Curbside Consult with Dr. Jayne 3/4/24

A number of my physician friends still work for independent medical practices, which is a bit surprising given recent market forces that have been challenging even for the most well run of them. Now that the Change Healthcare ransomware attack is approaching the two-week point, many are concerned that they are going to be in financial straits.

The first quarter of the year can be difficult for medical practices, especially if they have a large percentage of patients that are covered by high-deductible health plans. Those patients often avoid care until they reach their deductibles, which means volumes can be down in the practice. This tends to pick up towards the end of the calendar year, when patients have met those deductibles and are trying to squeeze in visits before the new year rolls around. 

Several of my friends were chatting about the inability to send claims to insurance companies and are worried about cash flow. I asked whether their business continuity insurance policies would cover the disruption and was surprised that more than half of them didn’t know if their practices even have that kind of insurance coverage. One would think that after coming out of a pandemic that significantly disrupted practices’ ability to function, groups would have looked into that if they didn’t already have coverage. Maybe the reliance on federal pandemic funds made them think they didn’t need to worry about it, but they are now wishing they did.

For those that outsource their revenue cycle management functions, they have been surprised by the lack of communication about the situation and what the third parties are doing to try to switch to other vendors. Some are wondering how they’re going to be able to make payroll and are trying to get short term loans to cover practice expenses. I’ve heard that a couple of local banks are stepping up to help out, but it sounds like national banks are less excited to be doing so. For lack of a better description, everyone is just scrambling at this point.

My current clinical practice pays me on a per-visit basis, regardless of a patient’s ability to pay or what insurance they might or might not have. That provides me a bit of a buffer from the Change Healthcare situation, although I know that the organization I work with is nervous about the situation. They’re committed to caring for patients and have a decent financial reserve, however, and I feel reassured that I’m unlikely to be benched like I was during the pandemic.

I’m exclusively seeing patients via telehealth these days, partly due to volume demands and partly due to my computer skills. I think my employers enjoy having someone who can power through visits, understands the need to set up their own favorites and defaults, and doesn’t complain about the EHR.

Patients have grown to rely on telehealth. The fact that we don’t know for sure what will happen with telehealth reimbursement is making a lot of organizations nervous. A little more than a week ago, 200 organizations signed on to a letter that asked the US Congress to take action to ensure that virtual care payments that were modified during the pandemic remain favorable. A couple dozen of these organizations were health systems, but among the rest were professional societies, patient advocacy organizations, virtual care companies, and tech giants such as Amazon. Big names signing on included Ascension, Intermountain Health, Johns Hopkins Medicine, Mass General Brigham, Michigan Medicine, Trinity Health, and UPMC.

The signers encourage Congress to take action now so that patients and care delivery organizations can plan and budget, rather than leaving them hanging until the eleventh hour as Congress tends to do. Organizations can be confident when they make investments in virtual and hybrid care models, which will be essential in managing workforce challenges. They also note the need for employers to be able to plan ahead for their health plan offerings for the coming year, which they can’t do if decisions aren’t made well before the traditional open enrollment periods that most employers have in November. Additional points made in the letter include:

• Patients have come to rely on telehealth, and ending payments will be detrimental to established care relationships.
• Safety net organizations have used telehealth to extend care, including community health centers and rural health clinics.
• Continued provision of mental health services via virtual care is essential.

I’m now in my seventh year as a practicing telehealth clinician, which is hard to believe when you think about it like that. It’s a skill that physicians of my training generation certainly weren’t trained to do, but we adapted quickly to it when our organizations decided to roll out programs. Those of us who were already seasoned definitely had an easier time during the pandemic. I was fortunate to be able to use a mature platform that hadn’t been cobbled together with Zoom, duct tape, and leftover Cat 5 cable.

I still chafe having to wear a white coat to perform telehealth visits, as required by my organization, but the annoyance of the scratchy polyester is outweighed by the fact that patients genuinely appreciate the flexibility of care even when I’m just providing advice and not sending out prescriptions.

I can’t think of any physicians I know who still perform house calls, but in many ways telehealth visits have become the house calls of the future. Especially when you can add technology like connected blood pressure cuffs, scales, and imaging devices, it goes along way towards what you could say was almost like being there. Now we just need to break down the payment barriers, and while we’re at it, I’d love to see our federal government find a way to break down the patchwork licensing restrictions in the US that keep me from seeing patients who live a couple dozen miles away from me but who are figuratively in a different world as far as me being able to care for them. My standard of care isn’t going to be different just because of where the patients live, but state medical boards sure try to convince people that it’s a real risk. It’s time for licensure reciprocity or a federal license.

I’m realistic enough to know that probably won’t happen before I retire, but a girl can dream.

What are the biggest priorities that our legislators should be tackling where healthcare is concerned? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/29/24

Lots of folks around the virtual water cooler are talking about the ransomware attack that has brought Change Healthcare to its knees. In addition to negatively impacting financial transaction, the trickledown effects are preventing patients from getting needed medication refills at the pharmacy.

The BlackCat gang claims that they took 6 TB of data, including clinical, payment, and claims files as well as patient demographic data. This includes data on active US military personnel. Spokespeople for parent company UnitedHealth Group have stated that 90% of affected pharmacies have switched to new processes to get the prescriptions moving. You can follow along on a dedicated status page.

From Phi Beta: “Re: healthcare financial departments. Are in full battle mode with claims authorizations and eligibility all off line due to Change Healthcare / Optum cyberattack. I’m hearing Duke Medicine cannot send out any claims. The financial costs for US healthcare entities are going to be massive. No one seems to be telling that story.” Now that the outage has gone as long as it has, I think people are starting to have those conversations. The impact of this will be staggering and cause everything from tsunami-size waves to ripples through revenue cycle processes for the next year.

Several people have sent me fun and sassy pics from ViVE, which were much appreciated since I’m hanging out at home in chilly weather rather than partying it up in LA. Roving reporters indicated that the Billy Idol concert was “shockingly good.” I did get annoyed by the repeated emails from ViVE asking if I had “FOMO.” By definition, can you still have “fear of missing out” when you are actually missing out? Inquiring minds want to know.

Even though many of us in the industry have followed the VA and US Department of Defense IT projects closely due to their sheer size and visibility, the fact that I have active duty military personnel in my family makes it even more interesting to me. I was intrigued by the reports that the EHR transition had slowed down recruiting and onboarding and wanted to know exactly why. Having used both systems in the past, it didn’t make sense to me that switching from one system to the other would have made such a huge difference in workflow or click counts that it would delay entry. Additionally, there were reports that after the new system went live, twice as many recruits were disqualified. That didn’t make sense at all, unless the new system had totally different parameters than the old one.

After doing some digging, reading a lot of articles, and confirming with military personnel, I finally understand. Although the EHR is involved, it’s really not the cause. It’s the sheer volume of records that reviewers are now having to address compared to what they had before. In the legacy workflow, reviewers had access self-reported patient histories coupled with a relatively small number of medical records for each recruit. In the new system, health information exchange technology is used to pull much larger volumes of data about individuals. Although some branches of the military have refused to comment on it, an Air Force spokesperson did provide information to National Review, which confirmed that higher numbers of records are revealing more disqualifying conditions, which then need to be investigated and evaluated.

Previously, 81% of all Air Force applicants passed on their initial screening during fiscal year 2021, but after reviewers had greater access to patient data, that number dropped to 69% in 2022 and eventually to 58% in 2023. Increased access to data led to increased time needed for review, and until additional reviewers were added to help catch up, there was a lag. I’m not sure how failure to staff up in the face of a significant increase in workload can be attributed to the EHR rather than to lack of understanding of the time needed to review records coupled with poor capacity management. It’s always easier to blame the technology than it is to hold management accountable, I suppose.

A UK coroner’s classification of a young woman’s death as “preventable” has landed the EHR in trouble. The 31-year-old patient died from a pulmonary embolism after presenting the day before at the hospital. The coroner’s inquest confirmed that staff identified the diagnosis, but there were “errors and delays” in administering the correct treatment on an appropriate timeline. The hospital’s new emergency department EHR was named as a contributor, noting that it lacked clear and color-coded indicators for patients who needed urgent care, which had been present in the legacy system. Instead, the Cerner system has symbols next to patient names that had to be clicked to indicate the acuity of care rather than the acuity being immediately apparent. The coroner noted that there had been clinician complaints that went unresolved after the transition to the new system. The hospital has 56 days to respond to a demand for action. When we implement healthcare technology, we have user acceptance testing for a reason. Let this be a warning to people who don’t listen to the users or overrule their findings.

From Less-than-happy Hybrid: “Re: return to work. I feel like a ping pong ball going back and forth between the annoyances of working in the office and my Zen home office setup. In the office, my entire group was moved to a different floor that is nothing but cubes. I can’t even see if other people are here, and since none of us have actual cube assignments I don’t know where to find people if I wanted to collaborate. There are no lockers or storage cabinets. so I’m stuck hauling my stuff home at the end of every day, which isn’t an employee satisfier. There’s also a cheapo battery-powered clock on the wall whose ticking is making me crazy. It may not survive the morning. I also just heard a very distinctive sound coming from across the aisle and confirmed that some guy was brushing his teeth. At his desk. I’m so glad we’re building all this culture.” Other readers have weighed in with annoyances with remote colleagues, including attendees who are consistently doing school drop-offs or pickups during standing calls, yet will not admit that the call is scheduled at a bad time and should be moved. I’ve worked with people like that and it’s maddening since you know that they are not paying attention and are possibly placing themselves and their children at risk driving while on calls. One reader shared some photos of backgrounds they’ve seen on calls, including messy unmade beds, sinks piled high with dishes, and inappropriate artwork in the background. I use a lot of platforms and every one of them has an option to use digital backgrounds or at least blur the background, so there’s no excuse for appearing to be in an unprofessional environment even if you are indeed in the middle of one.

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Curbside Consult with Dr. Jayne 2/26/24

In the US, our love of technology often overtakes our trust of people’s knowledge and expertise. I encountered this on a regular basis in the urgent care setting, where patients demanded testing for conditions that were well-suited to the use of clinical decision support rules. In other countries, clinical decision support rules are accepted – and even expected – as a way of helping patients avoid unnecessary testing and healthcare costs. Some of the most useful and validated CDS rules are those around probability of strep throat, ankle fractures, and pediatric head injuries. However, testing has become a proxy for caring, and if physicians don’t order tests for patients with applicable conditions, those physicians are likely to wind up on the receiving end of low patient satisfaction scores or even hostile online reviews.

I had been thinking about this when I stumbled across a recent article in the Journal of the American Medical Informatics Association that looked at whether explainable artificial intelligence (XAI) could be used to optimize CDS. The authors looked at alerts generated in the EHR at Vanderbilt University Medical Center from January 2019 to December 2020. The goal was to develop machine learning models that could be applied to predict user behavior when those alerts surfaced. AI was used to generate both global and local explanations, and the authors compared those explanations to historical data for alert management. When suggestions were aligned with clinically correct responses, they were marked as helpful. Ultimately, they found that 9% of the alerts could have been eliminated.

In this case, the results of using XAI to generate suggestions to improve alert criteria was two-fold. The process could be used to identify improvements that might be missed or that might take too long to find in a manual review. The study also showed that using AI could improve quality through identification of situations where CDS was not accepted due to issues with workflow, training, and staffing. In digging deeper into the paper, the authors make some very important points. First, that despite the focus of federal requirements on CDS, the alerts that are live in the field have low acceptance rates (in the neighborhood of 10%), which causes so-called “alert fatigue” and makes users more likely to ignore alerts even if they’re of higher importance. Alerts are also often found in the wrong place on the care continuum – they cite the examples of a weight-loss alert firing during a resuscitation event and a cholesterol screening alert on a hospice patient.

They note that alerts are often built on limited facts – such as screening patients of a certain age who haven’t had a given test in a certain amount of time. While helpful in some situations, these need to include additional facts in order to be truly useful; for example, excluding hospice patients from cholesterol screenings. I’d personally note that expanding criteria that underlie alerts would not only make them more useful but would avoid hurtful alerts – for example, sending boilerplate mammogram reminders to patients who have had mastectomies and the like. I’ve written about this before, having personally received reminders that were not only unhelpful but led to additional work on my part to ensure that my scheduled screenings had not been lost somewhere in the registration system. There’s also the element of emotional distress when patients receive unhelpful (and possibly hurtful) care reminders. Can you imagine how the family of a hospice patient feels when they receive a cholesterol screening message? They feel like their care team has no idea what is going on and isn’t communicating with each other.

The authors also summarized previous research about how users respond to alerts, which can differ based on users’ training, experience, role, complexity of the work they’re doing, and the presence of repetitive alerts. Bringing AI into play to help process the vast trove of EHR data around alerts and user behavior should theoretically be helpful, if it can successfully create recommendations for which alerts should be targeted. The authors prescreened alerts by excluding those that fired less than 100 times, as well as those that were accepted less than 10 times during the study period. They then categorized the remaining alerts depending on whether they were accepted or not, then going further to look at features of alerts that were not accepted including patient age, diagnoses, lab results, and more before beginning the XAI magic.

Once suggestions were generated, they were evaluated against change logs that showed whether the alerts in question had been modified during the study period. They also interviewed stakeholders to understand whether proposed alert changes were helpful. The authors found that 76 of the suggestions matched (at least to some degree) changes that had already been made to the system, which is great for showing that the suggestions were valid. The stakeholder process yielded an additional 20 helpful suggestions. Together, those 96 suggestions were tied to 18 alerts; doing the math revealed that 9% could have been eliminated by incorporating the suggestions. For those interested in the specific alerts and suggestions made, they’re included in a table within the article.

In the Discussion part of the article, the authors address the idea of whether their work can be applied at other institutions. From a clinical standpoint, they address conditions and findings that are seen across the board. However, if an organization hasn’t yet built an alert around a given condition, there might not be anything to try to refine. They do note that the institution where the study was performed has a robust alert review process that has been in place for a number of years – a factor that might actually underestimate the effectiveness of the XAI approach. For institutions that aren’t looking closely at alerts, there might be many more found that could be eliminated. The institution also has strong governance of its CDS technology, which isn’t the case everywhere. The authors also note that due to the nature of the study, its impact on patient outcomes and user behavior isn’t defined.

As is with most studies, the authors conclude that more research is needed. In particular, findings need to be explored at a number of organizations or by using a multi-center setup. It would also be helpful to those responsible for maintaining CDS to have a user-friendly way to visualize the suggestions coming out of the model as they’re rendered. It will be interesting to see if the EHR vendors that already have alert management tools will embrace the idea of incorporating AI to make those tools better or whether they’ll choose to leverage AI in other more predictable ways.

Is your organization looking closely at alerts, and trying to minimize fatigue? Have users noticed a difference in their daily work? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/22/24

Many parts of the US are starting to emerge from winter weather, and the healthcare IT folks are starting to emerge from their relative slumber to head into spring conference season. ViVE kicks off in Los Angeles this weekend, and if you didn’t register as an early bird you’ll be shelling out $2,995 for registration. Compared to that, HIMSS looks like a bargain at $1,675, although the ViVE people will remind you that their registration also includes breakfast and lunch plus its “Industry Night” celebration, although I haven’t yet seen mention of the headliner for that event.

Conferences have gotten expensive, and even the non-flashy ones will cost you a decent chunk of change. I’ll be attending a more academic/professional-focused conference later this spring, and when you add up all the costs – registration, travel, lodging, and meals – I’ll be spending at least $2,500 to attend, not to mention the cost of the time away from work. Sure, I’ll be getting some continuing medical education credits, catching up with friends, and doing some networking, but even if your employer is willing to subsidize your attendance at conferences, it’s hard for physician leaders to justify going to more than one per year. One of my local health systems still has a so-called “travel ban” in place, mostly due to finances rather than concern about infection control or staffing. Seems to me like just one more thing being attributed to the “new normal” post-COVID.

Nearly everyone around the virtual water cooler today was talking about Teladoc Health’s stock tanking Wednesday. The company released its financial results after the close of the market Tuesday, and the market provided its answer as the stock slipped lower. Like every company, Teladoc has had its ups and downs, but growth has slowed over the last three years despite a rise in consumer demand for virtual care services. As is the case with many companies, the combination of bad investments and bad management are difficult to overcome. Telehealth is a tough business to be in, especially when you’re trying to meet not only the regulations of 50+ US states and territories but also those of an international market. We’ll just have to see what the next couple of quarters brings for this company and whether its future can be salvaged.

For organizations participating in the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System (MIPS) Quality Payment Program (QPP), the data submission portal is now open for the 2023 performance year. Eligible clinicians have until April 1 at 8pm ET to submit their data via the Quality Payment Program sign-in page. If you don’t already have your login information, I’d recommend starting that process now even if you don’t have your data ready for submission, as it can take a couple of weeks to get access sorted out. For those of you submitting, I’d be interested to hear how the process of data preparation is going. If you’re relying on vendors to help you get the data ready, when do they project you’ll have it? Or are you having to do the entire lift yourself? Feel free to send your anonymous feedback about the process and we’ll share it with readers.

A movie that has stuck with me over time is “Up In the Air” starring George Clooney. For those who may not have seen it, Clooney’s character Ryan Bingham works for an organization that helps companies outsource corporate layoffs. He has a variety of ways to help label what is happening to impacted employees, along the lines of “making you available to the workforce.” A reader shared a couple of examples from recent layoffs: Citi recently referred to the loss of 20,000 jobs as helping to create “a simplified operating model” and UPS described 12,000 layoffs as trying to “fit our organization to our strategy.” Other bad phrases I’ve heard include “involuntary career event” and of course the dreaded “rightsizing.” The worst I heard recently was when American Airlines labeled their January call center layoff as a way to “better serve our customers.” Anyone who has ever waited in the interminable phone queue understands what an oxymoron that is.

Here’s another solution in search of a problem: The American Board of Family Medicine has created a new Digital Credential program, designed to provide physicians with a way to share their board certification status “through a live online platform” targeted for social media, email signatures, websites, and more. It also offers the option to add the credential to mobile wallets, “allowing you to quickly share your board-certified status on the go.” The number of times that anyone other than a Credentials Verification Organization has requested proof of my board certification is zero, so I’m not sure physicians were clamoring for this. I tried to use the system’s functionality to automatically add the credential to LinkedIn, only to have it try to add my board certification with today’s date rather than the actual issuance date many years ago. I’m still shaking my head and wonder how much our professional organization spent on this.

Baptist Health South Florida is using the fact that February is American Heart Month to offer “special pricing” on CT Calcium Scoring tests. Patients without insurance (or those who have insurance that does not consider the test a covered service) can have the test for $49 as long as they have a physician order. For those of you who have insurance and have not met your deductible, you’re on your own to figure out how much it will cost. I’m in favor of making healthcare accessible to all, but I don’t like the idea of a hospital organization using this as a loss leader to attract patients who might potentially need more costly services. These are people’s lives – not a rack of rotisserie chickens at Costco.

Many of the patients I see are struggling financially, so I’m always looking for free resources that will help support their health goals. I stumbled upon this video from the National Health Service in the UK and was immediately drawn in since it promotes belly dancing as an aerobic workout that can help improve flexibility and core strength. It also advertises mood-building benefits through music and exercise. If you’ve got 45 minutes to spend on your health, it’s worth checking out. The video does include a disclaimer that the program is “suitable for most people in good health with a reasonable level of fitness” and that you should get advice from a healthcare professional before trying it if you’re not sure about your current level of fitness or if you’ve had recent injuries or health conditions such as a heart attack or operation.

What’s the best you’ve seen as far as free tools for health promotion? Is belly dancing your new breaktime activity? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/19/24

For the past 20 years or so, I’ve volunteered to work on Super Bowl Sunday so that my colleagues who are die-hard football fans or longstanding party hosts can do their thing. If I’m working in a low-acuity emergency department or in an urgent care, the day is usually slow, although more patients present as soon as the game ends. Back when I was doing my training, I spent one Super Bowl Sunday covering a busy Labor and Delivery unit. It was eerily slow until the end of the half time show, and then things became wild as women headed in after realizing that sheer will power wasn’t going to keep their babies from arriving. Sometimes it’s slow enough to catch at least some of the commercials, but usually I end up reading after the fact about which ones caused the most conversation.

This year, I was surprised to see how many people were talking about healthcare-related commercials. Although most of them were local or regional, at least one ran nationally and received plenty of coverage. Patient advocacy organization Power to the Patients aired a public service announcement featuring rapper Jelly Roll, country performer Lainey Wilson, and singer-songwriter Valerie June. It called for healthcare price transparency and specifically called upon the US Congress to pass laws to support it. Points made during the ad include that 100 million people in the US are “drowning in medical debt” and that the greed of hospitals and insurers is “destroying the American dream.” Reports indicated that the campaign also had planes flying banners through the skies above Las Vegas.

Other organizations making a Super Bowl spend included:

• Connecticut’s Hartford HealthCare and Yale New Haven Health with competing ads.
• New York’s Roswell Park Comprehensive Cancer Center.
• Wisconsin’s Bellin Health.
• Tennessee’s Niswonger Children’s Network (part of Ballad Health) and St. Jude Children’s Research Hospital.
• Pennsylvania’s OSS Health.

I understand how organizations want to toot their own proverbial horn, but even the cheapest Super Bowl ad represents a lot of dollars that could be used to do things like provide patient care, support staff, improve facilities, and more. The reality is that organizations spend a tremendous amount of money on advertising. Case in point: A recent article noted that Atrium Health is paying $1.5 million over five years for naming rights at an amphitheater in Macon, GA, stating that “music is a great way to bring people together, and we know that strong social relationships have been associated with improved physical and mental health.” Atrium also paid to name a local minor league stadium in Kannapolis, NC, after the health system. They’re four years into a 10-year deal, so I wonder what kind of return they’re getting on their investment. It seems like an enduring presence at a local facility will get more attention than a fleeting Super Bowl ad.

Hospitals weren’t the only healthcare players getting in on the advertising game. Pfizer had an ad featuring the music of Queen that focused on its vision for the future of cancer care. Astellas Pharma promoted a menopause treatment that retails for $660 per month. MangoRx added an ad for its erectile dysfunction treatments to round out the health-related content. The United States is one of the only developed nations where direct-to-consumer advertising is allowed, and most physicians I talk to wish such campaigns would go away. In my experience, nearly all of the patients who follow the advice to “ask your doctor if drug X is right for you” would benefit from other (usually less expensive) treatments than the one that was featured in a glitzy marketing campaign.

I would be interested to see some industry data that shows how much the average hospital or health system is spending on marketing efforts and what they believe is their return on that investment. For example, we’ve all seen so many renaming and rebranding efforts that it feels like it’s impossible to remember who is who. One of our local hospitals spent a ridiculous amount of money putting a new light-up sign on the top floor of the hospital, replacing the existing light-up sign. This one is 50-percent larger and is borderline distracting when you’re on the freeway, and offers no other redeeming value – not even a conversion to more energy efficient LED lighting.

I continue to see hospitals that are penny wise but pound foolish. One local facility has a significant problem with employee turnover. Nurses are jumping ship because pay isn’t keeping up with local competitors. Instead, nurses are bouncing from hospital to hospital every 12 to 18 months in search of better pay and benefits. The lowest-paying hospital is losing tons of money due to the turnover costs, not to mention the loss of institutional knowledge and community reputation as nurses don’t hesitate to tell friends and family how “cheap” hospital administration is. Sure, administrators have controlled salary costs in the short term, but at what long-term cost? It seems that doesn’t really matter, since there is churn at the administrator level as well and people leave when there are too many questions. Still, the hospital supports various local sports teams, but it’s a sad day when it can’t prioritize reduction in nursing turnover. Another local hospital ended hot food service for overnight workers, which I suspect isn’t going to be a real satisfier for those who are on the night shift.

I’d be interested to hear from anyone who works for one of the institutions who made a Super Bowl ad purchase, or who is a consumer of healthcare in their region. Are you proud that your organization showcased its expertise or are you left scratching your head because you know they’re claiming financial hardships that should exclude a Super Bowl ad from the budget? Even if you don’t have an institutional connection, what do you think about healthcare organizations advertising in general? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/15/24

I’m always amazed when people want to use EHRs to drive non-EHR behavior, almost forgetting the concept of free will. A friend reached out to me to ask if I knew how to configure Epic EHR tools to help her track how much time she spends using the EHR on her days off, which includes work done during weekends, holidays, and when on vacation. She said she felt “blown off” by the IT team after opening a help desk ticket since they are only tracking so-called “pajama time” on scheduled clinic days. She feels that tracking the data on weekends and non-clinic days would help motivate her to work less. I explained how IT teams manage their work and how they typically focus on system enhancements that would benefit large numbers of users and explained that she’s essentially asking for a one-off behavior modification program. I offered some options for free time-tracking software on her phone, which I think would be even better, since she will have to consciously decide that she’s going to start her timer and use the EHR versus “just popping in for a moment” as she has become used to doing.

In talking through it, she never thought about using any other way to track her time – such as an old-school notebook or even a time-tracking app. I also mentioned the importance of tracking other time-sucking ways she spends her day, including social media, random internet surfing, online shopping, and more. Sometimes we just need to take responsibility for our own choices, and it’s not always the IT team’s job to figure it out or the EHR’s responsibility to track it. Of course, I know that EHRs have a way of wasting a lot of clinician time, especially if their organizations don’t have policies and procedures in place that allow clinicians to work at the top level of their licensure. However, this particular physician also admits she brings her own laptop to work so she can do things that aren’t allowed on the office computers, so I suspect the problem is much larger than her ending up doing work on the weekends.

I recently took over a new volunteer position and was given access to a shared drive full of documents and files with the advice that “everything you need is in there.” The extremely painful process of going through the folders reminded me of how spoiled I have become working for high-performing organizations where version control information is required to be clearly present on every document. Sure, you can access that information electronically from within the applications, but for long-standing documents, that can require a lot of digging. It’s also helpful to see who authored the document, the business reason for its creation, and a high-level overview of key changes that have happened along the way. You can bet that when I hand off the materials to the next person, the documentation will be a little stronger. I’m trying to dig through them with a glass of wine in hand, but I’m afraid my cellar will be empty before I get through all of the documentation.

Happy 30^th birthday to the Journal of the American Medical Informatics Association. The publication launched in 1994 and has had significant growth during its lifespan. The journal’s 2023 statistics: 1574 submissions received with 254 accepted for publication. Here’s to the next decade of quality clinical informatics literature.

From Cube Dweller: “Jayne, I appreciate your ongoing coverage of the return to office situation. I’m one of those people who has enjoyed being in the office all along, mostly to get away from my children and have a bit of peace and quiet. Now that all these hybrid people are being forced back to the office, our management is making us have all kinds of forced fun to welcome them back. I wish they’d take a page from this article about how to not make it feel like a bad middle school mixer.” I appreciated the content of the article, which shared one company’s idea of a better way to get employees to connect. The employer profiled is Verkada, which provides security equipment. CFO Kameron Rezai created what they call the “3-3-3 program,” which offers a reimbursement of up to $30 each for employees who meet at local businesses in groups of three or more after 3pm. Rezai cited autonomy as one of the goals of the program, stating, “We trusted our employees to go out and make their own connections.”

Since the program’s inception in April 2023, the company has had good uptake, spending more than a half-million dollars from a fund that formerly paid for structured events. As someone who has felt the pressure of trying to plan workplace events that have something for everyone, this feels like a win-win. Want to go hike with your coworkers and get a beer afterwards? Check. Want to visit a local tearoom or coffee shop? Check. Chill at the local gelato shop after a long day of meetings? Check. Staffers do have to post event snapshots before they file their expense reports, which I think would be great for helping others generate ideas. This would also potentially scale to remote workers, who could arrange delivery of snacks and drinks then hop on a virtual meet and greet together. Local businesses also benefit, so that’s another plus.

I’m mentoring a young clinical informaticist, and we have a lot of conversations about study-related concepts such as statistical power, correlation, and causation. There are so many studies out there that “link” different concepts or events together, which may have a tangled web of causes. My mentee brought up a recent Epic Research study that noted that for patients in the emergency department, there was a correlation between providers having access to outside records and a reduced risk of a “code blue” event. The article notes that previous research has shown a link between the presence of outside medical records information and patient outcomes such as visit length, tests and diagnostics that are ordered, admission rates, and even charges.

As someone who has spent a long time working in the emergency department, I understand that piece – having more information helps you better understand a patient’s current state and how their various health conditions have progressed. You can also see if they had recent testing that would reduce what you need to order today, or the presence of data can make a comparison easier. From a code blue standpoint, my experience is that those events are most closely tied to the patient’s current presenting problem: major trauma, heart attack, respiratory failure, etc., and are less closely tied to chronic conditions. As a scientist, it’s fun to find things that correspond, but the best studies are those that generate actionable data that can be used to improve patient outcomes. Maybe I’m missing something here, so if you’re seeing what I’m not, please clue me in.

My mentee is also working on a public health project that looks at foodborne illness and came across what can only be described as an attention-grabbing title: The Great Michigan Pizza Funeral. The “ceremonial disposal” of nearly 30,000 frozen pizzas occurred in Ossineke, Michigan on March 5, 1973, following a recall due to concerns about botulism-causing bacteria in mushrooms used to top the pizzas. The pizzas were placed in an 18-foot deep grave with the governor of Michigan in attendance. Later testing revealed that the mushrooms were not indeed contaminated, and that laboratory mice found dead during the initial testing suffered from an unrelated infection.

What kind of pizza would you never eat, unless it was the only food left to sustain you? Which is best – thin crust, thick, or pan? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/12/24

Several of good friends from medical school hold significant physician leadership roles. I always enjoy catching up with them and hearing what is going on at their hospitals, as well as trading ideas for solving the different kinds of challenges our organizations are facing. Sometimes one of us has already been through an issue and there’s no sense in reinventing the proverbial wheel when you don’t have to.

Although my colleagues are knowledgeable about their own departments as well as those that they have to work with closely, they don’t always have the broad view of hospital operations that I have as an informatics leader. I think that when working with large enterprise EHR implementations, clinical informatics leaders are just conditioned to make sure that we are thinking about every part of the hospital as well as systems that aren’t even under our roofs, such as emergency medical services, transfer infrastructure, and more.

Regardless of region or state, everyone is facing hospital overcrowding. When there aren’t enough inpatient beds available, patients start backing up into the emergency department. The root cause of the inpatient bed shortage is multifactorial. Sometimes physical beds are lacking, and sometimes there are actual beds open but the shortage is one of staffed beds. There just aren’t enough personnel to keep a unit open.

Although many disciplines are in short supply, including respiratory therapy, the major issue I see in my region is still a nursing shortage. Hospitals in our area are still playing games with nurse compensation and have instituted staffing policies that negatively impact nurses and their families. Of my friends who are nurses, all have left hospital care except one, and I guarantee if she worked on a medical/surgical unit, she would leave, too.

Unless people are actually impacted by these shortages, they don’t tend to get engaged around the policy work that is needed to solve the problems. I was excited to see NBC News bring some of these issues to light this week, as it reported on the potential end of funding for Hospital at Home programs at the end of this year and how that end might worsen already tragic emergency department (ED) overcrowding.

CMS created the program, which is officially called Acute Hospital Care at Home, in 2020. The program allows hospitals to deliver high-acuity care to patients in their homes, where they receive visits from community paramedics and are connected via technologies such as video visits and home-based monitoring systems. The programs can help boost ED throughput by admitting patients back to their homes rather than potentially having to board them in the ED while they wait for a physical hospital bed.

Although more than 130 health systems have been approved to participate, it’s difficult to understand how many are truly bought in or what level of resources are being dedicated to program initiatives. Even if they are participating, hospitals may be left dangling at the end of the year unless Congress votes to extend funding for the program. Although some private payers are participating, CMS still provides the majority of funding for programs.

Even for those organizations that have embraced Hospital at Home programs, their impact is incremental. Atrium Health, for example, is treating 60 patients per day in its program in North Carolina and hopes to ramp that up to 100 patients per day by the end of 2024, which is a fraction of its total count of inpatients. If Hospital at Home programs are sunset, patients who might have been referred to them are instead going to need regular inpatient beds, which will further worsen the situation in systems where those programs had been successfully making a difference.

Policymakers need to look at other causes of ED overcrowding. In addition to the shortage of staffed beds on medical/surgical units, there are fewer beds available in nursing homes, psychiatric units, and rehabilitation facilities. Mental health services are in short supply everywhere, with families sometimes bringing loved ones to the emergency department because they feel they have nowhere else to turn. Telehealth solutions can help mitigate this to some degree, identifying patients who might qualify for outpatient management or who need help navigating the system, such as obtaining medication refills or finding a new provider for ongoing care. Progressive states are looking at the upstream causes of the mental health crisis and are allocating money to community programs, but other states seem to be just looking the other way.

The report also mentioned other pitfalls of our state-by-state patchwork of healthcare solutions. It looked at data from Massachusetts hospitals, including data on patients who are boarded in the emergency department while they wait for beds in the hospital. It profiled the venerable Massachusetts General Hospital, which has been boarding at least 45 patients at a time for more than a year, and in January of this year hit a count of 103 boarders with 220 people across the state in the same situation. The hospital considers this to be a “capacity disaster” and has asked the state to approve additional beds to help the situation.

They have also instituted a Hospital at Home program and have created a Discharge Lounge to help speed patient departures from the hospital building. Patients can wait there for their caregivers to pick them up, rather than remaining in a standard hospital room. That intervention helps 125 patients per month leave more than 60 minutes earlier, which will add up over time and as the program is expanded. The hospital is also providing transportation services to help patients leave when they don’t have reliable transportation.

Other solutions that can help make beds more available include virtual nursing care, where offsite nurses can work with patients and families to deliver patient education and discharge teaching, freeing up bedside nurses to deliver care that must be rendered by an in-person nurse. Virtual nursing programs in my community are keeping nurses that have been placed on light-duty restrictions active in patient care, rather than sidelining them. The technologies can also be used as a “phone-a-friend” solution for early career nurses to bring in a second set of nursing eyes to evaluate a particular patient. Having been a newly minted intern, I appreciate the idea of using technology to consult dedicated virtual resources rather than having to interrupt colleagues who are already knee-deep in patient care of their own.

The NBC News report goes on to note that Massachusetts is “unique” in the way that it keeps statistics on emergency department boarding, and that many states are lacking high-quality data on the problem. I know my own state doesn’t do a good job of tracking it, let alone communicating it, which means that citizens in our communities have no idea there’s as big of a problem as there actually is. The majority of my neighbors and friends in the community think that because COVID is “over” and there aren’t daily stories on the news about how bad things are at the hospitals, that everything is fine. That is, until a loved one sits for 17 hours in the waiting room before they see a physician. But it’s unclear if those experiences translate to actions, such as lobbying one’s legislators.

Demographics are shifting in the US, with increasing numbers of elderly patients and more of us who are living with chronic conditions. We are not spending enough money on preventive care, health promotion, or disease prevention, so the problem is likely to get worse before it gets better. Let’s hope that stories like this help to raise awareness and generate change so that we don’t continue in the downward spiral in which many of us feel trapped.

Does your organization support Hospital at Home activities, and how are they going? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/8/24

I appreciate the fact that my health system of choice promptly shares visit notes with its patients. I’m less appreciative, however, of the fact that some physicians continue to refuse to follow documentation best practices, which have been designed for patient safety and improved patient experience.

As always, I dutifully completed the electronic check-in process well in advance, verifying my insurance coverage and ensuring that my pharmacy was up to date. When bringing me back to the exam room, the first thing the medical assistant asked for was my pharmacy information. She didn’t log into the EHR using the workstation in the room, but was instead working from a sheet of paper.

It would be one thing if the paper had my information printed and she was simply verifying, but this didn’t seem to be the case since she asked me to provide the address and phone number. I politely declined, stating that I had just updated them in the EHR the day prior.

I’ve been to this office many times before, and the physician has never used the EHR in the room. She uses a scribe and is good at verbalizing the exam so that the scribe can capture it. However, the practice continues to use templated documentation that doesn’t reflect the work that was done during the visit. My most current documented a “comprehensive Review of Systems” which was not performed and included a reference to “see scanned document completed by patient” which doesn’t exist, since I certainly didn’t complete one. I wonder if the physician understands that documenting work that wasn’t actually done is fraud.

As always, I noted my concerns when the inevitable Press Ganey survey arrived, so hopefully someone will see it and take action. In the mean time, I’ve decided to leave the practice, not only due to this, but due to poor appointment availability and annoyances with the billing processes, such as refusing to collect your co-pay at the time of service, leading to more work on my part down the road. This practice is crying out for process improvement work, but it’s unlikely that will commence any time soon.

From Public Health Nerd: “Re: the recent Senate hearing on social media’s impact on youth mental health. Here’s some data for your consideration.” The statistics provided included a dramatic increase in teens who report “persistent feelings of sadness or hopelessness,” especially among girls. There has also been an increase in diagnoses of depression and increased suicide rates among teens. Although rates of social media use correlate with these changes, it’s difficult to prove causation, especially considering all the other changes happening at the same time, including community violence, rising income disparities, racial tensions, global conflict, and high-conflict political processes. More studies are definitely needed.

From Coffee Klatch: “Re: return to office programs. Keep up the good work exposing them as the power grab that they are. If companies want people to come to the office without complaint, they need to make it a place people want to visit. Nearly all of my colleagues use travel mugs, which don’t fit into the new coffee makers that our company purchased. I tried to bring a ‘shortie’ travel mug, but it was too wide. We all end up using paper cups to transfer coffee to our mugs. So much for the company’s commitment to sustainability initiatives, since we’re creating more greenhouse gases driving to the office and now using a bunch of paper cups we didn’t need before.” I’m sure some people thing this is a small thing, but it’s just one more example of how decision makers who are out of touch with their workforce are contributing to employee resentment and potential turnover.

I’m sure no one was surprised to hear the news of Amazon’s planned job cuts at its One Medical and Amazon Pharmacy units announced earlier this week. Executives who may have had lesser degrees of healthcare experience prior to entering our industry often find out quickly that it’s much harder to get those big wins and revenue bumps than they were used to with their previous employers. Amazon promises to continue to hire providers for frontline care delivery, but it looks like they’re primarily focused on building their midlevel provider workforce rather than hiring physicians.

I’ve had several patients follow up with my practice in recent months after receiving interesting diagnoses from online practitioners who conducted asynchronous evaluations that resulted in what was ultimately a misdiagnosis. Sometimes a picture is worth a thousand words, but other times you really need to have a conversation with the patient to fully understand what is going on. Our society puts the responsibility of making sure their provider is high quality largely on the patient, which is hard to do when you’re placed in an anonymous queue and have no idea who you are going to see until they are actually participating in your care.

Last week was Groundhog Day, when many in the US traditionally look towards a rotund woodland mammal for predictions on upcoming weather. Since reaching a point in my career when I have the flexibility to provide behind-the-scenes medical support for events and gatherings, I tend to keep an eye out for how that plays into any large happening.

This year, officials predicted that up to 30,000 people might try to see the venerable Punxsutawney Phil, gathering in the cold dark morning at Gobbler’s Knob, Pennsylvania. Planners had approximately 20 professionals from five emergency response organizations standing by. In the past, problems have included hypothermia (not unexpected in years when the wind chill has been well below zero), cuts and scrapes, medical emergencies from patients who didn’t take their medications due to the early start of the event, falls, and even the occasional heart attack. There have also been issues with intoxication, even given the typical 4 a.m. arrival for some attendees. I guess it’s never too early to get the party started when groundhogs are involved. Props to Allegheny Health Network and Punxsutawney Area Hospital for their onsite support.

Does your area have a local groundhog, and what was its prediction? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/5/24

I was invited last week to an onsite meeting at the local office of a national company, where a “return to work” policy had recently been enacted. Employees are expected to be in the office at least three days per week if they live within a certain radius of an office, regardless of whether their teams are located in that office or not.

One of the attendees was grumbling about the fact that he is the only member of his team that works in this market, so he essentially drives to the office and sits in a cube, where he attends video conferences most of the day. He mentioned that despite the policy, he’s often the only person in his part of the office, which doesn’t do a lot for building employee morale or enabling the growth of the company’s culture.

I was interested to see all the amenities in the building, which included a nice-looking cafeteria and an area that could be configured with courts for indoor sports and lawn-style games. I suspect that they pre-date the era of remote work, when everyone was in the office and people weren’t coming back in a fragmented way.

Given the fact that for this company, proximity to an office determines the need to return to in-person work instead of being part of a specific team or holding a specific job role, it’s no wonder that people are not thrilled about the return to work policy. It will be interesting to follow up in a few months to see whether more people are embracing in-office culture or whether it’s just causing more bitterness. Expecting people to collaborate in an office where there aren’t any team members simply makes no sense.

Having worked in environments that are in-person, completely remote, and various combinations in between, I’ve seen how company culture is governed more by people’s behaviors than by whether they’re interacting in person or online. For example, in remote environments, particularly when people are working in multiple time zones, it can be easy to overlook people’s posted work hours and schedule meetings that are too early or too late for them. I’ve had to do that on occasion, but try to only do it when there’s an external constraint, like physician attendees who work from one of the coasts and need to accommodate clinic hours, or something like that. I always reach out to the impacted people rather than just sending the appointment, so that people know it’s coming and can let me know if they can attend the meeting or whether we need to make other arrangements. Using that approach, most people are willing to adjust their schedules to accommodate an early or late meeting, but it’s the fact that you discuss it that helps build rapport, teamwork, and by extension, company culture.

Whether in-person or remote, it’s also important to have a culture where people can put focus time or work blocks on their schedules and have those times be respected. Those blocks need to be created in a way that respects existing standing meetings or important team meetings, but no one should ever be made to feel bad that they want time during their scheduled workday during to actually do their work. Remote employees often struggle with failing to achieve work-life balance because they are always at their workplace, and creating an expectation for them to spend time after-work hours playing catch-up due to overly full schedules isn’t a culture builder.

It was interesting timing to have this meeting since several articles about the topic were published this week. Gizmodo had a headline offering “There’s More Proof That Return to Office is Pointless,” highlighting a study from the University of Pittsburgh that demonstrated that return to office policies don’t positively affect productivity. Researchers looked at a sample of S&P 500 companies and concluded that such policies were more about corporate control than stock performance. They found negative correlations between returning to the office and key indicators such as employee satisfaction, ratings of work-life balance, and opinions of senior management.

Companies allege that returning to the office builds trust, but I have found that trust is best built, regardless of work location, by doing things such as giving employees the resources they need, ensuring that employees have adequate time away from work (such as uninterrupted lunch breaks), not requiring employees to have their cameras on 100% of the time, and assuming positive intent when employees seem to be asking a lot of questions.

Another colleague I talked to is convinced that her company’s return to office policy is a play to make good on bad real estate decisions that were made when people failed to realize the impact of remote work during 2020, 2021, and 2022, when others modified their leases due to the impact of the COVID pandemic. One of the companies I worked with in 2020 saw the proverbial handwriting on the wall and made the decision to unload countless square feet of real estate. They made it clear that they wouldn’t be going back to in-person work, and unsurprisingly, employee satisfaction continues to be high and turnover numbers are smaller than they have ever been.

Fast Company also had an article on the topic that highlighted results from a recent survey that indicated that half of potential employees wouldn’t even apply to a job if it was entirely in-person. Flexible work can be a tremendous asset for neurodivergent employees or those with disabilities, chronic medical conditions, or high commuting costs. There’s also the issue of environmentalism and the potential to reduce carbon emissions when fewer people are driving to a physical office.

I’m not saying that allowing employees to work remotely is all sunshine and lollipops. I’m wondering if some of the movement towards return to office policies has to do with declining professionalism. I’m sure many of us working remotely have done the “business on the top, pajamas on the bottom” wardrobe look and that’s OK. The people I work with regularly either have tidy home offices or use electronic backgrounds, although I do get distracted by those that have animations such as rain or snow on the windows.

However, in attending meetings for professional organizations and committees, I see a lot of people whose home lives have become part of their work lives, including interruptions from children and pets. Life happens, but when your kids are wandering in and out of your call, there’s always the option to turn off your camera, make an apology for the disruption, or even step away.

There’s also evidence that virtual meetings aren’t being done optimally, causing employees to become fatigued and inattentive on calls. Researchers looked at employee engagement during calls, along with physiological measurements, over two working days, encompassing nearly 400 meetings. They cross-referenced their data with questionnaires about work attitude and engagement, finding that fatigue during calls is due to mental underload and boredom in the workplace. They found that disengaged employees have a harder time maintaining focus in meetings where cameras are off, leading to multitasking behaviors and further distraction. They mentioned that highly automated and non-cognitive tasks such as walking can be carried out during meetings, and I suspect that extends to the knitting and crochet that I see some of my physician co-workers doing during committee meetings.

I know of a number of hospitals and health systems that allow technology workers to live anywhere in the US, even though their patient care sites aren’t nationwide. It would be interesting to specifically compare their outcomes to those that require workers to do the same jobs in person that others do remotely. Only time will tell whether organizations will back off on their return to office mandates.

Have you recently been subject to a return to office policy? If so, how is it going? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/1/24

Physicians who care for children — including pediatricians, family medicine physicians, and psychiatrists — have been sounding the alarm for years with regard to the negative impacts of social media on the health of the world’s youth. I’ve been following the recent hearings in the US Senate Judiciary Committee this week on the topic of child sexual abuse. Executives from TikTok, X, Snap, Discord, and Meta were grilled by senators about the platforms’ role in child exploitation.

For those of you who might not be following the issue closely, abuse and exploitation of kids via social media platforms is more than cyberbullying and child pornography. The list of problems continues to expand, and includes not only the sharing of images and videos, but also predators grooming children for abuse and potential trafficking.

Drug use is also a serious concern. I’m sure a lot of parents don’t know that you can use Snapchat to buy fentanyl. As an urgent care physician, I’ve seen the faces of parents who can’t believe that the pricey TikTok-promoted cosmetic products they gave their pre-teen daughters for Christmas have caused the horrible rashes that resulted in a $100 co-pay and prescription medications.

I continue to encounter parents who are willing to help their children lie to gain access to social media even though they’re not old enough to meet the age restrictions, because they are terrified that their children will be ostracized if they’re not keeping up with their peers. I also see children who have zero parental limits on social media use, which can manifest with sleep disturbances, poor academic performance, and serious behavioral health issues.

One hot topic during the hearing was the Kids Online Safety Act, which only two of the five platform leaders were willing to support. Others claimed that the Act contains provisions which are too broad and may clash with free speech issues. The act includes language not only addressing abuse but also predatory marketing and would potentially reduce the power of notifications and auto-played videos that trigger users’ dopamine pathways and contribute to compulsive and addictive behaviors.

YouTube was notably absent from the hearing, despite the platform’s popularity among teen media consumers. Unfortunately, the hearing ended without consensus or clear solutions and those of us who have seen countless children harmed will have to continue to wait for yet another bill on Capitol Hill to finally get passed.

I received a message from the CDC’s V-safe program this week, inviting me to participate in health check-ins for the updated COVID vaccine. Unfortunately, one has to register within six weeks of receiving the vaccine. For those of us who are frontline physicians of a certain age who received the updated vaccine shortly after it became available, I guess we’re out of luck as far as participating in vaccine surveillance. Seems like that should have been something they coded and released to time appropriately with the vaccine’s arrival in retail locations.

Unfortunately, this is just the kind of food for thought that conspiracy theorists latch onto, since it can be used to try to support the assertion that that “government really doesn’t want us to know about how many people are harmed by these vaccines.” I serve on the health advisory board for our local school district, and most of us are still seeing COVID-deniers in practice. Many don’t want to seek medical care because they’re afraid they’ll be tested for COVID. Maybe someday health literacy in our country will improve to a place where clinicians can spend more time rendering care and less time refuting medical misinformation.

As a telemedicine physician, I’m concerned about the conflicting priorities that our industry faces, including balancing patient satisfaction and perceived convenience with elements such as clinical quality and antibiotic stewardship. One of the challenges is the lack of telemedicine-specific metrics, which leads organizations to try to mold in-person clinical quality measures to virtual care. The Agency for Healthcare Research and Quality has created the AHRQ Safety Program for Telemedicine, which will help prescribers look at antibiotic usage over an 18-month period starting in June 2024. The program will provide educational sessions to providers, including scripts for navigating patient concerns about not having their wishes met when they request “a Z-Pack to nip things in the bud since we’re going into a weekend,” which universally makes physicians cringe. Providers are expected to perform better on antibiotic-related quality measures after participating in the program, and continuing education credits are available. There is no charge to providers to be part of the program, which is a welcome element for those of us already spending too much to maintain board certification and other recognitions.

Mr. H recently mentioned concerns by developers such as Microsoft and Google with regard to the cost of the computing power needed for AI projects. I’m a bona fide space nerd, having once wanted to be the first physician living permanently in space. Instead, I’m content to watch from the sidelines as scientists execute cool projects that I could only dream of. I’ve followed NASA’s Ingenuity helicopter, which nearly every journalist describes as “plucky,” especially since it was planned for less than a half dozen missions and eventually flew 72. Ingenuity weighs less than 4 pounds, but provided an amazing amount of data about the ability to achieve powered autonomous flight on another planet.

A headline about the craft caught my eye this week, noting that the craft “packed more computing power than all other NASA deep space missions combined.” This was a challenge given its small size, with engineers having to forego heavy components whose design would mitigate radiation damage and the extreme temperatures on Mars. Instead, designers specified off-the-shelf components, including the brain of the helicopter: the Qualcomm Snapdragon 801 processor, which was used in smartphones nearly a decade ago. Here’s to those IPhone 6, Blackberry Passport, and Google Nexus 6 users whose daily calls shared NASA-worth technology and they didn’t even know it. Photo credit: NASA/JPL.

What was your childhood dream? Are you working in a related field or would you give up your meeting-filled days for a ride into outer space? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/29/24

I’m a big fan of virtual care. It has the potential to revolutionize healthcare if we can get patients, providers, payers, and state regulators all on the same page.

Unfortunately, there’s still a lot of disagreement on how reimbursement should work for the typical “outpatient” telehealth visit. Provider organizations are having to grapple with state licensure issues, especially if they are on a state border or have large numbers of patients who frequently travel away from the brick and mortar delivery site, or if they have large numbers of patients who live elsewhere but travel to the facility for care. It seems like most of the research articles I read are about that method of delivery, so I’m always interested when one comes up that features a different use case for telehealth.

This week’s JAMIA featured an article that looked at community tele-paramedicine (CTP) and how it can impact patient experience and patient satisfaction when varying levels of health disparities are present in a community. When I was a medical student doing ride-along shifts with our city’s fire and rescue squads, we spent most of our time transporting patients to the emergency department even though they didn’t have truly emergent medical conditions. A fair number of patients used EMS for transportation since they felt they didn’t have other options due to economic and geographic issues.

As a future physician, I felt powerless. It seemed like there should be a way for the paramedics and emergency medical technicians to deliver a basic level of care, such as a dressing change, without transporting the patients. However, the regulations and economic realities of the time left them with limited options.

Fast forward, and now that telehealth has become just another care delivery modality, healthcare professionals who are used to first responder roles now have other options for helping patients. New York City has embraced this, using community-based teams to deliver home-based care. Although the most visible parts of the team include community paramedics who can evaluate patients and facilitate video visits with emergency physicians, the teams also include care managers who are registered nurses that have with additional training in patient education and motivational interviewing. They coordinate with patients’ primary and subspecialty care teams, social workers, and others to make sure patients get the follow up appointments or home health services that they need. The paramedics also have additional training in the management of chronic diseases and assessing patient home environments.

Given the growth of the program and its interaction with patients who are part of vulnerable populations, the authors set out to look at patient satisfaction across areas of the city that were classified into high, moderate, and low health disparity Community Health Districts. As part of another clinical trial, the patients who were selected for this study were diagnosed with heart failure. The community paramedics who were part of the program had additional training on heart failure that included both lectures and case-based learning to simulate patient visits.

The service was available for home visits seven days per week, with nurse care managers staffed five days per week. The physicians who provided coverage for the video visits all had at least five years of post-residency experience and were certified by regional EMS officials to serve as online medical control for medics.

Patients were referred to the program after either a hospital admission or an emergency visit. Referrals could be initiated by ED / inpatient / ambulatory physicians as well as social workers and care managers, and referral was triggered within the EHR. Patients were deemed ineligible if they had active substance abuse or psychiatric issues, had been discharged to another medical facility, or were unhoused. Patients, family members, or the care team could request a home visit at any time using a triage process. Patients typically remain in the program for three months, and the program has completed 5,000 home visits since 2019.

Patients received a 12-question satisfaction survey that electronically collected anonymous data after each visit. Although medics could help patients access the survey, they could not help with completion. The authors found high levels of patient satisfaction that were similar across areas with different community-level health disparities.

They also conducted a small number of qualitative interviews, which identified some differences in how valuable patients found the service.  Those in high-disparity areas made comments that aligned with improved health literacy and more engagement with the health system, where those from areas with less disparity were more likely to comment on convenience.

The article includes direct quotes from the qualitative interviews, which touches on themes that we have known have influenced healthcare for a long time: transportation, the need to have someone to check on patients between scheduled appointments, medication education and tracking, and convenience for patients who have a large number of healthcare encounters, such as dialysis patients. 

The authors note that the program used in the study is “specific to our institution and geographic location” and that results might not be generalizable to other cities. However, I would hazard a guess that any large metropolitan area could conceivably achieve similar results. They also noted that the specific design around a heart failure diagnosis may create issues with trying to generalize performance to other chronic conditions. I would also guess here that other chronic conditions such as pulmonary disease, kidney disease, or diabetes may yield similar outcomes. However, we won’t know for sure unless we study other conditions in other geographies.

I’m hoping that other institutions might see this publication and consider conducting research on their own populations, or seeking funding for similar programs that might tell us more about healthcare in rural or other underserved areas.

Additionally, if you couple studies about these kinds of programs with cost savings data, we can build a stronger case about why telehealth provides good value in an environment where healthcare spending is constantly on the rise. We can also couple it with outcomes data to identify cases where care is not only equivalent to in-person care, but where it might actually be better. I think that if we fast-forward another five years, we will be able to make a lot stronger conclusions than we can make today.

Is your organization considering a community paramedic program or does it already have one in place? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/25/24

I had dinner the other night with a group of family physicians. It was an interesting bunch. Three of them have left employed practice models to open their own primary care practices. One is practicing with the local visiting nurse association. Another is working as the medical director for a local hospice. Several are on faculty at residency training programs, and two of us are clinical informaticists.

As one can imagine, telehealth was a hot topic. One of the physicians who is employed by a local health system was complaining about how her organization has brought in a third-party vendor to perform urgent care telehealth visits. In particular, she feels that continuity of care has suffered. One of our colleagues mentioned a recent study that was published in JAMA Network Open that looked specifically at virtual visits that were performed by the patient’s own family physician compared to those that were performed by an outside family physician.

The authors looked at 5 million Ontario residents who met criteria for having a family physician and for having had a virtual visit. They concluded that visits with an outside physician were 66% more likely to be associated with an emergency department visit in the next seven days compared to those visits that were conducted by the patient’s own physician.

If you dig deeper into the results, they looked at a matched subset of patients and found that the changes of an emergency department visit in the next week was even greater for patients with “definite direct-to-consumer telemedicine visits.” They specifically excluded virtual visits that were performed by another physician in the same group as the family physician, since they “sought to contrast the highest-continuity virtual visits (own physician) with lowest-continuity virtual visits (outside of group).” The authors go on to conclude that the findings “suggest that primary care virtual visits may be best used within an existing clinical relationship.”

The authors noted that increased emergency department utilization that were associated with low-continuity visits suggest that “virtual visits may serve a triaging function, allowing for the identification of patients who would benefit from an in-person assessment.” It would be interesting to see a similar study performed in the US, since there are likely differences in service utilization due to the payment landscape here. When patients are worried about co-pays and emergency department costs, they often make different decisions than they might if they were part of a system where they were at less exposure for unexpected healthcare bills. The authors noted that one of the limitations of the study was the lack of ability to identify patients where access was an issue, such as hours of clinic operation, physician availability, or scheduling difficulties.

The next time I see them, I’ll have to get my family medicine colleagues to weigh in on “The Case of the Disappearing Thank Yous,” which was published in JAMA Health Forum earlier this month. It begins by detailing a physician’s dissatisfaction when her employer began to filter messages from patients that said, “Thank you.” Although some may feel that such messages represent clutter, including EHR vendors who have acted on client requests to suppress them, this physician found them meaningful.

It’s the classic case of whether the good of the one outweighs the good of the many, but the author went on to discuss other ways that he feels that appreciation of accomplishments is lacking in healthcare. As an example, he mentions that Medicare costs have stabilized and that important public health worth continues to progress despite the persistence of negative headlines.

He mentions what most of us already know – negative news tends to generate more clicks than positive news. It’s all about monetizing those eyeballs. He notes that “a failure to appreciate past victories can also jeopardize efforts to tackle the health challenges of the future,” especially in the setting of low trust for government agencies which includes those that are involved in public health.

Especially for healthcare workers who have really taken a beating over the last several years, it’s important to feel appreciated. Employers tried to say thank you by issuing challenge coins and sending pizza, but it’s time to figure out how to demonstrate appreciation in a meaningful way. I know I would like to grow old in a society with highly qualified nurses that love their jobs, but the chances of that being a reality are becoming smaller every day. Here’s a challenge to administrators to start figuring out what really matters and putting their money to work.

I’m always on the lookout for healthcare technology that has an interesting backstory. Habit Camera is a wireless camera that is designed to allow users to inspect areas of the skin that they might not otherwise be able to see. Daily skin inspection is important for many patients, including those with diabetes, limited sensation, or active wounds. The camera connects to a smartphone app to enable live viewing of high definition images as well as video and image capture for sharing with clinicians or caregivers. The company is led by a US Marine Corps veteran who was paralyzed while serving in Afghanistan. He and his wife run the company, which employs veterans and their family members to assemble the devices.

I particularly liked the answer to one of their FAQ questions, which asks, “Is my clinician going to look at pictures if I send them?” The response: “It depends! Your clinician may be interested in doing this, but some may not. If you can’t share an image or video with your clinicians, then it can be really hard to explain what you see over the phone. Until a clinician can see it with their own eyes, they probably will ask you to make an appointment and come into clinic. This can be a bit of a hassle, especially if you have to take off of work and drive far, so we hope that pictures and video can help reduce unnecessary visits. A picture is worth a thousand words.” I don’t care how much a company pays for its marketing experts; you really can’t portray the patient experience any better than that.

What technology vendors have the best messaging? Is there a particular one that you feel just tells it like it is? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/22/24

Many organizations are focusing their healthcare IT and clinical investments on Social Determinants of Health. This could include configuring patient portals to gather relevant information, enhancing EHR workflows to allow clinicians to view and act on patient-specific factors, and looking at the data from a population-based perspective.

For some organizations, the return on investment that is needed to gather the data is clear. For example, a community health center might be the recipient of a grant that provides funding for gathering the data and taking steps to improve outcomes based on that data. For others, the return on investment might be less obvious.

A recent article in JAMA Health Forum reviews the need for benefit-cost analysis as organizations look at making investments in care related to social determinants of health. The authors note that there are many examples of the links between social factors and health outcomes in the literature and that organizations have responded by focusing on those with the strongest links. However, adding benefit-cost analysis to the review process would allow comparison of different interventions to determine which would be likely generate the most benefit.

This approach would allow greater understanding of the importance of spending your healthcare dollars in the right place, with the authors noting, “An effective intervention to address a minor risk factor may generate much larger net benefits than a less effective intervention targeted at a major risk factor.” We all have examples of health systems and other care delivery organizations that have fallen under the spell of shiny objects and then struggle to get return on their investments.

Sometimes those projects are more exciting than others and might bring more publicity, but there may be less clarity around how they will actually improve health or reduce morbidity and mortality. On the other hand, certain interventions can have tremendous outcomes, but aren’t seen as exciting. For example, how many people think that nutrition education is sexy? Talking about balanced meals or food deserts or the benefits of community gardens certainly isn’t as exciting as seeing your orthopedic surgery practice mentioned on the wall of the local baseball stadium, that’s for sure. But which one is likely to drive improved health outcomes for the long haul?

The authors discuss this in the context of organizations that focus their attention on return on investment goals that have short time horizons. This leads to failure of visualization of potential long-term gains. We see this with payers denying expensive therapies that may lead to savings many years down the road, when the patient might be on Medicare and offer no calculable benefit for the payer. The authors summarize this: “In contrast, benefit-cost analysis is generally conducted from a societal perspective and considers benefits and costs across all sectors and populations and over extended time horizons with appropriate discounting of future benefits and costs.”

This got me thinking about how we sometimes don’t give full consideration to the longer-term impacts of the healthcare IT projects that we are doing. Leaders are often under the microscope to show positive financial outcomes almost immediately after a project goes live. They are expected to demonstrate shocking reductions in costs or dramatic increases in revenue, and projects that fail to deliver such splashy results may be at risk for being canceled, or even worse, placed on pause and left in limbo. With complex processes, however, it might not be appropriate to push for a dramatic change.

When there’s a significant change happening, I’m a big fan of using pilots to make sure that process “improvements” aren’t going to create unintended problems. However, the pressure to constantly deliver results may make technology leaders less likely to consider piloting or a slower rollout of change.

Alternatively, an intervention might deliver significant results, but then teams move on to other projects, preventing forward movement in the cycle of continuous improvement. In other situations, the maintenance phase is skipped and processes slowly drift back to inefficiency, ultimately eliminating long-term gains.

If organizations focused more on longer-term analysis and ensuring sustained change, would it make a difference in the projects they select? Unfortunately for many, being able to target long-term goals is a luxury given the fact that a results-oriented culture actually means one of immediate results rather than truly designing models that will be sustainable for the long haul. We see this phenomenon often with the rip-and-replace approach to solutions, when we know in our hearts that the organization never spent the time, effort, or money that was needed to make the first solution successful.

I saw another example of this shortsightedness in my community earlier this month. A local hospital that was looking to reduce headcount decided to shutter its medical weight management clinic. Given the obesity epidemic in the US, this doesn’t seem to make much sense at first glance. However, in our community bariatric surgery is seen as more exciting than medical weight management, primarily because it generates higher operating room utilization and therefore greater hospital revenues.

Unfortunately, patients now have fewer choices and might be pushed towards interventions that aren’t right for them. It would be interesting to look at the modeling of both service lines looking at a three-year, five-year, and 10-year horizon to examine not only which one is more favorable from a revenue standpoint, but which one is likely to deliver the best clinical outcomes. I wonder if they even looked that far.

Other organizational cuts occurred in pediatric and women’s health service lines. That looks like it will create a significant gap in services for local families. It will be interesting to see if other hospitals in the area are able to increase access in the service lines that were cut or whether families will just be left with longer waits for services that were already scarce at times. Even without a detailed analysis, I can’t imagine that making it more difficult for women and children to receive care is in the best interests of the community in the long term.

The organization is classed as a non-profit, so we will see the community benefit statements they put out over the next couple of years, detailing their efforts to serve the underserved. I suspect they hope that no one is looking, and given the way that other hospitals in the area behave, I doubt anyone is.

Is your organization looking at the longer term or bigger pictures, or is the focus on delivering results in the next two quarters? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/18/24

The Lown Institute has released its 2023 Shkreli Awards, highlighting “the worst in healthcare profiteering and dysfunction.” The selection panel includes clinicians, journalists, patient advocates, and health policy experts.

In case anyone doesn’t recognize the name, the award is named after so-called “pharma bro” Martin Shkreli, who earned notoriety and scorn by purchasing the rights to manufacture a well-known antiparasitic medication and jacking up its price by 5,000%. Full descriptions along with the judges’ comments can be found on the Lown Institute website, but the winners are below. Given the nature of the activities, I can only imagine what was going on in those that didn’t make the cut.

1. Columbia University interferes with patients filing sexual assault complaints against one of its physicians.
2. Stunning CEO salaries at nonprofit hospitals (CommonSpirit Health is specifically called out, but they’re far from alone).
3. Pharmaceutical companies claim that price negotiations for Medicare drugs are unconstitutional.
4. Hospitals partner with private equity-backed companies to offer high-interest medical credit cards with rates up to 26%.
5. Vascular specialist allowed to continue to practice despite discipline in numerous states and failing to be able to write the essay needed to pass an ethics course.
6. GlaxoSmithKline hides evidence that its heartburn medication Zantac may cause cancer.
7. Indiana cardiologist accused of implanting unnecessary cardiac stents, including 80+ stents in a single patient.
8. Hospitals “dump” homeless patients who are unable to fully care for themselves.
9. Device manufacturer Medtronic incentivizes surgeons to implant devices in patients that may not benefit, all in the name of education.
10. Lehigh Valley Health – Cedar Crest Hospital threatens to medically deport a comatose patient receiving expensive care

From BlackBerry Forever, iOS Never: “Re: BlackBerry. I appreciated the picture of your old-school device. I also had the Torch and it was the best of both worlds – touch screen with a keyboard. Did you see the buzz about add-on keyboards at the Consumer Electronics Show?” Clicks Technology is offering the keyboard, which comes in either “Bumblebee yellow” or “London Sky,” which is decidedly grey. The accessory connects via the standard charging port and will start shipping on February 1. I haven’t met anyone who is remotely interested in buying one, so if you like the idea, feel free to weigh in. Personally, I loved the tactile BlackBerry keyboards and could type on them way faster than a touchscreen model. The roller ball mouse thing, not so much. There have to be others out there like me, so we’ll see if this results in an appreciable number of sales.

Another reader clued me in that BlackBerry is exhibiting at CES 2024, accompanied by a Monty Python-esque “I’m not dead yet” meme. Indeed, the company even has a website highlighting its participation, and it looks like it’s mostly tied to automotive technology. I have to admit I haven’t followed the company since my former employer killed off its BlackBerry server back in the day.

Other interesting items coming out of CES include the Withings BeamO multiscope device. Although it reminds me a bit of an early generation Wii remote, it’s designed to quickly produce vital signs data for use during non-office healthcare encounters. It can deliver temperature, oxygen saturation, heart rate, and electrocardiogram data that can be sent to healthcare providers using an app. Withings has an application in for FDA approval of certain features, such as detection of atrial fibrillation. The device is expected to hit the shelves in July and will retail for $250.

Speaking of cool devices, I see all kinds of wearables out on the trail and at the local YMCA. A recent Stat opinion piece calls for a “data diet” to help curb the growing obsession with data. I’m sure there’s a boom in sales during the early part of the year as people seek digital help tracking their progress towards various New Year’s resolutions and annual goals. The article confirms this, noting that fitness app downloads are more than a third higher in January than at other times. It also notes that the fitness tracking industry rakes in $45 billion annually and that there are 400 personalized nutrition companies out there. The article questions the role of fitness trackers in trying to curb the obesity epidemic and the increase in chronic diseases. It suggests that we’re tracking the wrong data, and that in order to harness technologies like AI to better use our data, we need higher-quality data in the first place. The author shares vignettes of several patients gaming their fitness trackers, one sitting in a meeting but waving his arm trying to clear an alert telling him to move. It will be interesting to see how the fitness tracking movement evolves and whether we start getting better data or just more mediocre data.

I’m always looking for interesting new companies and was excited to run across CareLuminate. Their premise is straightforward: if one understands how nurses feel about the care being delivered in their workplaces, one can better understand clinical quality and help reduce healthcare costs. CareLuminate can help those who are paying for healthcare (such as employers) steer their workers towards facilities with higher quality. The company’s founders have background in clinical outcomes and industry research, coming from the nursing world and from KLAS Research and specifically its Arch Collaborative. By interviewing nurses directly, the company generates independent and current data that they note hasn’t been “gamed” by health systems. Some of the measures captured in interviews and through available data include nurse perceptions of care safety, patient satisfaction, infection rates, and readmission rates. I’ll be watching them closely to see how they gain traction in the industry. They’re worth checking out.

Speaking of checking companies out, I was happy to book my first celebrity Booth Crawl for HIMSS24. Since I’ll be the only member of the HIStalk team in attendance at the show, I feel particularly responsible to capture the glitz, glamour, and exhaustion of the event. It’s my first time to schedule a booth crawl on the opening day of the exhibit hall when people are fresh and should be eager to chat.

What are your hopes for the HIMSS24 conference? Is there anything you’d recommend as can’t miss opportunities? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/15/24

I’ve been practicing in the telehealth space since before the pandemic. We deal with a lot of situations that other physicians don’t want to deal with – patients calling for antibiotics, patients with questions about lab results they received through their patient portal after most physician offices are closed, and requests for refills on chronic medications for patients who haven’t been seen by their physicians in a long time period.

Most of the primary care physicians I talk to are grateful that we are out there as a buffer, allowing their patients to receive care without having to be on call 24×7 themselves. However, this week I discovered that apparently a subset of physicians thinks that those of us who practice telehealth exclusively are less than “real” physicians. A newly formed physician education program refused to let me join because I didn’t have an ID badge that has a hospital-style “PHYSICIAN” designation on it. In fact, I don’t have an ID badge at all, which was also an issue.

I submitted a copy of a different photo ID along with a copy of my state medical license, thinking that would suffice. Instead, they asked me for my National Provider Identifier number, which was particularly silly since that can be found via a web search. Once I provided that, they wanted copies of my medical school diploma and residency completion certificate. I’m not sure why a state license wasn’t sufficient, and I hope they had fun trying to read the Latin on my diploma. I had to go digging for those documents since I’m not one of those folks that has them hanging on my office wall. Next time I’ll just use the magic of computers to make a simulated ID badge and be on my way.

The entire experience was annoying, though, and impacts not only telehealth physicians, but any physician who isn’t working in a clinical setting. One doesn’t stop being a physician because they’re not seeing patients. I am definitely going to address this once I am established in the program.

Speaking of annoyances, I had to deal with some annoyances from CMS this week. I received an email from the CMS Identity Management System telling me that my account was going to be deleted due to inactivity. I attempted to log on but couldn’t, and the password recovery system presented a security question that I swear I’ve never seen in my life, because I would have said it was ridiculous if I had. It asked me to provide a telephone number for a relative that was not my own number. I tried to guess when it was that I had set up the account and tried some numbers, which of course were not correct, and the account was locked. The system unhelpfully told me that I needed to call the help desk associated with the application I was trying to access, which was also silly because I have access to multiple applications through the CMS Enterprise Portal. Each of them has their own help desk.

Of course, I was trying to do this at 10 p.m., so I waited until the next business day when I had a gap in my schedule and started calling help desks. The first one was closed because their office hours are only until 4 p.m., and the second one allowed me to hold for 11 minutes and then disconnected me. I called right back and went directly to an agent, so I can only assume their phone system was having a momentary malfunction. The agent clearly had no idea how to help me and was reading from a help desk manual and couldn’t even pronounce some of the application names. He provided another phone number to call. That agent asked me for a bunch of personal data. I finally interrupted and asked whether she’d like to know why I was calling. She seemed surprised that I would want to tell her that. I told her my story, and she said, “Oh, so you just need a password reset?” Bingo! She switched gears and did the reset, giving me a 15-character complex password that I had to write down.

Fortunately, she stayed on the line while I did the reset. The process requires two-factor authentication. I chuckled when I got to the screen that recommended Google Authenticator because it’s supported for “iPhone, Android Phone, and Blackberry.” I wonder how many Blackberry devices they get accessing their system these days. Finally, I was able to set a new password and was on my way. The agent disconnected and I went to set a new security question, since I still had no idea what the answer was for the one with a relative’s phone number.

The list of security questions had some interesting choices. Not only were they strange, but they’re also things that change over time for many people, which doesn’t make them a good security question. The highlight reel:

• What did you earn your first medal or award for? Hmmm, was it swim team or horseback riding in elementary school? I have no idea.
• What is your favorite movie quote? I’m at a point in my life where I can barely remember the things I’m supposed to remember, let alone the specific grammar and syntax of a movie quote.
• What music album or song did you first purchase? I seriously have no clue since it was more than 40 years ago.
• What was the first computer game you played? Truly have no idea here either, although I was tempted to put Oregon Trail due to the lack of good questions.
• What was your grandmother’s favorite dessert? I can’t wait until I’m old enough to have a grandchild call and ask me this.
• Where were you on New Year’s Eve in the year 2000? I think the better question for healthcare workers was where we were on New Year’s Eve in 1999, since many of us were in Y2K hell.
• Who is your favorite book/movie character? I read more than 50 books a year, so I wasn’t touching this one.
• Who is your favorite speaker/orator? I can’t remember the last time I saw the word “orator” and was tempted to put Abraham Lincoln, but I knew I wouldn’t remember that down the line either.
• What is your favorite security question?

I couldn’t believe it when I got to that last one. Again, how would I ever remember the syntax if I selected that one? Maybe “what is the answer to your favorite security question” would have been a better option, since it wouldn’t involve more than a word or two. Still, the entire experience was bizarre and fortunately I was quick enough to grab a screenshot of the list of crazy questions. I sent it to one of my favorite online security experts who replied with four different kinds of eye-roll emojis and GIFs. You can’t make this up, folks. Thanks to CMS for keeping it real.

What’s the weirdest security question you’ve seen? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/11/24

Masks are back on at my local hospitals. Our area is seeing a surge of COVID, influenza, and RSV patients. We’re seeing full intensive care units. Nursing exhaustion is approaching pandemic levels.

Across the US, hospitals are experiencing staffing challenges, which often cause beds to be unavailable because they aren’t staffed. This rolls downhill in the hospital, landing in the emergency department that has to board the patients until beds are available. In turn, this can back up ambulances, which leads to delays in 911 calls. For my friends working in EMS, this is starting to feel a lot like 2020, and in my community, the COVID-related hit to EMS staffing is still present.

If you’re on the healthcare IT side and the clinical staffers that you are interacting with seem frazzled and distracted, it’s because they are. One of my ICU nurse colleagues commented, “It’s like people forgot what we went through and just don’t care about healthcare workers any more.” Let’s remember to wash our hands, stay home when you’re sick (or wear a well-fitting mask if you can’t stay home), and look after each other. We’re all in this together.

I’ve started working on a project that involves an area of clinical informatics that I haven’t worked on in some time. To get up to speed with the vendor landscape, I’ve been visiting lots of websites to view white papers and customer case stories. Maybe my brain is just used to operating in an older way of working, but I find myself increasingly annoyed when companies have decided that the only way they’re going to share information on their websites is through videos. Some of us absorb more through reading actual words. Of course, others are more visual or auditory learners and might do better with that kind of content.

For me, it’s often a time issue. I can read much faster than most video presenters speak, which means that when there is only video content available, I tend to perceive the sites as not being a good use of my time. It left me wondering what happened to the good old written word and whether it’s just me or whether times have changed and I need to get used to my work taking 50% longer than planned.

A primary care colleague reached out to me today, venting that her organization has yet to configure the EHR to allow physicians to submit the G2211 billing code that went into effect on January 1. That’s an add-on code that allows physicians to submit charges for the time they spend building longitudinal relationships with patients and addressing patients’ issues over the long term. CMS describes the code as billable for “visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed healthcare services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition.”

The nature of the relationship between the patient and the physician is the factor that determines whether the code should be used. It’s worth around $16 when billed for Medicare patients, so it’s not designed to drive significant revenue, but rather to offset some of the valuable whole-person care that is provided by primary care physicians. Medicare’s documentation about the change says that the typical primary care physician who has Medicare beneficiaries in their patient panel will coordinate care with 229 physicians in 117 disparate practices. If it hasn’t yet been added to your EHR workflows, your clinicians are missing out.

The US continues to have supply and demand issues with stockpiles of personal protective equipment (PPE). A recent AP report explored the fact that states that had scarcity of supplies during the high points of the COVID pandemic are now dumping PPE at an alarming rate. Ohio has auctioned off nearly 400,000 protective gowns and has thrown away 7 million gowns along with countless masks, gloves, and other supplies. States are having to determine their go-forward strategies for supply stockpiles and preparation for potential disasters.

The amount of materials that is being shredded, recycled, or destroyed is simply staggering. Georges Benjamin, MD, executive director of the American Public Health Association, mentioned that our “bust-and-boom public health system” creates waste as well as lack of preparedness. Many states didn’t respond to the AP’s request for information, so it’s hard to know exactly how large the problem might be.

As a CMIO, I’ve worked on a number of projects around health literacy. I would bet that most people in healthcare IT don’t understand the level of understanding of the average patient. For written communications, we need to focus our writing at roughly the fifth-grade level to ensure that patients will be able to understand any instructions we provide. Organizations have also made significant efforts to provide documents for as many patient-preferred languages as possible.

I was excited to see this article that looked as the association among hospitalizations, emergency department visits, and health literacy interventions. Researchers concluded that patients who read patient education materials and summarize their understanding back to the care team are 32% less likely to be hospitalized and 14% less likely to visit the emergency department. Additionally, there was an association with overall declining health costs in patients who received the intervention. The study was performed using subjects that were part of an employee health plan, so it’s not clear if results are generalizable to all patients. Thanks to Healthwise for including this study in their blog, otherwise I would likely have missed it.

The Consumer Electronics Show is upon us, and Garmin is finally taking a giant leap forward in the realm of wearables by introducing a women’s heart rate monitor that clips onto a sports bra and doesn’t require a separate strap. For anyone who has had to deal with a heart rate monitor strap interfering with your bra, this is a welcome addition. The HRM-Fit strap retails for $150.

What are the best and worst things you’ve seen coming out of the Consumer Electronics Show? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/8/24

This weekend was all about playing cleanup. The new year brings a lot of things for the physician to-do list, one of which is starting my quarterly questions that are needed for me to maintain my specialty board certification.

The Maintenance of Certification (MOC) process is almost universally hated by physicians, to the point where some of them will take a high-stakes exam every 10 years rather than participate in the program. I was part of my specialty’s pilot program for MOC and much prefer the quarterly questions to an all-day exam, especially since I haven’t practiced full-spectrum primary care in quite a while. Unfortunately, my specialty still thinks we should be able to manage all the conditions we used to manage during our residency training programs, so I have no choice but to play along.

The quarterly MOC questions are open book, so that’s something, and usually if I don’t know the answer, I can find it using a combination of UpToDate, the online version of my specialty’s flagship journal, and the website of the US Preventive Services Task Force.

Arriving in the New Year also means paying an annual fee to the board, which I had forgotten about. Many of my colleagues who are in purely informatics roles have to pay these expenses out of pocket, which is burdensome. The boards assume that physicians are either self-employed and can take their board fees as a business expense, or that they are employed and receive reimbursement from their practice, hospital, or health system.

There’s a lot of chatter in the physician world right now about the value of MOC, with oncologists and cardiologists being among the most recent to launch challenges. Usually, physicians have to maintain particular board certifications approved by the American Board of Medical Specialties in order to be granted hospital privileges and to join insurance plans. However, there’s a movement towards supporting an alternate organization, the National Board of Physicians and Surgeons. Although it’s gaining traction, NBPAS isn’t accepted in my area, so I haven’t pursued it.

Some clinical informaticists see MOC as an opportunity where AI tools might help physicians trim the time-consuming process. Rather than having to search three or four websites, one could query a generative AI system to provide the information that is needed to answer the questions. Physicians could also perhaps ask a virtual assistant to search the rules and regulations for their specialty and create calendar appointments for all the deadlines that are required to maintain certification. For those of us who have multiple board certifications, that might help a lot, especially since each board has its own timeline and requirements that differ depending on where you are in your certification cycle. The questions I did this weekend didn’t have any disclaimer that you couldn’t count AI tools as some of the online resources used in answering the questions, but I’ll have to keep my eye out for such prohibitions in the future.

Also on my list for the weekend was setting up a new laptop that was sent by a client I recently started working with. This is the first time I’ve had Microsoft balk at my use of a password that doesn’t contain words. I’m not sure how someone would guess a 10-character password that contains two numbers, three lowercase letters, three uppercase letters, and two symbols or why Microsoft would have seen my particular combination of characters “too many times.” I certainly don’t use the same password on all of my accounts, so this just seemed like a weird error. I had to try three versions of what I wanted to use before it finally gave up and let me set my password.

I also caught up on some reading, which put me to sleep the first time I tried to get through it. ONC is scheduled to publish its “Health Data, Technology, and Interoperability: Certification Program Updates, Algorithm Transparency, and Information Sharing” final rule this week. The rule implements pieces of the 21st Century Cures Act through the creation of new requirements for health IT developers under the Health IT Certification Program. The rule includes provisions for developers to report metrics that give insight into how organizations are using certified IT products, updated criteria for decision support interventions, and updates to patient demographics and electronic case reporting. It also requires developers to move to the United States Core Data for Interoperability (USCDI) Version 3 standard no later than January 1, 2026. This will help organizations better share data that will promote health equity, reduce healthcare disparities, and improve the interoperability that is needed for public health efforts.

Of course, no ONC final rule would be complete without a mention of information blocking, and I can assure you that’s in there, at least in the current unpublished version that’s available on the Federal Register website. Its 804 pages of double-spaced delight isn’t much of a beach read, but it contains other hot topics, including a C-CDA Companion Guide update, a Synchronized Clocks Standard, information on a patient’s Right to Request a Restriction on Use or Disclosure, and more. The rule will become effective 30 days after it is published in the Federal Register.

The final cleanup activity of the weekend was catching up on a New Year’s Resolution on which I had already fallen behind. This year, I’m aiming to read two scholarly articles each week that cover an area of medicine or clinical informatics that isn’t part of my usual practice. One of my articles this week was “Effect of an Intensive Food-as-Medicine Program on Health and Health Care Use.” The article, which was published in JAMA Internal Medicine, covers a randomized clinical trial designed to see if a program for patients with diabetes that provides healthy groceries, dietician consultations, education, and health coaching would improve blood sugar control in compared to the usual care they would otherwise receive. The study had over 400 participants. Although the authors didn’t find an improvement in blood sugar control, they did find improved patient engagement in preventive health care interventions. They recommend that additional studies be performed to find optimal “food  as medicine” interventions to improve patient health.

Since this resolution was designed to stimulate my curiosity, I wandered around the internet a bit to learn more about food-based medical interventions. I was intrigued by The Goldring Center for Culinary Medicine at Tulane University. The Center has been around for more than a decade and was designed as a teaching kitchen to educate future physicians “to understand and apply nutrition principles in a practical way” and to better work with patients on diet and lifestyle modifications. The Center also provides cooking classes for the community. I was glad to see that they offer continuing education classes for practicing physicians since many of my medical classmates subsisted for anywhere from seven to 10 years on a diet of ramen, sandwiches, drug rep-provided lunches, leftover patient meals, and a stash of graham crackers and apple juice that was liberated from nursing unit stockrooms.

New Orleans is a great city. Anyone up for a HIStalk continuing education field trip? Leave a comment or email me.

Email Dr. Jayne.