrified that they might have COVID, those who are likely to actually have COVID but don’t think it could possibly happen to them, and the usual things that come into an urgent care, such as lacerations, chest pain, and traumatic injuries. We’re also seeing patients at the urgent care who are terrified of going to the ED since the state is in a surge situation, so they stay at home too long with complicated problems. Tonight ended with an elderly patient who fell and whose family kept them at home due to those fears rather than seeking care. Ultimately, they did little more than prolong the patient’s pain and delay definitive care for her broken femur.

We’re also seeing a total breakdown in the primary care infrastructure. Patients can’t get in touch with their providers to determine the best place to seek care. We’re seeing more and more patients relying on us for basics and necessities such as medication refills and quarterly labs.

Despite everything that is supposed to be going on in the realm of value-based care and management of costs, it feels like things are upside down and we’re just lighting money on fire rather than delivering coordinated care. If we as a society can’t manage something as straightforward as medication refills, I’m not sure how we think we’re going to motivate patients to make major health-related changes or meet their growing psychosocial needs as the pandemic rages on.

I struggle to figure out the answer. I’m certain technology isn’t the full answer, although I’m eternally grateful that Epic has essentially taken over the market in our area. Nearly every patient has a phone and can access MyChart, so those of us in the urgent care trenches can figure out what’s going on. Except for those patients who flit around the urgent care market between CVS Health Hub, the Walgreens clinic, and the handful of urgent cares in town, in which case all bets are off. Most patients don’t know that they can coordinate their MyChart accounts though and pull in data from the different health systems, so it feels like I do a fair amount of technology teaching some days as we try to see an integrated picture of patients who seek care across the different systems.

I have noticed an improvement in the medication history information we can receive back through Surescripts, which helps quite a bit when you’re trying to figure out how compliant your patients are. Our prescription drug monitoring program database also continues to perform like a champ, which helps bridge the gaps. Still, the bottom line is that I’m usually in at least three or four different systems trying to do my job, which doesn’t seem right in the middle of a public health crisis that should be driving us towards greater sharing and improved patient care.

I’ve also noticed an increase in patients who want to discuss politics during their visits. It always gives me a little chuckle when they ask me whether I think COVID is as bad as the media make it out to be. My double mask and the face shield should be an indicator. Still, it doesn’t seem like there’s much realization that healthcare workers are desperate to not take the virus home to their family members, or that we are stressed to the max and both physically and mentally exhausted, given the complaints that we get when anyone has to wait more than 30 minutes for their visit.

We’re squandering resources right and left as colleges and universities mandate COVID testing, but on a clinically inappropriate timeline. A negative test 10 days before move-in day is meaningless unless the students have been quarantining. We’re also still seeing employers that demand patients who have negative tests get a second negative test to return to work despite the CDC updates that occurred more than three weeks ago that say this is unnecessary. I’m sure the local school district’s HR department is far wiser than infectious disease experts, so we do what has to be done regardless of whether it makes sense or is a good use of resources or not.

I had an interesting conversation with my scribe today, I didn’t realize he is a COVID survivor. He was pretty sick and spent a couple of weeks in the hospital, receiving convalescent plasma and not requiring intubation. He’s glad to be recovered, but worries about the long-term consequences of the disease, especially since he’s under 30 and hopefully has many years ahead of him. He’s focused on making it to medical school in a year or so and I can’t help but think that his experience will make a difference in the kind of physician he grows into.

He had never heard of clinical informatics, so I was able to do some education there. It’s good for those who aspire to join the healthcare team to know the underpinnings that try to hold it all together. We talked about some of the work I’ve done in the past, which had me hankering for a good lab interface build or maybe some kind of a legacy EHR conversion. It’s funny how the things we thought were arduous at the time take on a whole new look when we’re faced with something that has changed our perspective as radically as COVID has.

Regardless of how tedious our days seem or how frustrating some of the interactions might be, the reality is that we’re dealing with someone’s mom, dad, grandmother, daughter, sister, and more. It’s a unique privilege to care for people. I’m hoping we will eventually be able to elevate our game and find a better path forward.

What is your employer doing to change the big picture of healthcare or drive innovation forward? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/13/20

August 13, 2020 Dr. Jayne No Comments

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For many practices, it’s a COVID-related surprise and not necessarily a fun one. New national requirements for COVID-19 testing data went into effect August 1. Ordering physicians now have to supply demographic information to help public health agencies track the disease’s spread and identify areas that are seeing large number of cases.

The requirements were included in the Coronavirus Aid, Relief, and Economic Security (CARES) Act. It requires that laboratories that test for COVID or its antibodies report 18 data elements to HHS. Some of them don’t typically appear on a lab requisition, such as race, ethnicity, and county of residence. There are also “ask at order entry” questions to identify whether the patient is a healthcare worker, whether they are housed in a residential setting, whether they are pregnant, or if they have been hospitalized.

Labs are pushing back on practices to supply this information when tests are ordered rather than having to track it down manually. Depending on how up-to-date your EHR is and how well it supports the use of these fields during laboratory ordering, you may or may not be compliant.

I worked with several practices this week who were not compliant and were trying to become so after receiving complaints from their lab vendor. Fortunately, I was able to do some workarounds for the paper requisitions that accompany specimens, but I won’t be able to modify the lab interfaces without support from the vendor.

My participation in the ONC Tech Forum this week was interrupted by the crisis with the lab requisitions, although I would have stepped away and helped my client regardless of whether the conference was in-person or virtual. That’s one of the joys of doing what I do in healthcare IT, as I help practices and organizations navigate the many challenges that get thrown their way.

I was glad to hear National Coordinator for Health IT Don Rucker talk about the utility of health information exchanges in dealing with the COVID pandemic. He acknowledged that we have a way to go before we’re going to be able to make the most of data exchange and the ability to share patient information. He called out the ability for HIEs to receive data for organizations that might not be top of mind for care delivery, such as group homes and shelters. My state has a long way to go with regards to HIE, so I’m fairly convinced that having a truly functioning system that shares data from all physicians at any point before I retire is just a pipe dream.

This week has been all about preparing proposals for potential consulting gigs, so I’m actually looking forward to going back to the clinical trenches this weekend. What I’m not looking forward to are the hundreds of charts awaiting my signature for the shifts I worked prior to vacation. I tried to work on them while I was out of the office, but our Citrix platform is unstable unless you access it from the internal network. They don’t have any incentive to investigate the issue since it doesn’t matter to them how arduous the chart signing process might be. The ongoing message is for us to be happy we haven’t had pay cuts or layoffs, so most of us are just staying quiet. Such is the state of healthcare in the US these days, and my colleagues elsewhere are sharing the same kinds of stories.

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The American Medical Informatics Association has booked Anthony Fauci, MD for a special fireside chat at its Virtual Annual Symposium to be held November 14-18. The session will only available to registered conference attendees. I’m sure it will have a lot of people on the edges of their seats. The man was already a legend prior to COVID and having served as an advisor for six US presidents speaks for itself. I enjoy his matter-of-fact style and can’t wait to see what he has to say. Apparently I’m not the only one that likes his style since the Dr. Anthony Fauci Fan Club group on Facebook has over 150,000 members.

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A friend of mine knows that I’ve been checking out various virtual conferences since the pandemic started and invited me to visit something a little out of my subject matter area. The QSO Today Virtual Ham Expo was the gathering place for thousands of amateur radio operators over the weekend. I have to admit I really liked their platform. They had a virtual expo hall where you could see various “booths” and click on them for a virtual visit and even a live chat. Accessing speaker sessions was very easy even after the conference ended, with the sessions presented as embedded videos within the agenda.

Since amateur radio operators tend to be pretty techy, most of the videos I sampled had reasonably good production values and excellent audio. It was interesting to see how another industry is handling the problems we face, and with over 21,000 registrations, it’s certainly comparable to a healthcare conference.

A couple of friends at software companies say they are working on their own platforms for virtual user groups. I hope they are doing plenty of usability testing and focus groups with prospective attendees. I’ve been to good conferences and bad ones, and there’s definitely a negative impact if the tech isn’t good, the speakers aren’t prepared, or the background filters are doing funky distracting things.

Most of the vendor user groups that I’ve attended are part education, part rah-rah sessions to try to bond users to the company and help them forget all the crummy things the software does to them on a daily basis. It’s going to be hard to get that vibe going virtually unless they really work at it with specific engagement sessions and bulk-mailed swag like they did with the recent InTouch Health / Teladoc conference.

I’d love to hear from vendor folks about how they are planning to approach virtual user groups and the challenges they are facing. I promise to keep you anonymous. If you’re a potential attendee, what are you looking forward to or dreading with virtual conferences? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/10/20

August 10, 2020 Dr. Jayne 1 Comment

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I thought I had previously registered for ONC’s tech forum this week, but when I noticed I didn’t have any meeting information, I figured I should double check. Turns out I didn’t register.

I would have definitely remembered, because I thought their registration form was a little problematic. First, one of the required fields for registering is a Twitter handle. Of course, one could just put junk in that field, but I found it odd that it was the first field required past name and email address. Another required field was “Affiliation” without any indication of what they were looking for. Did they mean employer?

I’m becoming quite the connoisseur of virtual conferences and have enjoyed doing a few more of them than I might otherwise have done had travel been required. For those of us who foot the bill for our own conferences and education rather than charging it back to an employer, it’s all about making the most of your time and your travel resources.

Speaking of, I cancelled my hotel for HIMSS21 “spring edition” today and worked on making my reservation for HIMSS21 “roasting hot desert summer edition.” Unfortunately, my hotel of choice isn’t taking reservations just yet, but I was able to book a backup for reasonably cheap. Like Mr. H, I’m a little uncertain on exactly where the conference will take place since the official notice includes Caesars Forum and Wynn as venues as well as the expected Venetian-Sands Expo Center. I loved my stay at The Venetian a couple of years ago, but it’s not in my current budget. My new hotel is fully refundable, as was the previous one (and the credit was already showing up in my online account before I had booked the next reservation).

The flight is in my budget, however, as I’m sitting on several thousand dollars of unused plane tickets that were supposed to take me to all kinds of interesting places this year. Now the challenge will be to use them before they expire. Some airlines have been more generous than others in pushing their expiration dates well into 2022, but I anticipate more than one will just become a loss. I’ve found charities that you can donate miles to, but haven’t figured out a way to donate tickets since they’re supposed to be nontransferable. If anyone has ideas, let me know. I doubt I’ll be rescheduling my trip to the Vancouver area anytime soon, given the current status of coronavirus transmission in the US.

Once I finished moving my hotel reservation, I was in an administrative mood, so I spent some time trying to do forecasting for what I’ll be doing the rest of the year. It’s a difficult time to be an independent consultant. Earlier in the year, I watched six months’ of bookings evaporate in a single afternoon, and it hasn’t been easy replacing that business. Many of my ongoing clients are mid-sized organizations that are in dire financial straits as they wrestle with continued shortages of personal protective equipment and struggle to try to figure out how to kickstart their revenue streams during failed economic re-openings across the US. My larger clients are experiencing across-the-board project freezes after furloughing internal staff. They’re more likely to reactivate those staffers than to use an external consultant, which is understandable.

For those clients who are continuing to have me work, I’ve seen some fairly extreme layoffs and restructuring, with one client literally moving the work of two departed project managers onto the one remaining one. The remaining project manager is struggling under the workload, but is afraid to complain because he fears he might be next. As you can imagine, the project management that’s occurring is fragmented, behind schedule, and generally ineffective, because you simply cannot just pile work on people and expect them to work magic. I’ve had a couple of conversations with the director of the program management office about it, but she just throws her hands up because she doesn’t have the authority to challenge decision-makers who still want all the projects running.

It feels like everything we’ve learned about happy staff being productive staff has been thrown out the door in the last few months, and people are operating from a position of desperation. This is only being magnified as various parts of the country head back to school and working parents are trying to figure out how they’re going to juggle childcare with assisting children who are expected to learn at home. I have a lot of friends who are able to work their IT jobs from home and have been successful during the pandemic, but all bets are off when they’re expected to support their elementary aged students in virtual learning plans that have varying degrees of planning and forethought.

Despite industry players like Epic pushing to have workers return in person in the name of “culture,” it feels like most of the health system folks I speak with are happy to let people work at home as long as possible while making plans to jettison the soon-to-be-unused office space and its associated costs.

Two more of my physician friends made plans to close their offices this week. One was already struggling with health issues when the pandemic hit, and the stress has definitely worsened her condition. Another is retiring early to move in with her physician daughter to help with her grandchildren. Both of these physicians thought they had much more time in their careers. Their patients will certainly miss them.

The local health systems have all stopped acquiring practices and one has laid off dozens of physicians, so there wasn’t an option to sell the practices. Since they each carry several thousand patients on their panels, I’m not sure where all those patients are going to receive specialty care, and they only have the state-mandated 30-day notice period to figure it out.

We’re certainly living in strange times. Although my practice hasn’t had to lay anyone off, they’ve made it clear that physicians aren’t getting any extra money regardless of our insane patient volumes and that we should be happy we are employed and working a normal number of shifts each month. They did give generous bonuses to the staff, which we appreciate, but you would think physicians seeing an extra 20-30 patients a day might be worth a little financial boost. I suspect that more than one of us is planning to depart after the end of the year because you can only work at this pace for so long before you start to crack.

In the mean time, it’s all about keeping your chin up, your mask on, and putting one foot in front of the other. We’re all looking forward to the time when this pandemic is under control . We are crossing our fingers that it’s not going to be confounded by a hellacious flu season once we ease into winter. Normally we start our flu vaccination campaigns in September and October, so only time will tell on this one.

Are you preparing to cope with children learning at home? Have any good strategies to share with the rest of us? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/6/20

August 6, 2020 Dr. Jayne No Comments

CMS continues to forge ahead as if providers have nothing else going on, releasing final scores for the 2019 Merit-based Incentive Payment System (MIPS) program. Every time I see one of these announcements, I’m again grateful that my practice decided to opt out and take the associated penalties. It’s worth seeing an extra patient here or there to cover any losses so we can focus on care delivery and not clicking boxes.

Other hot federal topics include a Medicare proposal to expand telehealth benefits permanently. I’ve seen what a benefit it can be for patients who don’t want to risk going to a physician office, but I’d like to see more practices offering it as a routine part of their care rather than patients having to go to third-party vendors for care.

A good chunk of what I do in the telehealth arena should ideally be managed by either the primary care provider or a subspecialist managing a particular condition, but our healthcare system continues to be broken in even basic ways. Several recent calls were around medication refills, not only for patients unable to make appointments with their regular physicians, but to even get a response to a refill request for a medication. When you hear some of the stories, you wonder if they’re made up, but based on the recent runaround I’ve had with my own family’s physicians, I have no reason to doubt the stories patients tell.

They also released the 2021 Proposed Rule for the Quality Payment Program via the Medicare Physician Fee Schedule Notice of Proposed Rulemaking. They did at least note that “in recognition of the 2019 Coronavirus (COVID-19) public health emergency and limited capacity of healthcare providers to review and provide comment on extensive proposals, CMS has limited annual rulemaking require by statute to focus primarily on essential policies including Medicare payment to providers, as well as proposals that reduce burden and may help providers in the COVID-19 response.” Although that’s small comfort to the people who have to wade through the original content of any proposed rule, at least they’re recognizing that most of us have other things on our minds. For those of you still in the game, comments are due by October 5 at 5 p.m. ET.

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Props to Google Cloud for their “oops, that didn’t go so well” email after a bulk mail failure. It’s always good to tackle errors with a sense of humor, and I appreciate the acknowledgement rather than just getting another email. I also appreciated that their email linked directly to case studies about their products rather than forcing me to give my contact information to download an e-book or other fluff piece.

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I’ve heard a lot of talk lately about EHR vendors that plan to use “AI” to help with physician documentation. In reading between the lines of some of these articles and ad pieces, the devil is truly in the details. One client was bragging about his vendor’s plans to add AI to their application and I was glad I was on a voice-only call because I’m sure I wouldn’t have been able to contain my facial expression. You have to have a reasonably robust backbone to add AI to an application, and this particular vendor is far from it. Their EHR is about two steps away from being a Microsoft Word document, and I can’t fathom how they think they’re going to “AI enable” that unless they’re just adding voice recognition and putting a lot of lipstick on it.

I think there is a tremendous amount of promise for AI-enabled documentation technologies, but to be as effective as a live scribe, they also have to be able to handle questions on information recall and analysis. I’m constantly asking my scribes to provide information from previous visits or to see if there are patterns with interactions. There are certainly technologies that can provide these functions as well and I’d love to see them be able to handle mainstream primary care and urgent care encounters like I see day-in and day-out. So far the only ones I’ve seen that are able to do a decent job are only able to do so in the subspecialty realm.

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Low tech, but literally cool: Shipping giant UPS is readying freezer farms in preparation for the eventual shipping of vaccines against the novel coronavirus. Each unit can store up to 48,000 vials of medication, with a total of 600 units being placed at facilities in Kentucky and the Netherlands. I’ve only been on the receiving end of vaccination shipping and know what a major logistic undertaking it is for flu season, so I can’t imagine what it might look like when people are clamoring for the vaccine across the globe. (I am betting that for the 60% of US residents that say they won’t get it, there will be plenty of takers in the rest of the world.)

Since we don’t know what COVID will look like when flu season hits, many clinical organizations are already ramping up their plans for vaccination campaigns. There is plenty of good technology out there for the patient outreach piece and getting those patients who typically receive a flu vaccine should be easy. It’s also easy to identify the patients who have high-risk conditions and alert them to the benefits of the vaccine.

What’s not easy, however, is ensuring that practices have enough personal protective equipment for their staff members, which is still a struggle in many practices. Despite the availability of testing supplies in my community, many primary care offices are choosing not to test because of concerns about PPE, which sends patients to urgent cares, other health systems, or the CVS Pharmacy drive through. Fragmentation of care is still the order of the day for many patients, and until we get a national coordinated strategy, I imagine it will continue to be this way.

In the meantime, I’ll keep helping my clients ready their campaigns, prepare their word tracks for patients who are reluctant to vaccinate, and look at creative ways to leverage their technology assets to maximize scheduling and vaccine delivery. Just another day in the clinical informatics trenches.

How is your organization preparing for flu season? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/3/20

August 3, 2020 Dr. Jayne 1 Comment

I’ve written about business continuity planning previously. It seems like every year it becomes a germane topic as we experience tropical storms, hurricanes, wildfires, and floods across the US and around the world. Throw in a global pandemic that shuts down medical offices and curtails hospital services and you’ve created a situation where continuity planning is an absolute necessity. Did I mention cyberattacks and ransomware? These are a couple of other good reasons to go through a planning exercise if you haven’t done so already.

Business continuity planning is part of the consulting work I do, so I’m no stranger to helping organizations walk through some of the circumstances their practices might encounter. As a CMIO, people expect me to be versed in the IT side of things, and many clients are concerned with the obvious things like EHR outages, power outages, etc. Clients living in coastal areas typically have a decent hurricane / storm plan, but many organizations haven’t thought about the natural disaster aspect. One summer my little corner of the world experienced floods, tornadoes, an earthquake, and locusts, so it was a bit of a sign that we all need to think about these things.

As I’ve worked with clients on this the past couple of years, we’ve spent more time discussing cyberattacks and ransomware, as numerous healthcare organizations have been hit by this. As of the last couple of weeks I have a great new case study for this with Garmin. They were hit by an attack that disabled their services for more than a week. They claim they didn’t lose any client data from their sites, but the reality is that clients lost data because they couldn’t sync their devices with the Garmin services. Understanding the anger in the client community about exercise data from wearables should make physicians think twice about how patients would feel if their actual medical information were lost or held for ransom.

When I go through a business continuity planning exercise with a client, I usually include a discussion of what it would look like if key human resources became unavailable. For example, what would happen if the CEO or COO departed the organization? Do others have signatory or contracting authority, and how would day-to-day operations run? For smaller practices, what is their plan if they lose a key biller or scheduler? Most of the time we’re focused on the operational and financial side of the house, with a brief but general discussion on the clinical side.

The clinical side of business continuity planning certainly came into focus earlier this year with COVID-19, as practices shifted to a telemedicine models and looked for new technologies to be able to safely reopen their patient care operations. I added a couple of different dimensions to my client-facing materials based on those experiences and they’ve been well received by organizations I’ve worked with. Still, I was thinking in more broad strokes about how organizations might be impacted if they can’t see patients and looking at it from a macro level.

Unfortunately, this week I had to think about it from a micro level, as my practice suddenly lost one of our full-time providers. Since I’m just a worker bee at my brick-and-mortar practice, I’ve never been privy to their business continuity planning and didn’t worry about it too much since my clinical work isn’t my main source of support. One would think that in the event of the loss of a provider, they could use the same checklists they might use when a provider quits or retires. It quickly became apparently, however, that they either didn’t have such checklists or were so overwhelmed by grief that they hadn’t worked through the process.

My involvement started when one of the nurse practitioners called me, as the most senior physician working at the time, asking what to do about the fact that the EHR was still putting my late partner’s DEA number on her prescriptions. Pharmacies in our area have an issue with NPs who write controlled substances and often ask for the supervising provider’s information as well, so we’ve added that to our prescriptions. I’m not sure if it’s custom code with our EHR vendor or a feature that they offer, but it’s how we roll. This was three days after his passing, so I can only guess that the other midlevel providers for whom he was the collaborating physician either didn’t write any controlled substances prescriptions in those days or didn’t think about what went out on the script since it hadn’t yet been addressed. In the short term, I supervised the NP for the prescription in question so the patient could be managed, but it made me wonder about the plan.

I also had the unique experience of staffing my late partner’s primary practice location, where our staffers had created a temporary memorial with flowers, photos, candles, and other tokens representing his personality. I’m not sure the organization had thought about how that would impact patients or the staff working at the location, since many patients had questions about the memorial and what had happened that our employees were unprepared to field. I was surprised by one particular patient who hounded me for details. I learned later that she had already posed the same questions to the receptionist and the nurse, but wasn’t deterred by their comments about the situation. Having to constantly respond to questions certainly weighed on the staff throughout the day.

As someone who has led other organizations, part of me wanted to go ahead and raise the question to leadership about the handling of the memorial and potential word tracks for staff, but didn’t want any inquiry to be seen as interfering with our practice’s collective grief. Knowing there are often no good answers to these issues, I opted to say nothing and let the organization figure it out. It felt like a bit of a cop out since usually I’m one to tackle problems head on, but maybe it was part of my own grief reaction. It was hard enough to get through the day with his presence all around us, and after a long day of COVID patients, I was ready to let it go.

It also served to illustrate something I’ve acutely questioned this year, the idea of “who cares for the caregivers?” Most of us are getting burned out and certainly all of us are tired, and the worst part is we know that there is no end in sight. My colleagues who have been in military operations have had the best advice for coping, but I’m concerned that this recent loss will put some of our team over the edge.

I hope sharing this story encourages organizations who may not have thought about these issues to add them to your to-do list, because it’s only a matter of time before a similar loss might impact them. If you haven’t done business continuity planning, you need to do it now. If you’ve already done it, take a moment to look at your plan to see how your organization plans to handle the loss of key staffers and consider how co-workers and the community might be impacted by such a loss. Having a plan and implementing it during stressful times certainly beats feeling like everything is swirling around you.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/30/20

July 30, 2020 Dr. Jayne No Comments

It’s been a wacky week in the informatics trenches, as I had a run of non-clinical days in preparation for working three in a row this weekend. I used the time to attempt to catch up on email and voice mail. Although I’m still woefully behind, it’s a little more under control.

One of the voice mails that was left for me was priceless. “Hi, this is Kate from X Company. We’re one of your company’s approved vendors for staff augmentation services and wanted to talk to you about your upcoming projects and any staffing needs you might have.” Since I’m the person that would approve any vendors and had never even heard of this company, I just chuckled and hit delete. I wonder if this is the way they do business all the time, and if people actually fall for it.

I also had a chance to catch up with some of my colleagues across the country and get a feel for how they’re coping with either an extended first wave, or the beginnings of a second wave, of COVID cases. It seems the theme of the last couple of weeks has become “patients behaving badly,” with increased conflicts at the front desk from patients who refuse to wear masks. Especially entering a medical office, I think having a healthcare institution require a mask is no different from “no shoes, no shirt, no service” anywhere else (although I always wondered why they didn’t require pants, but that’s another discussion).

One colleague’s practice had to bonus their receptionists because they were threatening to quit due to the stress of having people come in and yell at them. Another physician friend told a story about coming around the corner in the office and having a patient raging in the hallway about being refused a rapid test, because his son is a major league sports player and the dad needs a documented negative to be able to interact with him. The kicker – dad was standing in the hallway with no mask on in a healthcare facility that has a 20% positive return rate on tests. You can’t make this stuff up.

In other news you can’t make up, rumor has it that HIMSS is moving the HIMSS21 conference from spring to August next year, but still in Las Vegas. A friend mentioned it after seeing it in Modern Healthcare, but HIMSS didn’t bother to put an announcement on its website or send anything out to members, including our local chapter president. Seems like their communication is really improving since the debacle of this spring.

That would make it almost a year and a half between HIMSS meetings, which is plenty of time for vendors to come up with new and creative offerings. Still, it remains to be seen how many companies will actually exhibit, given how much money was lost on HIMSS20 and the potentially limited pool of attendees if international travel is still snarled and domestic institutions aren’t eager to allow their employees to head to a 40,000 person Petri dish. I spoke with my favorite traveling technology consultant the other day and his employer has him grounded, even though he’s amenable to travel and clients are requesting him on site.

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Perhaps by August 2021 we’ll see a healthcare implementation of smart glasses again. Remember the exciting times of Google Glass and when wearables were just coming on the market? We need some cool offerings to get us excited again. Vuzix has an industrial application that includes Bluetooth connectivity and voice recognition, which might be attractive in healthcare. Apparently, several healthcare institutions in the US are already piloting the device and it’s also being used internationally. Battery life is supposedly 16 hours, which is pretty impressive. It uses the same chip as Google Glass, but seems more rugged and can be disinfected with alcohol-based products so it meets the COVID challenge. If they’re looking for a sassy urgent care doc to give it a try, I might know someone. It might also find interesting applications in education, since it looks like many school districts across the nation will be embracing distance learning this fall.

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I attended the Health Impact Summer Forum and really enjoyed the keynote speech with Wendy Dean MD, who is a psychiatrist and co-founder of the non-profit group The Moral Injury of Healthcare. I’ve written a couple of times about moral injury and it’s gotten even worse with COVID. Organizations are still rationing personal protective equipment and we’re still operating under crisis standards of care, seven months into this pandemic. Clinical workers are risking their lives daily, often for patients who don’t care and who may be hostile to them. One local practice refused a physician’s request to put up signs asking patients to keep their masks on in the exam room while waiting because it would be perceived as “unwelcoming.” This is nonsense, plain and simple, and Dr. Dean validated the negative impacts of decisions like this.

She commented that calling healthcare workers “heroes” makes the public think we can do anything, when in reality our “superpower” is our humanness. She commented on the business challenges that are impacting clinical care as well. The pandemic certainly highlighted the broken pieces of our healthcare system in the US and identified opportunities for improvement. She notes that there is no clearly drawn road map that gets us where we want to go and proposes that we start orienteering with our moral compass as our guide and excellent patient care as our true north.

As someone who knows her way around a map and compass but who has been lost in the healthcare trenches for years, that definitely resonated with me. I really enjoyed Dr. Dean’s commentary on the issue and just having my feelings validated gave me hope. There’s another Forum in the fall and I’ve already signed up.

Is your employer taking any steps to combat moral injury as the pandemic rages on? How are your support structures? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/27/20

July 27, 2020 Dr. Jayne 5 Comments

I’m not sure if I ever thought I’d reach this point, but today marks my 1,000th post for HIStalk. I should have hit it earlier in the year, but without daily posts from HIMSS it took a little longer than anticipated. I’ve been struggling with what to write about, since I felt like it should be something with gravitas for a momentous occasion. I don’t think any of us thought we’d be in the middle of a global pandemic this year, and that our industry would be going through all kinds of changes as the world’s healthcare system is pushed to the breaking point. After floating in the neighbor’s pool for a couple of hours, which is marvelous for achieving clarity, I decided to do a little tour down memory lane.

My first post appeared on January 8, 2011, when we were deep in the world of Meaningful Use. Browsing through my first few months of writing, I came across a quote that certainly applies to 2020. “The life of a CMIO is never dull; there’s always a fire to be put out somewhere, and usually an angry physician behind the scenes holding a lit match.” Over the last nine and a half years, the physicians have become less angry about IT projects, but now they’re burned out and frustrated from the challenges of treating a brand-new and deadly virus in less than ideal circumstances. I don’t envy members of technology teams that have to try to deploy new solutions in this challenging new environment.

The next year brought such adventures as the transition to the HIPAA 5010 transaction standard and the beginning of Medicare allowing its claims database to be used for provider report cards. August 2012 brought the passing of astronaut Neil Armstrong, and I had a few things to say about his passing that still ring true today:

His death was marked in a way that matched the way he lived – quietly and with little fanfare. By commanding the Apollo 11 mission and being the first person to walk on the moon he had earned the right to be celebrated. The amazing part of his story however is what happened after July 20, 1969. He didn’t dance in the end zone or become tabloid fodder. He went back to work and back to his roots. I’m touched by a quote from an article marking his passing. In an interview in February 2000 he said:

I am, and ever will be, a white socks, pocket protector, nerdy engineer. And I take a substantial amount of pride in the accomplishments of my profession.

We should all take a substantial amount of pride in the accomplishments of his profession. Not to take anything away from the astronauts, but I’m talking about the engineers. NASA’s steely eyed missile men sent people to the moon using chalk boards and slide rules. They didn’t have anywhere near the technology that most of us carry in our pockets today, but they changed the world.

Those of us working in health care IT today are up to our eyeballs in technology. It feels like things are moving so fast we will never catch up. As hospital leaders we are challenged to deploy the latest “thing” regardless of quality or outcomes. I have many friends in the medical software industry ranging from developers to CEOs. The aggregate of their skills and creativity could propel us into a new era of patient care. Instead we seem mired between the twin terrors of governmental compliance and simply improving yesterday’s products. I want to see the software equivalent of the space race where vendors are competing for the best designers and engineers and working to deliver a superior product.

Rather than the challenge of getting a man to the moon and returning him safely, the goal should be to deliver patients safely through the health care experience while we collect all the telemetry data needed to make the next trip with even better safety and quality. Another challenge – it’s easy to forget that as broken as our health care delivery system is, it is still better than what is available in some parts of the world. Let’s figure out how to make those leaps for all mankind.

It really got me thinking about whether we’ve really made the great leaps we could have been making over the last eight years. Although there are some nimble companies innovating, from the physician end-user perspective, it feels like we’re still dealing with marginal improvements on older products. The exam room of the future has not yet come to pass for the more than a handful of physicians, and although we can ask Alexa for the weather forecast, we certainly can’t ask her to predict when we’ll actually see the results of the COVID swab we just ordered. We’ve had a substantial missed opportunity as far as improving the lives of our end users, who have largely slipped into the mode of learned helplessness.

Thumbing through posts from around Thanksgiving in that year, I had a moment of sadness as I read “Dr. Jayne’s Holiday Recipe Guide.” I think it’s safe to say that the days of the office potluck are over for the foreseeable future. I treasure those times spent with my team as well as the delicacies shared – whether it was Bianca Biller with her “Hot Bacon Dip” or Paul the Intern with his “Crave Case” of White Castle hamburgers, there was always a variety of interesting things to eat and a lot of laughter.

Don’t get me wrong, things can still be fun and relationships can be built in the virtual world, they’re just different. In a world built around virtual meetings, I certainly wouldn’t have been able to clink glasses with both Jonathan Bush and Judy Faulkner within 10 minutes of each other (thank you, HIStalkapalooza 2013). There’s something about the bonding that happens when you stroll the HIMSS exhibit hall with a friend (especially one wearing a beauty queen sash that he won the night before), whether you’re trying to do serious work or just making fun of the insanity that is our industry. There’s also something about trying to get your shoulder back into its socket after dancing with Matthew Holt, but that’s another story for another day. Perhaps one day we’ll be able to do those things in-person again, and when we do, I’ll have the sassy shoes I purchased for HIMSS20 at the ready.

To my readers, thank you for being part of my world for the last 1,000 posts. I hope that each of you is able to stay safe, healthy, and sane during the great dumpster fire that is 2020. Whether you’re on the clinical front lines or in a supporting role, I appreciate your contributions to the care of patients around the world. The practice of medicine would be substantively different without everyone in the healthcare IT family. And so, I raise my virtual martini glass to each of you – here’s to the next 1,000 posts, and to better times ahead.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/23/20

July 23, 2020 Dr. Jayne 1 Comment

The big news of the last week has been the unexpected and mandatory shift in COVID-19 data reporting away from the Centers for Disease Control and directly to the US Department of Health and Human Services. It was done with minimal communication and in the middle of a pandemic, which isn’t the ideal scenario for any IT project. I guess the contractor involved had never heard of setting up a parallel system and validating data or having a robust cutover plan, let alone involving stakeholders and end users in the testing.

Needless to say, more than 100 industry groups have signed on to a letter asking the White House to reverse the shift. The major concerns revolve around transparency and data availability, but the undercurrent of public health policy versus politics is a factor as well.

Small news of the week includes a reprieve for Elizabeth Holmes, whose trial might be delayed until 2021 due to COVID-19 concerns. The trial was scheduled to start in October, but attorneys argued via Zoom that moving ahead with a trial would create risk. More than 170 people from 14 different states are on the witness list, with more than a dozen of them being high risk due to age. An August hearing will determine the exact date for a new trial.

This week has driven me to the maximum level of frustration with regards to COVID-19 testing. We are now seeing patients who have had five or more COVID tests because they continue to engage in risky behavior and “just want to get checked out.” We’re also running into employers who are requiring negative tests before allow patients to return to work. Those who have multiple positive tests but who are no longer considered contagious by the CDC standards are subjected to unnecessary medical procedures as they continue testing, which also takes away supplies from other patients. Employers are requiring testing of workers who have even remote contacts with potential patients, wasting more supplies.

We have been out of rapid testing kits for weeks, but somehow the NFL, NBA, their respective employees and the media have access to them. This is in the context of announcement that the US is trying to reduce unnecessary COVID testing. As far as I’m concerned, the message can’t get to these employers soon enough.

I also had my first patient come back in for a visit hours after he was texted with his positive COVID result, for a re-test “just to be sure, because it might be a false positive.” Hate to tell you, sir, but (a) you are still quarantined regardless of the outcome of this second test; and (b) congratulations on exposing my office staff, me personally, and everyone you might have come into contact with along the way. We had a difficult conversation which I’m sure will lead to a one-star or zero-star review, but at this point I say “bring it,” because in many ways, it would be relief to just get fired by my ratings-centric employer. I hate that the pandemic is turning something I used to love (seeing patients in person) into something I sometimes dread, and that it’s being driven largely by economic forces.

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I found some time to recharge my batteries this week and enjoyed attending the Telehealth Innovation Forum on Tuesday and Wednesday. It was a welcome break from what I’ve been doing for the last several months. The sessions were engaging as well as fun. Tuesday’s end-of-day session included a live martini class, where we learned tricks of the trade. I was glad to learn that the way I shake my martinis is how the pros do it, but apparently I’ve been holding my jigger wrong.

Wednesday we had our volunteer activity of decorating backpacks that will be filled with school supplies and sent to Puerto Rico, while learning about the World Telehealth Initiative. As much as we think about telehealth as a convenience in some countries, it’s striking to realize how much of a true game-changer it can be in developing nations. Thanks to the many sponsors that made this activity possible and to Teladoc Health for putting it all together.

The US is still pretty keyed up about the promise of telehealth, although a new survey from Sage Growth Partners and Black Book Research highlights that many organizations anticipate a decline in telehealth volumes over the next year. Respondents cited lack of integration and/or interoperability as a key reason for dissatisfaction, along with a lack of data needed for continuity of care. Payment issues also made the list.

I say the jury is still out, because we have no idea what will happen when flu season starts and other respiratory pathogens start rolling in. If you’re still using Zoom to try to deliver virtual visits and haven’t begun the transition to an integrated system or one that at least plays nice with your EHR, I suggest you start looking.

In other telehealth news, I received an email announcing the “HHS Telemedicine Hack,” which is apparently a 10-week virtual learning community aimed at accelerating telemedicine implementation among ambulatory providers. The program includes various online panels and presentations along with virtual discussion boards. It runs from July 22 to September 23. I wonder if I’m the only one who thought it was weird that they announced it after it had already started. I read my CMS emails pretty religiously and searched both my voluminous inbox and my trash without finding any other announcements.

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The American Board of Surgery admits a complete meltdown of its online general surgery board qualification exam last week. Candidates describe a “nightmare” scenario where morning test-takers finished Day One of two, but afternoon testers had technical issues, so the entire test was canceled early Friday morning. The Board promises to “regroup and develop a new process.” Candidates were also frustrated that the Board was communicating via Twitter rather than directly with them through email, citing delays in mass emails to over 1,000 impacted surgeons as an explanation.

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The absolute highlight of my week was a care package from the folks at Medicomp Systems. The company is a Founding Sponsor of HIStalk, a former sponsor of HIStalkapalooza, and has supported our favorite charities as we’ve competed on their game show stage at past HIMSS conferences. Along with a UV sanitizing bag for my constantly rotating supply of masks, they managed to source some coveted N95 respirators from 3M as well as classily embroidered multi-layer masks that have both a bendable nosepiece and adjustable straps. They are the “little black dress” of masks.

Given our current situation, I’m thinking of shifting my love of shoes to one of stylish masks. A patient had on a bedazzled mask last week, so there’s plenty of opportunity for creativity and style. I’m touched that they would think of me and sincerely appreciate the additions to my PPE wardrobe.

What’s the sassiest mask you’ve seen? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/20/20

July 20, 2020 Dr. Jayne 2 Comments

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The team at the Virtual Telehealth Innovation Forum and Teladoc Health continues to hit it out of the park with the preparations for their virtual conference. I received my welcome package at the end of last week, which includes “a notebook to capture thoughts” along with “cocktail making materials to unwind at the end of day 1 with our guided mixology session.” The cocktail supplies included a jigger, an insulated tumbler (courtesy of NTT Data), and an engraved cocktail shaker to commemorate the event. A girl can never have too many martini shakers, and the tumbler is the perfect accessory for my upcoming efforts as a pool sitter for my neighbor later this week.

They also emailed a shopping list for the martini-making session on Tuesday. The State Street Martini looks simple yet elegant: vodka, St. Germain, lemon juice, and basil. I have everything but the elderflower liqueur. I’m pulling long shifts in the ED the next couple of days, so I’ll be the person at Total Wine when they open on Tuesday morning so I can pick up the final supplies and get home for the conference sessions.

Another aspect of the virtual Telehealth Innovation Forum is for everyone to lunch together using a Grubhub gift card on Tuesday. I received an email over the weekend notifying me of my new Grubhub account and inviting me to set my password, so everything is happening as planned. The only element I’m missing is the supply package for the virtual volunteer activity on Wednesday, but I suspect it’s en route based on a random USPS Package Tracking notification I received.

I’m curious whether putting an event like this together is more or less stressful than trying to do one in person. Over the years, I’ve gotten to know the marketing teams of some of the major vendors pretty well and know how exhausting it is to put together an in-person show.

Earlier this year, I was accused of being negative towards marketing professionals when I wrote about the HIMSS rebranding efforts. I’m not going to deny the fact that I still find it annoying when companies spend too much time talking about their brand as opposed to talking about what they do or what they make. I loathe press releases with phrases like “our brand is reflected in our new color scheme” or when they attempt to explain nonsensical-sounding company names selected after mergers.

So far, my impression of this week’s conference and the surrounding communications are that they represent branding done right. They didn’t have to come out and say “our brand, with its clean, hip graphics and soothing light teal color typifies martini-loving healthcare folks,” but rather they’re letting their materials do the talking for them. Let’s hope the conference lives up to the hype.

I’m intrigued by the whole virtual conference transformation. I figured that without having to rent conference center real estate, pay for security, order signage, and provide an assortment of questionable finger foods and cheap drinks at the obligatory opening reception, that online conferences should be cheaper. That’s not the case with most of the conferences I’m seeing advertised.

Certainly organizers are playing up the fact that you don’t have to pay travel or hotel expenses, but they’re not discounting much off the fees. Most are not offering truly interactive sessions, so I can’t imagine they are spending as much money on conference software as they would have on hotel ballrooms or the trimmings. If someone really wants to put a believable message out to attendees, they should specifically note how much less their attendees will spend on exorbitantly-priced but mediocre coffee outside an exhibit hall, or how short the line in their kitchens will be for their beverages of choice.

Looking at international flight restrictions that are likely going to persist for months, it’s hard to imagine that an in-person HIMSS21 is even on the table. The US is doing so poorly with this that it’s going to be amazing that anyone from a country that has the virus under control would want to come here. A friend of mine from Australia that was scheduled to visit the States this fall told me his airline wouldn’t ticket anything for him this calendar year. I shamelessly booked my Las Vegas accommodations outside the HIMSS room blocks right after the Orlando hotel debacle, so on the odd chance that the virus “disappears” as was previously predicted, I’ll be covered with somewhere cheap. It won’t be as classy as my last stay at the Venetian, but $300 per night is steep, especially when you’re paying for it yourself and not charging it off to your company or health system.

One of the conferences I was supposed to attend in April was postponed to September, but with the COVID-19 cases on the rise in the South, it’s been canceled altogether. Although Southwest Airlines extended the expiration dates on tickets for flights during the first peak of the pandemic in the US, these tickets were somehow outside that window and are going to expire in October.

This is a weird year for me. I’ve only been on two planes the entire time, and I have to say I’m eager to go somewhere other than my house or to a medical facility. Since the tickets are use it or lose it, I’m tempted to book a random flight to a part of the country that’s relatively unscathed, if for no other reason than flying two segments would let me preserve my frequent flyer status and I’m out the money regardless. Too bad many of the beaches I usually frequent are in hot spot areas because I could use some sand between my toes about now.

I’d love to hear from marketing folks about your plans for virtual meetings and seminars. How does the planning of the different types of events differ? Is there commercially available software that meets your needs, or are you having to cobble solutions together? Have you had to institute special processes to make sure presenters are camera-ready in an appropriate environment? You can speak on the record or I’m happy to keep you anonymous. This is your chance to let the entire healthcare IT community peek behind the curtain of the new normal in professional meetings.

For attendees, what are your thoughts? Good, bad, or indifferent? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/16/20

July 16, 2020 Dr. Jayne No Comments

I was glad to have had some time off from the clinic recently. I’m tired of dealing with patients who have unrealistic expectations.

We’ve been running out of testing swabs for COVID-19 tests nearly every day. Patients absolutely lose their minds when our receptionists tell them we’re out. For everyone who ever said we can’t reform healthcare because it would lead to rationing, guess what? We’ve been here a long time and the fact that we can’t manufacture enough glorified Q-tips to help slay the monster isn’t very reassuring.

Speaking of the monster, I strongly recommend that people read this Twitter thread by Sayed Tabatabai, MD. Although I’m not working in the ICU, my friends who are agree with his depiction. It should be required reading for the PA in my practice who keeps posting selfies from bars, often hugging on someone who doesn’t live in her household. I think I’m going to start calling her Typhoid Mary the next time I see her.

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I enjoyed this JAMIA piece on “User reactions to COVID-19 screening chatbots from reputable providers.” The authors recruited 371 people to watch a two-minute video of a staged chat between a user and a COVID-19 screening hotline. Participants were told that the video was either a real person or a chatbot, although the same video was used either way. The study found that perception of the agent’s ability was the primary driver of user response, noting the need to help users better understand that chatbots can use the same knowledge base as humans and can have the same quality outcomes as a human-human interaction.

The whole idea of “what is a chatbot” is somewhat debatable. The ones I’ve seen vary from using simple responses to suggest an outcome, to much more complex interactions. An example of the former is the CDC’s COVID-19 symptom checker, which basically uses data points such as age, location, medical conditions, and recent exposures to suggest whether you need a test or not. I wouldn’t consider it a true chatbot per se since it’s not truly interactive and users are just selecting items from a menu.

I’m working with a health system right now that is trying to create a chatbot, but it really isn’t interactive. Although the prompts are written in a conversational style and it tries to have a certain tone and vibe, it’s really no different than a person with a clipboard peppering you with questions. Needless to say, it has a high abandonment rate when patients try to use it, so we’re trying to walk the fine line between gathering the data they want and keeping patients from dropping out.

Other chatbot solutions parse the language in the user’s responses to make it a more interactive experience compared to selecting from a list and reorder the prompts based on information it receives. The most sophisticated ones also incorporate AI and machine learning to become “smarter” as they go, detecting new patterns and being able to identify elements such as regional variation in content.

I find some website-based chatbots annoying, especially if they keep popping up on the screen asking you if you need help even after you’ve already tried to minimize or close them. It will be interesting to see where chatbot technology goes in the next few years.

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The American Academy of Family Physicians is talking up its new website that is set to launch on August 17. Among the changes is a replacement of unique user names by one comprised of the user’s email address. AAFP warns practices that use shared email addresses that it might be a good idea for physicians to have their own. I wonder how many physicians share email accounts at this point?

Other changes include “expandable mega-menus,” which sounds kind of scary. I hope they didn’t include a bunch of hidden controls. I’ve experienced other recent redesigns (including some Windows and Office elements) and am sick to death of controls being hidden until I mouse over them. It’s distracting and often requires a decree of precision that my tired hands and eyes don’t have at the end of the day. If you have the real estate, show the controls already.

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I’m still wildly optimistic about the Telehealth Innovation Forum that is scheduled for next week, sponsored by the folks at Teladoc Health. They recently released their agenda and I love the calendaring portion of the process. It allows you go to through the agenda and select the sessions you’re interested in and creates a personal calendar for you. Once you’re done, you can select to have the whole thing set up for you in your calendar program of choice. In Outlook, it adds the appointments as a separate calendar that you can turn on and off, which is especially cool for those of us managing multiple calendars. I don’t have to have it cluttering up my screen until it’s time.

Much better than other conference platforms that create a calendar for you but require you to be in their app or logged into their website to see it. I’m also geeking out about the inclusion of a Mixology course on Tuesday afternoon where I can expand my martini skills. Wednesday afternoon is the volunteer activity. I’m still waiting for my backpack decorating kit to arrive, but I’ll have my fabric markers at the ready.

I’ve been away from patient care for a while but have to head back into the trenches on Friday. My boss has coined a new word – we are not short-staffed, we are apparently “overpatiented.” And the patients are becoming increasingly frustrated by our long wait times and lack of COVID testing supplies.

Despite seeing more patients in June than I’ve seen since I worked there, I received a very small productivity bonus due to low patient satisfaction scores. I’ve never been below 98% and this month I was apparently at 92%. The entire company’s scores were down, but it doesn’t make me feel less annoyed, especially since my employer received a nice chunk of Paycheck Protection Program funds. Seems like this would have been a good time to change the bonus formula to take into account the extenuating circumstances and properly compensate the team for working their tails off.

Not only have we been challenged by the high volumes, but nearly every patient is upset and cranky by the time we see them. I’m told that we should be glad to be employed, since our hospital colleagues are taking pay cuts. I guess we’re going to start going the way of many industries and join the race to the bottom.

Has your patient satisfaction suffered in the era of COVID-19? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/13/20

July 13, 2020 Dr. Jayne 2 Comments

HIPAA has been a thing for most of my medical career. Although the Health Insurance Portability and Accountability Act was actually enacted on August 21, 1996, it didn’t actually begin to go into effect until April 14, 2003 when the HIPAA Privacy Rule was required. Of the sub-parts of HIPAA, this is the one that most people know the most about.

It is also frequently used to create an inappropriate barrier to information sharing. I can’t count the number of times that hospitals have told me they can’t tell me the status of a patient who I have referred to their emergency department “due to HIPAA.” Apparently they think that HIPAA is a magical force field, and if you’re not part of the hospital’s medical staff, you can’t be allowed in.

Despite the Privacy Rule being in place more than 17 years, I’m working with an IT organization that isn’t doing very well from a Privacy Rule standpoint. They are a mature user of their EHR, having been on the system for at least a decade. However, their use of its features hasn’t kept pace with the evolution of the tool, and they find themselves in a bit of a legal pickle.

I enjoy working on projects like these. It gives me a chance to dust off my database skills and help a group understand its vulnerabilities and how it can improve. Some of these items spill over into the HIPAA Security Rule, circa 2005, with its emphasis on technical safeguards for protecting patient information. In the spirit of sharing some free consulting, I offer you the lessons learned from my client’s situation.

First, have a documented policy and procedure on access to electronic health record systems and other ancillary applications, such as laboratory information systems, radiology information systems, and any other systems where Protected Health Information is stored. These are part of the administrative safeguards in the Security Rule, but beyond that, you can’t claim employees didn’t do the right thing when you never spelled out what actions were right and what actions were wrong. The policy should include a mention of educational resources to be sure that staffers understand the terminology of HIPAA and understand how those elements fit the systems they access.

I remember the health system I was working for when the Privacy Rule went into effect made a series of videos that were themed somewhere in the vicinity of gangsters a la Al Capone, and the fact that they’ve stuck with me this many years later shows that they were memorable. The video linked back to written content that we had to review along with an acknowledgement we had to sign in order to continue being employed. The organization I’m working with at present has an outdated employee handbook with little mention of HIPAA and the obligations of staff to do the right thing.

Second, be sure you have clearly documented job descriptions as well as roles and responsibilities. When you find out that someone administrative was trolling around in EHR charts that have nothing to do with their role in the billing department, you don’t want them to explain that they were “helping Dr. X that day” or that someone was out so they were doing “other duties as assigned” with no way to prove or disprove that what they were doing in the EHR was inappropriate. For those situations where people do have to cross cover, make sure they know where their boundaries are. As an example, someone covering telephone messages for refill requests probably doesn’t need to be accessing the alcohol and tobacco history in patient charts.

Third, make sure you are keeping up with the security features of your EHR. If it allows you to restrict security by job role, make sure you have this set at the most granular level appropriate for the job roles in your organization. Purely clinical employees shouldn’t have access to the billing side of the system, and non-clinical employees who might have to reference clinical information should have their access appropriately controlled. If a billing team member often has to provide copies of office visit notes or test results, give them access to those parts of the system. Do not give them access to document on clinical visit templates or to order medications.

I’ve seen unfettered access more times than I care to recall. If your system allows use of inclusion/exclusion lists to further secure subgroups of patients (such as employees, or professional sports teams, or VIPS) consider using those features.

Fourth, make sure you understand the audit functionalities of your system and that you have a policy in place for regular auditing, even if it is just spot auditing. Of course, if you see high-profile or celebrity patients, you might need to have a more active audit program, but many organizations can get away with spot audits to make sure employees are doing the right thing.

One of the issues facing my client right now is that they didn’t have the right pieces of the audit tool enabled. Although they were tracking access to clinical data, they weren’t properly tracking whether that data was updated, printed, exported, or simply viewed.

Finally, make sure you have a policy that addresses access of patients’ own charts or those of their family members. Even if a staff member is legally permitted access to a patient’s information, whether by being a parent / guardian or through a signed release, it’s probably not a good idea to allow them to access those charts on their own. In my practice, if I want to print a copy of my own lab results for my personal records, I have to work with one of our clinical staff to request the document and have them generate it for me, just like any other patient would. The only difference is that I’m making my request in person rather than over the phone. Our process keeps everyone honest and reduces the risk of inappropriate access.

These are simple things, and you would think organizations would have figured them out by now. Unfortunately, quite a few haven’t.

How does your organization handle similar issues? What’s the wildest HIPAA violation you’ve seen? Leave a message or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/9/20

July 9, 2020 Dr. Jayne 2 Comments

CMS never misses an opportunity to make its incentive programs more complicated, so they recently posted guidance on how telehealth encounters will fit in for Eligible Professional and Eligible Clinician electronic Clinical Quality Measures for the 2020 and 2021 performance periods. This includes the Quality Payment Program with its Merit-based Incentive Payment System and Advanced Alternative Payment Models (APMs); Comprehensive Primary Care Plus; Primary Care First; and Medicaid Promoting Interoperability Program for Eligible Professionals. Honestly, at this point I’m not sure many of us care any more. My brain is too fatigued at this point to even try to understand this:

There are 42 telehealth-eligible eCQMs for the 2020 performance period. When reviewing this list of eCQMs, please note there may be instances where the quality action cannot be completed during the telehealth encounter by eligible professionals and eligible clinicians. Specifically, telehealth-eligible CPT and HCPCS codes may be included in value sets where the required quality action in the numerator cannot be completed via telehealth. Therefore, it is the eligible professionals’ and eligible clinicians’ responsibility to make sure they can meet all other aspects of the quality action within the measure specification, including other quality actions that cannot be completed by telehealth.

I’m personally going to blame my foggy-headedness on having to wear a mask all the time, since my patients have been telling me they trap carbon dioxide and need work notes so they don’t have to wear masks. As someone who grew up watching M*A*S*H and idolizing Hawkeye Pierce, masks are cool, and I’m not about to make you miss out on the pleasure of wearing one. In all seriousness, there are a couple of good health-related reasons why people shouldn’t wear masks, but I have yet to have a patient request a note for one of those reasons.

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I’ve been down on conferences lately, especially after being burned by the HIMSS hotel debacl, the non-event that was HIMSS Digital, the American Telemedicine Association’s sad attempt at a virtual conference. With that in mind, I want to give props to people who are doing it right. The Telehealth Innovation Forum’s initial communications caught my eye, so I signed up. They provided plenty of lead time to allow people to block their schedules for July 21-22, and have been transparent about the sessions.

They sent out an attendee update last week, and I have to say they’re about as close to pulling off the feel of a real conference in a virtual format as I imagine you can get. First, they’re mailing some kind of swag kit to those who request it. Second, they’ve got a volunteer activity with the World Telehealth Initiative. Participants will receive materials to decorate backpacks that will be filled with school supplies and donated to children in need. I’m eagerly awaiting my backpack and have some bedazzling supplies at the ready. I always enjoyed the vendors who had similar activities at HIMSS. Last, they’re offering a virtual “lunch together” with digital GrubHub gift cards sponsored by NTT Data for use on July 21. Kudos to the team at InTouch Health (now part of Teladoc Health) for getting the plan right.

One of our physician assistants called me today to vent about life in the patient care trenches. I feel for her, because she’s early in her career and hasn’t been through a truly terrible flu season yet. As such, she hasn’t learned how to “embrace the suck” or figure out how to arrange her own personal psychology to make it through the crazy practice environment we’re currently in.

Apparently patients were lined up in lawn chairs outside the office today before the clinical team even arrived, and everyone was expecting to be tested. While another provider focused on handling the in-person visits, she had the unenviable task of calling patients whose lab results have finally returned after 10 days (thank you, Quest Diagnostics!) and most of them have already ended their quarantines based on CDC’s time-based strategy. It’s absolutely surreal that professional athletes are getting daily COVID tests and the average person in our city may have to wait more than a week to get results back.

The big hospitals are adding to the problem because they are refusing to test patients unless they are referred to the testing sites by physicians who are on their medical staff. Funny, they were happy to run lab orders and profit on radiology studies from independent physicians previously.

Since Quest Diagnostics and LabCorp understandably won’t perform COVID swabs in the patient service centers, the patients have descended on the urgent cares, where the lab backlogs are crippling. It’s not like we could all work together and serve the community – I guess it’s much better for them to protect their fiefdoms.

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For those of you in the trenches, you’ll recognize the four Abbott ID NOW machines in the photo above. We have more than 100 of them at our sites, but we can’t use them because we can’t get supplies. Apparently you don’t get testing supplies unless you’re a hot spot, even though the only way to avoid being a hot spot is to have testing supplies so you can give solid advice to patients other than “everyone just stay home,” which isn’t happening.

I was able to talk my colleague to a semi-happy place, but it’s a shame that providers have been put in this position by ineffective and uncoordinated response over the last four months. It’s bad across the country, not just here. One friend of mine in California told me about how bad things are at local hospitals and having dubious honor of being tied for the most saturated ICU.

Another friend of mine in the Midwest who was furloughed for two months  — unpaid and without the option to use PTO or vacation time because he’s part time and doesn’t have those benefits — learned through a news story that his clinic received more than $5 million in Paycheck Protection Program funds. It’s not like they only furloughed the docs since nearly 50% of their workforce was off without pay. He’s wondering what happened to those funds and why they weren’t used to protect paychecks as intended. Unfortunately, in the current environment with physicians being downsized across the country, he’s reluctant to speak up about it.

Did your organization get PPP funds and how did it use them? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/6/20

July 6, 2020 Dr. Jayne No Comments

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I survived the Independence Day weekend in the emergency department trenches without seeing anyone who had finger or eye injuries, so it was a good one.

I didn’t get to see any fireworks or have popsicles, but the PPE fairy paid me a visit. I’m happy to report that exactly four months after seeing my first positive COVID-19 patient, I finally have an honest-to-goodness actual 3M healthcare N95 respirator, as opposed to a non-medical version from the hardware store. To be precise, I have two of them. Which I’m supposed to rotate indefinitely.

Excuse my cynicism, but I’m not exactly sure what the US has to celebrate today. The actions of our fellow citizens exercising their freedom to not wear masks and their freedom to congregate in large groups is sending patients to the hospital, if not to their graves. Our testing volume is up by about 20%, but our positive case rate is nearly triple what it was recently, so we’re gearing up for a bumpy ride.

Our group has moved into testing entire cohorts of workers from various employers, which is straining resources. The first bolus of patients came from a hair salon, where they are meticulously separating clients with plastic barriers and stylists and clients are all masked. Unfortunately, the 20-somethings who work there all huddle up in a break room together between clients with masks off, or stand outside the door smoking, so close to 80% of them came back positive. No surprises there.

The next set of workers came from a country club, where even though the dining area has been moved outside, servers are still in close contact with patrons. The wait staff also had a communal break area, and frequently took masks off in between runs to the dining area. Now everyone gets to hang out at home for 14 days waiting for tests to come back. Unless something changes with our reference lab, there’s a good chance we’ll be clearing them based on time before their results come back — the lab’s turnaround time has skyrocketed to 10 days.

At this point, I truly wish my EHR had the capability to do a standard visit that could be copied from patient to patient. Although we have some templates for physical exams, everything else has to be keyed from scratch for each patient unless they’re a returning patient. I’d love to be able to bulk-copy these HPIs since they’re essentially the same. “Patient presents for employer-mandated testing, was exposed to a patient over the last two weeks who is now positive. Patient reports non-masked interactions at close range in a common break area and sharing of plates of food by co-workers.”

You might ask why I’m writing an HPI when the patient is just there for testing. Our new reality is that payers have gotten burned by the “sure, we’ll pay for COVID-related visits” policies and are now requiring documentation of medical necessity to support payment for testing. I thought this article from mid-June was over the top until I started experiencing “concern” from payer reps about our testing patterns.

As much as everyone is focusing on the struggles of the hospitals and the potential for overwhelmed ICUs, ambulatory practices (especially independent ones) are really struggling right now. Many are not performing testing because of lack of PPE and we’re still challenged to keep patients safe. Unlike larger facilities, small offices don’t have the luxury of being able to set up dedicated respiratory clinics within their footprint or to offer separate waiting areas for suspected COVID patients. The best they can do is to try to separate patients temporally, bringing in the well patients in the morning and sicker patients as the day progresses.

Many of my colleagues in this situation are using automated screening solutions to try to risk-stratify patients the day before, although the system isn’t perfect. For example, one of my patients who came in for food poisoning recently was actually COVID. It’s hard to triage that without doing a full telehealth visit up front.

I get a lot of direct to doctor emails from tech companies, and I’m surprised by the silence from the companies that have sanitizing technologies. There seemed to be dozens of booths at HIMSS for solutions to sanitize laptops and keyboards and otherwise keep technology clean. If anyone is in that space, I would be interested to see what business looks like right now and if you’re just overwhelmed or how things are going.

The push for telehealth technologies has also slowed. It feels like practices that jumped into the pool with Zoom or other non-healthcare solutions are starting to transition to telehealth solutions that are embedded in their EHR or otherwise integrate. I agree that expecting clinicians to work in two systems is daunting and no one wants to do it for long.

There used to be several players in the hand hygiene market. What’s going on in that space? Are hospitals going high tech to monitor staff compliance, or are they running out of money and worried about taking care of the basics? Any action on expansion of robotic healthcare assistants to reduce the need for humans to go in and out of exam rooms?

It seems like there are so many interesting technologies with potential, but I struggle to keep up with how other organizations might be innovating because I’m simply swamped seeing patients.

I hope that readers had a chance to recharge at least a little this weekend. Many people had Friday off in honor of the holiday or had modified work schedules. In many states where cases are rising, this is just the beginning of a long slog.

How is your organization helping workers recharge their batteries, or making sure they are holding up OK under the stresses of our new normal? Have you instituted new technologies to try to make an impact? What about the addition of recharge zones or stress reduction rooms? Leave a comment or email me.

Email Dr. Jayne.

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