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Curbside Consult with Dr. Jayne 6/27/22

June 27, 2022 Dr. Jayne 2 Comments


It’s that time of year, when I typically take a week off to volunteer at one of the nation’s premier summer camps. It’s always an adventure. I’m hoping that despite COVID surges in the area that we have what we previously would have considered a “normal” summer camp experience. Of course, there will be masks indoors when we are in close quarters, but there will be plenty of time to run around in the great outdoors and for the campers to have fun with their friends.

It’s been a scorcher across large parts of the US over the last couple of weeks. I’m hoping for at least a little break so that I don’t have to spend the week treating heat exhaustion, headaches, and dehydration. I’d much rather be teaching fire building, knots, lashings, and wilderness survival skills.

Although the camp offers most of the traditional activities like fishing, swimming, canoeing, kayaking, archery, and various other shooting sports, it also offers some great STEM (science, technology, engineering, and math) options. Welding is available, as are programs in movie making, game design, electronics, and geocaching. There is something for everyone. Usually the best part of the day is dinner, where an adult sits with each table of campers and gets to ask questions about their day and what they liked best.

I always get some interesting questions about what I do in my real life. The staff knows I’m a physician, but they also know I do something with computers on the side. Almost every adult has used a patient portal by this point, so I use that as a way of explaining the kind of work I do and how we help physicians make better use of information and that we help patients have a better experience. There are usually a lot of questions about what kinds of things we can do as telehealth physicians.

Although this camp is old school as far as facilities, I’ve worked with camps in the past that have remote examination setups that really deliver as far as telehealth infrastructure. Given the fact that this particular property is about 30 minutes from a very capable rural hospital, I’m not surprised that they opt to send campers into town if they need more than what we can offer on site.

Since I’m in the middle of a major project, I’ve got my wi-fi hotspot at the ready in case I need to join any calls (courtesy of my public library, which lets you check them out for a couple of weeks at a time). However, for the first time in a long time, I’m working with an extremely capable team, and I would be surprised if I hear from them. There might be something that they need that requires a physician credential to accomplish, but it’s nice to know that they’ve got my back and I can actually take time off without worrying that I’ll walk into a disaster when I return.

I’m sure that some of the people on the team think I’m a little loopy to do this kind of thing for fun, but at least one of my co-workers has made me promise to take pictures of a couple of things I’ve talked about, so I hope I can deliver. I’m just hoping this year is better than the experience I had a couple of years ago, when I ended up with a squirrel leaping from a tree to my head when I least expected it. Honestly, not having a squirrel in your hair seems a low bar when you think about it.

As a consultant, some of my major areas of work included change leadership and teambuilding. I have to say, although I have had plenty of formal training in those disciplines, some of the best training I have had has been in outdoor programs like this one. A very wise man once said, “A week of camp life is worth six months of theoretical teaching in the meeting room.” Having done this for many years, I have to agree. It’s extremely gratifying to see young people learn new skills and discover that they are more capable than they ever thought. This generation of campers has had a couple of summers of COVID-related modifications, and many of these experiences will be new to them. They will be challenged to try things outside of their comfort zones and will be allowed to fail in a safe and supportive environment. They will also probably get sunburned and get lots of mosquito bites because they’re pre-teens and teens and they won’t heed our warnings, but those too will be growth experiences.

For some of the oldest campers who come back year after year, I’ve worked with them since 5th grade and they’re now high school seniors. They’ve had phenomenal growth emotionally and mentally (and also physically, since most of the eldest tower above me). It’s been a pleasure seeing them take leadership roles and I enjoy seeing how the youngest campers look up to them and start to envision what they might look like in a few years. Many of last year’s graduating class headed into tech fields, and one of my older campers from many years ago is now applying to medical school. I hope that as they head to college and into the real world that they take the problem-solving skills that they learned at summer camp with them and figure out how to apply them, not only to the challenges of today, but to what we might run into tomorrow.

If there’s anything we’ve learned since 2020, it’s that life can always throw you a curve ball and we have to figure out how to rise to the occasion. Although I’m looking forward to a week relatively off the grid, I know I’ll come back energized and ready to get back to work (even though my body will be tired). Being around young people with so much potential and so much eagerness to learn always delivers a spark.

Who’s ready for some basketry, rock climbing, and whittling? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/23/22

June 23, 2022 Dr. Jayne 2 Comments

I wrote recently about hospital shootings and the other unsafe situations that healthcare workers are encountering with greater frequency. We can add another hazard to the list. Earlier in the week, batteries exploded in a Milwaukee hospital parking garage, injuring two people. The incident, which occurred at Aurora St. Luke’s Medical Center, is attributed to an acid spill in a container that was holding recycled batteries. Unanticipated combustion is a thing, and it just goes to show that regardless of how well you think you’ve planned or prepared, there’s always something that has the potential to surprise you.

I’ve read a lot of articles about how physicians should manage their social media profiles, but I haven’t seen too much on how they should manage their non-work-related TV appearances. Amar Shere MD, a cardiology fellow at Saint Louis University School of Medicine, was selected to complete on the NBC show “Dancing With Myself.” Shere appeared in his white coat, but was cut after the fourth round. He has used TikTok to share his dance skills along with patient education and eating tips. He’s also a fitness instructor with an interested in promoting heart health in the community. Kudos to Dr. Shere for putting himself out there, and I hope his patients enjoy his care as much as it sounds like he enjoys delivering it.

Many physicians are watching carefully to see what happens to telehealth provider Cerebral as it has come under fire for deceptive business practices and poor patient care. I’ve seen a number of patients in the brick-and-mortar urgent care world who were trying to get refills on their prescriptions after being denied ongoing treatment due to billing disputes. Cerebral is accused of pushing patients to take controlled substances in an effort to increase patient loyalty. The company used flexibility in telehealth rules to prescribe highly regulated medications without any in-person care. Pharmacies were seeing so many prescriptions they stopped filling orders from the company and flagged its business practices for scrutiny.

Cerebral is no longer starting new courses of therapy with controlled substances and patients who are already under treatment have to transition to other drugs or different providers by mid- October. Given the severe shortage of physicians willing to take over these prescriptions, my clinical employers included, it’s going to be rough for patients who are trying to figure out how to continue treatment. The company has been removed from insurance networks and patients are left holding the bag while they go on waitlists for psychiatrists and call from urgent care to urgent care looking for anyone willing to give a 30-day prescription.

Speaking of brick-and-mortar urgent care practices, I’ve been receiving harassing emails and phone calls from a particular insurance company as they try to recredential me to deliver care at an organization where I haven’t practiced for more than a year. Apparently, their calls and emails to my former employers weren’t managed in a timely fashion (not surprising given the overall turnover in the organization), so they decided to contact me personally. They tracked down personal email addresses that I never would have used on a credentialing application and also used several emails associated with the LLC that I use for my consulting business (but never for clinical care). I finally convinced someone to understand that I don’t want to be recredentialed so they can stop trying, but it took several phone calls and quite a bit of frustration. Supposedly they’ve been trying to reach me for months to see if I wanted to remain on the plan. You’d think they’d be able to look at their own claims data and see that I haven’t submitted anything in a year, but that would require coordination within the organization. I’m less than thrilled that they spent patients’ premium dollars exploring my personal websites, but I guess they consider it trying to be engaged with their providers.

Monkeypox has arrived in my state and medical misinformation is running rampant. I’ve seen comments on local news articles suggesting that transmission is limited to certain sexual behaviors, complete with links to bogus articles blaming this “scourge” on immorality. News flash from infectious disease specialists – monkeypox is spread through contact with body fluids, monkeypox sores, contaminated clothing or bedding items, and through respiratory droplets. It’s been a long two and a half years dealing with patients who have decided that social media is more believable than their own physicians, and I sure wish we could mandate public health and hygiene classes in schools. The World Health Organization plans to rename the disease to reduce stigma and racism, but unfortunately people’s attitudes aren’t going to be easy to adjust.

I just finished reading the novel “Hamnet” by Maggie O’Farrell. It’s a fictionalized account of the life of William Shakespeare’s son, who died at age 11 at 1596. The book’s subtitle clearly says it’s “A Novel of the Plague” and there’s an underlying story about the child’s mother being a healer and her encounters with the medical establishment of the times as the bubonic plague reaches her family. My book club has a way of selecting less-than-cheery readings at times, but I enjoyed the book and found it to be a relatively quick read. Within a day or two of finishing it, I came across an article that summarizes findings about the origin of the Black Death, which ravaged Europe for hundreds of years. Researchers propose that the Black Death began in the late 1330s in North Kyrgyzstan, based on analysis of DNA extracted from skeletons found in the region.

I wonder what historians in the future will say about our current pandemic when they’re looking back at us. They’ll probably think we were similar to what modern medicine thinks about medieval “plague doctors” who wore bird-beaked masks stuffed with herbs as a way to ward off disease. Hopefully, our next book club selection is a little lighter read, but I’m always looking for summer reading suggestions whether I have the ability to make them truly a beach read or not.

What’s on your summer reading list? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/20/22

June 20, 2022 Dr. Jayne 1 Comment

I get my news from HIStalk just like everyone else, so I was very interested to read about US hospitals sending patient information to Facebook. Involved websites include a third of those listed as Newsweek’s “Top 100 US Hospitals.” Using the Meta Pixel tracker, Facebook is receiving the IP address of patients who scheduled appointments online, as well as the physician’s name and the search-term used to locate them. Investigative reporters also found that multiple high-profile hospitals have installed the tracker on their respective patient portals.

Of course, the major concern is that these organizations may have violated HIPAA by sharing patient health information with a third party without obtaining appropriate consent. During the investigation, one of the scenarios used was as follows. On the website of University Hospitals Cleveland Medical Center, for example, clicking the “Schedule Online” button on a doctor’s page prompted the Meta Pixel to send Facebook the text of the button, the doctor’s name, and the search term used to find her: “pregnancy termination.”

The data being sent from within hospital patient portals is even more concerning. The Pixel Hunt project is a crowd-sourced effort to locate places where the Meta Pixel tracker is installed. Five real patient participants in the project had sensitive data sent, including names of medications, allergic reactions, and details about pending medical visits. The hospitals in question denied having contracts in place that would have permitted the release of this data, and investigators found no evidence that the hospitals were appropriately obtaining patient consent. Multiple organizations have since removed the tracker from their websites and patient portals, but the fact that it was there in the first place is highly concerning.

It’s unclear what Facebook has been doing with the data, and whether it’s using it for marketing or other for-profit purposes. As a patient, I find it horrifying that a health system would willingly put this kind of tracker on a patient-facing site and would want to understand why they would do that. The short answer is that those who do install it have access to analytics about ads they may have placed on Facebook and Instagram as well as access to additional marketing tools. In my opinion, neither of those reasons is enough to justify why my personal information should be sent outside of the healthcare organization. Even worse, the article notes that “if a patient is logged into Facebook when they visit a hospital’s website where a Meta Pixel is installed, some browsers will attach third-party cookies – another tracking mechanism – that allow Meta to link pixel data to specific Facebook accounts.”

As a physician who was previously employed by a health system, we know how much health systems profit from the labors of the clinicians that work under their banner. Data from 2016, which is the most recent year I could find, shows that primary care physicians generate $1.4 million in revenue each year. Some specialists, such as cardiologists and orthopedic surgeons, can generate $2.4 to $2.7 million annually. We’ve come to terms with our participation in that equation, but I doubt that physicians think favorably about health systems profiting from confidential patient information that we have worked hard to protect.

Putting on my clinical informaticist hat, the IP address is one of 18 HIPAA Identifiers that are considered personally identifiable information. I remember memorizing these for my last clinical informatics board exam because there were several questions on the topic on practice tests. When you take a piece of personally identifiable information and combine it with clinical data, it is considered Protected Health Information. When investigators were on the Scripps Memorial Hospital physician website, clicking the “Finish Booking” button sent Facebook the physician’s name and specialty as well as the patient’s full name, email address, telephone number, city, and ZIP code. The hospital removed the Meta Pixel from the final stages of the appointment scheduling flow after they were made aware of the investigators’ findings. The article contains a host of other examples of other private information elements that were shared, including patient comments about their medications and information on sexual orientation.

For every patient who has been told they can’t have a copy of their own records, or who has difficult sending records to a consulting physician due to an organization’s misapplication of HIPAA, this is particularly offensive. Glenn Cohen, faculty director of Harvard Law School’s Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics notes, “Almost any patient would be shocked to find out that Facebook is being provided an easy way to associate their prescriptions with their name… Even if perhaps there’s something in the legal architecture that permits this to be lawful, it’s totally outside the expectations of what patients think the health privacy laws are doing for them.” I’ve been privy to dozens of complex legal agreements over the years as well as numerous health systems’ Terms of Use documents for their websites and Conditions of Care documents that they make patients sign. I could see someone nesting language in those documents that might permit a number of things that if spelled out would make patients cringe.

Of course, that assumes that the health system knows what they’re doing and deliberately includes that provision. Maybe we need a law that requires language around data sharing to be in 14-point font at a sixth-grade reading level so that patients can understand, or that requires organizations to present this information in line-item veto format for patients to better identify their wishes. I don’t think the majority of patients would answer “Do you want us to share your medical information with Facebook?” in the affirmative, but then again, you never know. However, from the health system responses cited in the article, it seems that perhaps some of them didn’t fully understand the ramifications of installing the Meta Pixel tracker or what it was actually doing. Others indicated that they have confidence in Facebook’s ability to filter out patient information, and I think the majority of us would suggest that confidence is misplaced.

Since healthcare is going to an increasingly online, patient self-service model, this issue isn’t going to go away. However, I don’t see legislators or regulators dealing with it proactively since they can’t deal with other high-profile issues that dramatically impact our population. I’d love to see a flurry of complaints filed for HIPAA violations and watch Facebook burn money trying to defend itself. Needless to say, it will be a while before we see how this plays out.

If there’s anything that shows how slow the wheels of justice grind, it’s the marking of the Juneteenth holiday, which commemorates the day in 1865 when Major General Gordon Granger delivered the Emancipation Proclamation to enslaved people in Texas – more than two years after it was issued. This is the first year I’m working for an organization that observes the day and it’s a good opportunity to reflect on ways that we can do better as we work to care for all people.

What do you think about the Meta Pixel tracker and its use by healthcare organizations? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/16/22

June 16, 2022 Dr. Jayne No Comments

The American Medical Association Annual Meeting is happening in Chicago this week, with the group gathering in person for the first time since the beginning of the COVID-19 pandemic. Many physicians feel the AMA has lost relevance and doesn’t speak for the majority of physicians. Regardless, I found the list of issues that the House of Delegates plans to address to be an interesting commentary on the times:

  • Addressing public health disinformation by health professionals.
  • Regulating ghost guns.
  • Declaring climate change a public health crisis.
  • Banning cannabidiol ads in places that children frequent.
  • Preventing loss of insurance coverage after the COVID-19 public health emergency ends.
  • Urging the Food and Drug Administration to swiftly review and approve over-the-counter status for oral contraceptives.
  • Decreasing bias in evaluations of medical student performance.
  • Ensuring accessibility of quality childcare for physicians in training.

Additional special sessions will include talks on the need for ethical guidelines around private equity acquisition of physician practices; Hattiesburg Clinic’s results when it looked at the impact of nurse practitioners and physician assistants; having physicians work at the top level of their licensure and not performing non-physician work; and reducing burnout.

I’m not sure how you miss this on a background check, but Bay Area Hospital in Oregon recently fired its chief operating officer after only four days on the job. It was discovered that in 2015, he had been sentenced to serve half a decade in federal prison for committing wire fraud and false representation of a Social Security number. Additionally, he used company credit cards for personal purchases. The hospital claims that it conducts criminal background checks across multiple jurisdictions, so I’d be interested to understand how this one slipped through the cracks.

In other legal news, a New Hampshire hospital has lost more than seven gallons of the drug fentanyl, which is a synthetic opioid that is 50 times more potent than heroin. Multiple hospital employees have been suspended. Drugs continued to disappear despite precautions that were added after initial losses were identified. A single nurse admitted taking more than half of the missing drugs, but the fate of the rest of the missing drugs continues to be unknown. Board of Pharmacy documents state that the nurse in question stated she took the fentanyl “for her own use as a way of coping with the stress of working during the pandemic” and also gave some to a friend. The nurse died unexpectedly in March. Nursing and pharmacy leaders at the hospital have also been suspended, with decisions on whether the hospital will lose its pharmacy approval expected later this month.

CMS has started levying fines against hospitals for noncompliance with federal price transparency laws. Atlanta-based Northside Hospital was fined more than $1 million due to problems at two facilities. One didn’t have the required consumer-friendly list of standard charges and the other didn’t have the searchable list posted in a prominent manner. CMS has issued a number of warning notices to noncompliant hospitals, but these are the first fines. Of note, neither hospital submitted a plan for corrective action which might have helped them avoid the penalties. One health policy expert cited in the article describes the hospital’s behavior as “contemptuous” in its lack of response or remediation.

A recent report from the Center for Connected Medicine (which is a partnership of Nokia and UPMC) looks at the reasons why patient self-scheduling isn’t advancing. Not surprisingly, lack of physician buy-in is a major factor. The report notes that 88% of respondents plan to prioritize investments in self-scheduling technologies in the coming year.

My primary care physician is part of a large medical group affiliated with a major integrated delivery network, and their efforts towards self-scheduling have been haphazard at best. Each office within the group is allowed to do their own thing, and then within the office, providers can opt in or out. Although I can’t even request an appointment with my physician online (other than sending a message, which I know is annoying to the staff) I can directly book with the nurse practitioners in the office. I’m overdue for calling to schedule my visit since he’s got a six-month wait, but I never seem to find time to make the call. At least I could self-schedule in those precious minutes between Zoom calls while I’m waiting for attendees to arrive at a meeting or while I’m waiting for the next patient to pop into my virtual waiting room. I definitely can’t make a phone call at either of those times.

Being a patient seems to be getting more and more difficult. I waited more than two weeks for some recent results, only to find that the ordering clinician failed to include the clinical history with the order, which might have made a difference in the results. It took four days from when the results posted in the EHR to when my clinician finally messaged me with note that “all is well, have a great summer,” which is a somewhat useless comment when you’re a patient who wants to know what the follow-up plan should be given the clinical history. Additionally, my physician eye detected a comment in the actual result report that called into question the adequacy of the specimen and that doesn’t feel like “all is well” to me.

I was forced to see this clinician because my own physician was out on a medical leave and the wait for new patient visits for other physicians in this specialty can be several months long. The visit itself was less than satisfactory, and after seeing how the results were handled, I’ll be looking to transfer. I’m fortunate to be a physician with plenty of resources, who not only knows how to research clinical guidelines but who could also reach out to friends in this specialty for advice. Both of my favorite “phone-a-friend” docs agreed with my self-created care plan so that’s something, but overall, the situation is just disheartening.

I feel bad for my physician colleague who is out on leave, because I know the backstory and that she not only feels terrible that her sudden illness left the practice in the lurch, but that there’s a good chance that she may not be able to practice medicine again. She’s an employed physician, though, so it falls on the group’s leadership to ensure that patients receive appropriate care in the face of the unexpected. I wonder how many other patients received less than outstanding care in the last few weeks and whether there will be any long-term consequences.

How have physician or other medical staff shortages impacted your own health or your patients’ care? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/13/22

June 13, 2022 Dr. Jayne 2 Comments

I was sorry to read of Mr. H’s COVID-like symptoms, which as of his last post hadn’t yet resulted in a positive test. Especially in vaccinated patients, we’re seeing a pattern where antigen testing doesn’t become positive until five days or more after symptoms have started. Although vaccinations are still very good for preventing hospitalizations and death, I’m seeing a fair number of people with some pretty debilitating symptoms as well as a large number of patients with long-COVID symptoms. Best wishes for a speedy recovery for Mr. H.

As a physician who has spent thousands of hours staffing emergency departments and urgent care facilities, I fully support the idea of having interoperable systems to better understand patients’ medication histories. My first informatics employer stood up a private health information exchange (HIE) to help its employed physicians better share data with community physicians who also used the same EHR. It was an exciting time to learn how the connectivity needed to work and to navigate through decisions such as whether we would be an opt-in or opt-out platform in the face of changing privacy laws and state requirements that weren’t keeping up with the times. As the first HIE in the state, if was something to be proud of, but we knew it could be done better and were ready to support broader statewide efforts when they came along.

One of the major benefits of even our limited regional system was being able to see prescription histories and to identify patients who were visiting multiple physicians for controlled substances, or who were trying to refill their medications sooner than they should. Having the data made it easier to have those uncomfortable conversations with patients so that we could try to arrange appropriate follow up. From those experiences, it was natural to be a champion for Physician Drug Monitoring Programs (PDMPs) when they were first proposed. Some states were faster in creating these programs than others, and at least one state still doesn’t have a true statewide platform. As soon as one became available to me, I signed up, and before long I was using it nearly every day.

My last urgent care employer had a large number of midlevel providers seeing patients – nurse practitioners and physician assistants outnumbered the physicians nearly three to one. In my location, those providers weren’t allowed to sign up for the PDMP on their own, but required a sponsoring physician to allow them to be a delegate on their account. I thought that was unusual since those providers can prescribe controlled substances in my state as long as they have the name of their collaborating physician on the prescription, but I’m not the one who makes the rules. Several of the nurse practitioners asked me to sponsor them even though I wasn’t their collaborating physician. Apparently, the physician owners (who were the collaborating physicians for many of the midlevels) refused to sponsor them for the PDMP because they didn’t want it to create inefficiency in the workflow.

I found that approach to be short-sighted as well as non-collegial, so I agreed to sponsor a few of them who I had worked with for years and knew very well. They continued to use the system under my sponsorship until I left the practice and terminated the linkage between our accounts. It looks like their collaborating physicians still won’t sponsor them, because every two weeks I get an email from the PDMP noting that I still have open requests for sponsorship. In thinking about the fears of inefficiency, it’s likely more complex than that since the practice dispensed medications on a cash basis (including controlled substances) and was well known for making sure providers were “treating the heck out of symptoms.” Patient satisfaction was also a big push and of course it takes more time to counsel a patient about something you might find in the PDMP versus just prescribing medication. The practice also refused to install technology that would allow e-prescribing of controlled substances, so you get the picture. Attitudes like that are part of why I no longer work there, but one does still have to think about the impact of any new systems on efficiency.

An article in JAMA Health Forum addressed the topic this week, with findings that having a PDMP that’s integrated with the EHR led to increased use of prescribing recommendations by primary care clinicians. It shouldn’t be surprising to anyone that if you have a solution that makes it easy to do the right thing, people will be more likely to actually do the right thing. The researchers looked at 43 clinics and how they used the Minnesota PDMP. There were 21 clinics that had the PDMP integrated with the EHR, which reduced the need for a separate login to the outside system while also lowering the need to intentionally think about using the PDMP.

Monthly query rates for the non-integrated sites were 6.6 per clinician before the intervention versus 6.9 after. Monthly query rates for the integrated sites were 8.8 before the intervention and 14.8 after. Additionally, the findings showed a greater impact of the EHR integration on less-experienced clinicians, which they noted “may reflect a less inflexible practice style and/or faster uptake of new features in the EHR.” While the study was underway, Minnesota initiated a mandate that clinicians query the PDMP before prescribing opioid drugs, which led to an uptick in query counts in both groups, although that increase was more significant for prescribers in the intervention group.

There are several potential limitations to the study, including the fact that it didn’t directly assess opioid prescribing. The study was also limited to a single health system and its affiliated prescribers within a limited geographic range, although there was inclusion of urban, suburban, and rural areas. The study also could not identify whether queries were clinically appropriate or not or whether the PDMP queries led to providers deciding to not prescribe controlled substances when they otherwise might have. The authors do plan to look at this in a further analysis using information from the EHR.

I do hope that those who are trying to increase the adoption of EHR-integrated solutions use information like this to show that they can have a positive impact on provider workflow. They can also have a significant impact on patient outcomes when it comes to identifying patients who might benefit from an intervention with regard to controlled substances. I’m interested to see what results other organizations may have had with EHR integration and how their clinicians responded to it.

Have you integrated your state’s PDMP with your EHR? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/9/22

June 9, 2022 Dr. Jayne No Comments

Since there have been so many dramatic changes to many workplaces over the last two years, many companies are re-evaluating the meaning of the workweek. I always keep my eye out for articles on this topic, as well as literature from other countries where work-life balance seems to be much higher priority than it is in the US. There have been several writeups this week about a move in the United Kingdom for large numbers of workers to adopt a four-day work week. There are 3.000 workers taking part in a six-month project to assess whether shortening the work week will alter productivity, employee turnover, company revenue, and more.

The article mentions strategies different companies have taken in trying to alter the work week, including streamlining meetings and reducing inefficiencies. Kickstarter, which is small at only 90 employees, has given them Fridays off. I know of quite a few larger companies that don’t necessarily give people Friday off, but instead offer “Focus Fridays” and other themes where employees are supposed to have uninterrupted work time without meetings or distractions. For employees who are self-motivated, this can be a solid strategy. One of the health systems I worked for pre-pandemic allowed employees to work remotely one day each week and I have to say it was some of the most productive time I had, because in the pre-Zoom era, there weren’t any meetings or calls.

Another strategy that I see some companies offering as a means to improve work-life balance is that of unlimited time off. In speaking with friends that work at a large tech company where this is the norm, it can be less of a benefit than advertised, since workers who aren’t accustomed to tracking time off may not take full advantage of the paid time off that they might have received under a more traditional system. Although when these programs were initially rolled out, there was a lot of concern about people abusing it, many companies find that workers actually spend less time away from the office. I’ve worked with plenty of people over the years who only took days off when they were “forced” to in order to get the days off the books.

Other groups are offering dedicated days where employees are supposed to focus on self-care. Advocate Aurora Health is one of those, offering “renewal days” where employees are supposed to meet together for support. I found it interesting that their original program was a three-day workshop designed to focus on finding meaning in work while building skills to combat burnout, stress, and compassion fatigue but it has since been compressed into a single-day program. That seems such a parallel to everything that has happened since January 2020, where most healthcare workers are expected to do more with less even in the face of previously unheard-of stressors. I still hear about plenty of healthcare organizations that are trying to combat serious organizational issues through the application of pizza lunches and therapy dogs so I’m not sure we’re making much progress.


The University of Missouri launches a telehealth program to train rural primary care physicians in the use of Canvas Dx with the goal of supporting autism diagnoses. The tool, from Cognoa, will be added to the platform used by the University of Missouri ECHO Autism Communities Research Team. The group will explore the time it takes from a physician’s initial concern that Autism may be a factor to a diagnostic determination via Canvas Dx. Earlier diagnoses should lead to earlier interventions and hopefully better outcomes for patients and families. The study plans to recruit up to 15 clinicians to evaluate as many as 100 children at risk for autism spectrum disorder or developmental delay. As a side note: has anyone ever noticed that the MU logo contains a mule? I don’t know how many times I’ve seen the logo but never the mule.

US Representatives Madeleine Dean (Pennsylvania) and Larry Bucshon (Indiana) introduced a bill this week that aims to protect healthcare workers from violence. It is modeled after existing protections created for airline and airport workers. The Safety from Violence for Healthcare Employees (SAVE) Act would make assault or intimidation of hospital employees a crime. Representative Bucshon is a physician, so I’m disappointed that the bill appears to focus on hospital workers and not on the tens of thousands of healthcare workers in other locations where they might be even more vulnerable, including ambulatory offices and home care. Workers in those locations don’t have anywhere near the level of security or assistance found in the average hospital. As a healthcare worker who was left out of vaccine allocations because I didn’t work for a hospital (despite delivering a high volume of COVID care) it looks like we haven’t learned and will continue to propose short-sighted policies.

One of my healthcare providers recently notified me of a data breach that may have exposed my personal health information. According to the documentation, the organization learned that an “unauthorized person” gained access to a subset of employee email accounts over a more than three-week period. Investigators were not able to determine whether emails or attachments were actually viewed, but the emails included data on both patients and research subjects including names, birth dates, addresses, medical records, insurance information, Social Security numbers, and more. It’s not clear now many patients have been impacted but they promise to reinforce training on avoiding suspicious emails and to make enhancements to email security, so it seems obvious to me how the breach occurred. Depending on what data might have been exposed, some patients will receive credit monitoring and identity protection services. Regardless, it’s going to be unnerving for many of us for a long time to come. At this point I get a breach notification every year or two, so it seems there is a lot of opportunity for improvement among the various members of my healthcare team.

Judging from my social media feeds, many people are taking advantage of what they perceive to be a “normal” travel season. I’ve seen plenty of pictures from amazing places, but my own summer will be a little low key this year. I’m juggling some big projects and a go live, so I’ll only be occasionally off the grid. It just gives me more time though to plan the next big adventure.

What are your summer travel plans, or are you going the staycation route? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/6/22

June 6, 2022 Dr. Jayne 3 Comments

It’s been a long week, and I’ve spent a good bit of it trying to process the recent episodes of violence against healthcare workers in Tulsa and Los Angeles. The Tulsa incident had a particular impact on me since I did some EHR optimization work for Warren Clinic in the past. As the news reports unfolded, and before we knew exactly where the shooting occurred, I wondered if any of the staff that I worked closely with had been impacted. Although it turned out that I hadn’t worked with any of the victims, it was still devastating to learn of the loss of dedicated healthcare professionals who had given so much to their patients and who still had many more years of service ahead of them.

Hearing of the stabbing in Los Angeles later in the week was almost too much to bear. Those who see patients in person go to work every day knowing that it’s going to be difficult, but generally they don’t expect to be shot or stabbed on the job. I’ve worked in plenty of “tough” clinical locations. At one hospital emergency department, I had to park in a secure garage that was lined with chain link fence, essentially creating a cage. You had to have a badge to get in or out via car and accessed the hospital through a secure elevator that either took you directly into the ED or up to the ICU waiting room. I often wondered what would happen if the power went out, but fortunately it never did during the years I worked there.

Patients and visitors to that facility had to go through metal detectors. I had a security guard posted at my clinical workstation in the event things became contentious. Sometimes my patients were handcuffed to their gurneys since they were being evaluated to ensure they were “fit for confinement” after being arrested by local law enforcement.

Additionally, the emergency department exam rooms all had two doors on different sides of the room so that there was always a way for you to get out. I’ve worked in large urban trauma centers, locked psychiatric emergency units, and critical access hospitals where all kinds of unusual cases have come through the doors. I’ve had patients become agitated and aggressive before, and I was even stalked by a patient, but even in those circumstances I never actually imagined that I was at risk of being shot, stabbed, or killed while trying to help patients.

Violence against healthcare workers is at an all-time high. It’s not just physical violence or homicide, but more often includes verbal abuse and threats. The Bureau of Labor Statistics indicates that healthcare and social assistance workers have the highest rates of injuries due to workplace violence. In fact, workers in those industries are five times more likely to be injured at work than workers overall. Incidents of workplace violence have been rising nearly every year since they were tracked, beginning in 2011. Although the Occupational Safety and Health Administration has guidance for employers, there are no federal requirements for healthcare organizations to protect their employees from workplace violence.

Some states have addressed the issue. A Wisconsin law makes battery against certain healthcare workers a felony. There has been some action at the federal level, but nowhere near enough. Personally, I’d like to see healthcare organizations have to report their statistics just like college campuses do – collecting detailed information about violent incidents and reporting their numbers annually. At my last in-person physician gig, my employer had numerous episodes of workplace violence and no clear mitigation strategy. Incidents were hushed up and employees were discouraged from discussing them for fear that staff wouldn’t want to pick up shifts at certain locations. There certainly wasn’t any kind of post-event debriefing for those impacted by violent incidents. Everyone was just expected to pick up and carry on, which is exactly the opposite of what is needed.

Those incidents seemed to escalate during the initial phases of the pandemic, when everyone was scared and uncertain. They became worse as certain unapproved treatments were pushed on social media, and patients would become aggressive when told we would not prescribe ivermectin or other drugs that had been shown to not only have no benefit but to have significant risks. Patients argued with us about their diagnoses despite having positive lab results and told us directly to our faces that we didn’t know what we were talking about and that we were either lying or part of a vast conspiracy. One of the worst things I had to deal with during the pandemic was patients who refused to wear a mask in the exam room, or who would take it off as soon as I walked out the door, to fill the room with their exhaled breathing so I could walk back into a cloud of virus. To have to deal with that hour after hour, day after day, and to not be able to confront it for fear of lowering patient satisfaction scores was one of the things that contributed to my departure.

Still, I’m here, and although no one has tried to directly kill me at work, it’s certainly on my mind that what happened last week could have happened to any one of us at any time. Along with many of my colleagues, we’re feeling a certain level of survivor’s guilt after seeing so much loss in the healthcare community over the last few years. Although we’ve gotten better at protecting ourselves from disease, the steps that we need to be taking to protect ourselves from workplace violence are less than clear. Regardless, healthcare employers owe it to their teams to assess the safety and the workplace and the wellbeing of those in it. Every healthcare organization should be offering employee assistance programs to those who are struggling with the recent tragedies and increasing violence.

Readers may be asking themselves what all this has to do with healthcare IT. If you’re a frontline IT support person who works in clinical areas, the answer to that is clear. It’s also a heads-up about what the people you’re trying to support might be going through. If they seem on edge or preoccupied, there’s a good chance that they are one of both of those. I’m sure that if I were seeing patients in person, I’d be less interested in learning about new features or workflows that are about to be deployed than I would be in learning how the hospital plans to keep me safe. Even if you’re not working in a clinical area, you’re not immune to workplace violence. All of us should be standing together to demand solutions that ensure we all make it home to our families at the end of the workday.

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EPtalk by Dr. Jayne 6/2/22

June 2, 2022 Dr. Jayne 2 Comments

Surprise, surprise: research shows that patients understand their health records better when they are not full of abbreviations. The study, published in JAMA Network Open, showed improved comprehension when certain abbreviations and acronyms were spelled out. Although study subjects had previous exposure to healthcare organizations, their initial understanding of some common abbreviations was below 40%. Looking at a set of 10 common abbreviations, expanding them increased comprehension from 62% to 95%. The authors urge clinicians to consider that patients may not understand abbreviations and medical terminology. Abbreviations aside, it’s important to understand the low level of health literacy across the US and the need for most patient-facing communications to be written at or below the sixth-grade level.

I recently had another trip into the Patient Zone, and even as a healthcare provider, I found some of the things I encountered confusing. I know how to navigate the system and I still have a post-visit issue that remains unresolved three days later. The office was running significantly late, so I got to listen to quite a few inappropriately overheard conversations. One involved a staffer who kept confusing two “sound-alike” medications to the point where I wanted to step out to the clinical station and correct her. Losartan is for blood pressure, Loestrin is an oral contraceptive. I later found out that she wasn’t working in her usual clinical location because they had floated people to the office to cover shortages. Still, I hope that no one was harmed on their watch. I received some wonky directions from people in the office and it makes more sense if they were temporary staff, but the average patient might not know to question it.

I’m also trying to put myself in the shoes of patients who are receiving immediate lab results via their patient portal accounts. The clinician I saw warned me, “you’ll probably see your results before I will” and she wasn’t kidding. Barely six hours after I left the office, I started receiving a flurry of “new result available” alerts. I’m not sure how the labs were ordered, but each component of the blood work was coming back as an individual result with its own notification. It was unnerving to say the least, especially since the ones I was really waiting for weren’t among the first to return. As a physician, I know what the results mean, but as a patient I can imagine it might be very frustrating. My guess is it won’t be until sometime next week before I receive an official interpretation, once all the results have returned. I’ll be interested to see how the rest of the process goes, and if my pharmacy benefit manager will ever sort out the erroneous script that was sent. I tried to resolve it, but they were never able to find the provider’s name in their system (despite me being able to see the erroneous script from the patient-side login) so I’m betting at some point I wind up driving to the office to pick up a paper script and fax it in myself.

Needless to say, there’s a long way to go for some healthcare organizations to really embrace the idea of patient-centered design. There have been a lot of healthcare futurists over the last decade who have said that patients will vote with their feet and drive their healthcare dollars towards organizations that deliver care that is personalized and consumer friendly. Pre-pandemic I still saw the majority of patients choosing their care based on insurance coverage with very little consideration of quality metrics or anything else. Now, with all the staffing shortages and physicians leaving patient care in droves, patients seem to just be getting in wherever they can. In my area, one of the largest health systems has over 4,000 patients on its wait list for a particular specialty, which now refuses to accept any referrals from outside the health system. That doesn’t seem terribly patient-centric to me. The organization blames its inability to recruit for the shortage of clinicians. I guarantee that if they raised their salaries above 25th percentile they’d be able to recruit.

After reflecting on these recent experiences, I wasn’t sure I was in the right frame of mind to read yet another article about a “man on a mission” in healthcare. One of my shoe-loving friends has a huge crush on Glen Tullman though, so I figured I better keep up so she and I have something to chat about. The premise of Tullman’s latest venture, Transcarent, is leveling the playing field for patients as they try to meet their healthcare needs. He calls out the fact that the health insurance industry is one that doesn’t operate in the best interests of its customers. The article calls out the fact that when insurance companies profit, each dollar represents care that patients didn’t receive. Tullman proposes giving those dollars back to large, self-insured employers who are footing the bill for coverage.

It will be interesting to see if Transcarent is able to succeed where other companies have failed. Haven tried to do this a few years ago for employees of Amazon, Berkshire Hathaway, and JPMorgan Chase. So far, more than 100 companies have signed up, eager to see savings on their healthcare spending. Transcarent makes its money by taking a cut of that savings, which is achieved through pre-negotiated pricing for services as well as by directing patients to lower-cost alternatives. Corporate customers are gravitating to the approach as are health systems, some of which are financially backing the endeavor. Walmart is jumping in with a recent agreement to become a preferred provider, offering primary care, mental health, and dental services. The article was enough to hook me, so I’ll be following along as the company expands. They’ve already hired some really smart people, and I’m eager to see if they’ll be able to move the needle.


Happy 19th Birthday HIStalk! I didn’t have time to do proper pastry therapy, so this option from my neighborhood Costco will have to do. Even though white cake is my favorite, you really can’t go wrong with a cake that is filled with their signature mousse.

What’s your favorite birthday pastry? Leave a comment or email me.

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EPtalk by Dr. Jayne 5/26/22

May 26, 2022 Dr. Jayne No Comments

Plenty of clinicians and health organizations are less enthusiastic about wearables than you might think. They’re still worried about the sheer volume of data that can be generated by patient-owned devices and how that needs to be managed with respect to electronic health records and who should own the follow up for any abnormal data. As wearable devices begin to identify more physiologic phenomena, this continues to come up in conversations. A recent JAMIA article looks at whether the ability of Apple devices to identify abnormal heart rhythms could potentially prevent strokes. The authors considered how they might identify high-risk patients in whom device data could lead to a diagnosis of atrial fibrillation and whether those patients would benefit from treatment with blood thinners.

The study used data from over 1,800 patients at Cedars-Sinai Medical Center and looked at both EHR and Apple Watch data collected between April 2015 and November 2018. They estimated the number of high-risk patients using three different methods: medical history, Apple Watch wear patterns, and atrial fibrillation risk determined by an existing validated clinical model. The authors concluded that using clinical and demographic data from the EHR might be helpful to identify patients who would benefit from device monitoring. They noted that “a randomized controlled trial to study the benefit of consumer-directed heart rate monitoring devices in preventing strokes would require either a massive sample size or an enriched sample of patients very likely to experience stroke” due to atrial fibrillation. They noted that Apple Watch users tend to skew towards young healthy, which might not be the best demographic for identifying those at high-risk for stroke. I’m sure there’s more to come because clinicians will continue to question how to best use patient-generated data.

Last week, the American College of Obstetricians and Gynecologists dropped New Orleans as the site of its 2023 annual conference, citing concerns about Louisiana’s restrictive stance on abortion. The group’s official statement noted: “Holding the nation’s largest gathering of obstetrician-gynecologists in a location where the provision of evidence-based care is banned or subject to criminal or other penalties is directly at odds with our mission and values.” There’s been quite a bit of discussion whether other groups will move their conferences as well. It’s a difficult decision as contracts and venues are typically negotiated years in advance.

Other groups are at least talking about it, though. The American Medical Informatics Association published a set of “guiding ethical principles” for selecting venues for AMIA events and conferences. The authors specifically note abortion and voting rights as issues that have led members to question where meetings are held. The document was created with input from AMIA’s Ethical, Legal, and Social Issues Working Group as well as its Ethics Committee and was approved by the AMIA Board of Directors in April 2022. Among the principles are commitments to:

  • Right to benefit from science.
  • Right to safety and security.
  • Freedom to travel.
  • Freedom of speech.
  • Right to nondiscrimination and civil discourse.
  • Human rights.
  • Access to professional development.
  • Transparency and veracity.

AMIA notes that it does not have a list of excluded or boycotted locations, but that the document will allow those who hope to host an AMIA meeting to evaluate their eligibility and the likelihood of a successful bid.

Speaking of organizations selecting interesting locations, University of Pittsburgh Medical Center has opened a cancer center in Sicily, with clinicians receiving support from those at the Pittsburgh location. They’ll be offering medical oncology services that build on the hospital’s surgical focus areas including gastrointestinal and cardiothoracic cancers. In addition to this program, UPMC also has cancer center offerings for radiotherapy in Roma and Campania. I’m sure there are a fair number of clinicians who might be looking forward to rotating at the new site, depending on their love of cuisine and beautiful landscapes.

I’ve been doing a fair amount of work in telehealth, and there are still plenty of barriers to audio-only telehealth visits. Recently, the US Department of Health and Human Services held its first National Telehealth Conference and audio-only telehealth was discussed as a key strategy for health equity. Voice visits can be done without a smartphone or internet connection and can be useful for managing chronic conditions as well as many acute problems. In my urgent care telehealth practice, it’s usually the patient’s story that most leads me to the assessment and plan rather than the cues I might get from a video exam. Of course, certain conditions necessitate a video visit or at minimum a photograph, but often the value of the visit lies in the physician’s advice and counsel rather than with the exam.

Many of the telehealth patients I see are just looking for reassurance that they can wait for an in-person appointment in the morning. Others might not have tried any over-the-counter remedies and are looking for advice in that regard. Some have a self-limited problem that really doesn’t need a visit at all, but the patient’s employer is demanding a work note, resulting in unnecessary healthcare expenditures. There are still barriers to audio-only visits, including payer requirements for initial and/or ongoing in-person visits that aren’t an option for physicians like me who don’t have a brick-and-mortar location. If I couldn’t practice telehealth, I’d be out of direct patient care entirely, which doesn’t seem like the right answer for a nation with a primary care physician shortage.

Audio-only visits are important for rural patients who often have less access to telehealth services compared to their urban counterparts. A recent article notes a gap not only in telehealth service offerings, but in marketing them to rural patients. In rural areas, there are approximately 40 primary care physicians per 100,000 population compared to 53 in urban communities, and as rural areas struggle to recruit, this is not likely to improve. Of the patients I’ve seen in the last month or so, I’d estimate that 80% of them are from outside major metropolitan areas. I always find it interesting to see exactly where people are located as I confirm their pharmacy information or ask questions about their exposures as related to outdoor activities. (It’s tick bite season, in case you’re wondering, so please remember to wear long pants, long sleeves, and some insect repellent.) I’m glad that I can be a resource for those patients, but look forward to solutions where they have their own primary physicians who can coordinate care.

Have you had a telehealth visit in the last year? Was it audio, video, or asynchronous? What did you think? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 5/23/22

May 23, 2022 Dr. Jayne No Comments

I’ve been mentoring young physicians for many years. I was recently asked by one of them to speak to a group of physicians who are struggling with burnout and inability to effectively balance work and home life. Some of them are even thinking about leaving medicine altogether. They were looking for tips from someone a bit more “seasoned” (which is just a nice way to say that at least for those still in training, I’m nearly old enough to be their mother). As we got into the conversation and they were talking about the stresses they were facing in their daily work, I realized several things.

First, these young physicians have always used EHRs. They had no frame of reference for the era of paper charts and how outpatient practices used to operate. They had never been confronted by an unreadable chart, much less a chart that was missing entirely, and as such have never had to perform an established patient visit “blind” as many of us have. There is tremendous anxiety at the idea of not having all the information at their fingertips.

Conversely, they have never had the satisfaction of being able to know what is going on with a patient by scanning a brief note that might say, “Strep, Amoxicillin x 10 days” as the assessment and plan. They’ve been surrounded by so-called note bloat for their entire careers and are used to wading through pools of useless information to try to find important nuggets to use as they care for patients.

Additionally, they’ve never had to go through an EHR implementation, so they have not had the experience of carefully evaluating their workflows to determine if they make sense, or if they need to do some streamlining. They’ve not had much experience pushing back on administrators and tend to be much more likely to take things at face value than my colleagues who trained 20 years ago and who have been through various stages of clinical transformation. Because they’ve always had an operational EHR, they haven’t had the opportunity to ask a lot of questions about why the workflow is the way that it is, or if anything can be made better.

For example, one of them was complaining about the sheer volume of inbox messages that she receives from their practice’s patient portal and how none of them require her expertise. She regularly receives appointment requests, billing questions, and other non-medical messages that she then has to forward to others to address. I asked her why her practice has all the patient portal messages routing directly to the physicians rather than to staffers who can filter the messages. She was unaware that you can even do that with an EHR (and having been a user of her particular system I know it can be done) so didn’t think to ask.

I challenged her to think critically about the other processes in her office. Do all the telephone messages come directly to her, or are they worked by the scheduling team, a medical assistant, and others first, with only those that no one else can address coming to the physician? There’s no reason that messages originating from the patient portal should be handled any differently. I could almost see the light bulb going on over her head as she thought about pushing back on the task of being her own receptionist.

Second, I found that there was a large amount of learned helplessness among these physicians. Some of them are doing four or more hours of documentation at home after leaving the office, but they’re not willing to discuss it with their practices for fear of appearing weak or looking like they can’t keep up or aren’t as productive as their partners. I think some of this comes because of their being in training or their recent proximity to training and not wanting to do anything that would raise a red flag about not being a team player or that they’re not good candidates for highly competitive fellowships or job opportunities.

For the most part, they didn’t seem to be aware of resources that are available to them, such as EHR optimization assistance, classes on personalization or creating templates and macros, or being able to book time with a trainer. It made me wonder if this situation is part of their having grown up in an entirely tech-enabled universe where they assume systems are intuitive even when they’re not, and where people are rewarded for problem-solving on their own without any help. I know that during the early stages of the pandemic, a lot of organizations cut out some of these services, but to not even be aware of a super user in your practice that could help you out is concerning. To be afraid to ask for administrative support is even a bigger red flag as practice arrangements go.

Third, I noticed that many of these younger physicians have no business savvy. There are few subspecialties that require practice management education during training (thank goodness mine is one that does) and I was shocked by the general lack of knowledge around navigating workplace situations. Of the group, only one had an attorney review their employment contract, and most of them weren’t even aware with how much notice they would have to give if they decided to leave or if their medical liability insurance “tail” would be covered upon departure. Failing to understand or negotiate these things up front leaves them locked into these positions longer than they might want. And the lack of business savvy wasn’t only in their own employment – due to the challenges in arranging childcare as a physician, nearly all of them have household employees such as nannies or housekeepers and not a single one had a signed employment agreement or contract for services.

With that lack of understanding, it’s unlikely that any of these physicians would be able to have their own practices or succeed in a physician partnership as compared to being an employee. If they’re not able to demand a drug screen and adherence to policies and procedures for the people caring for their children, would they be able to demand those things of their medical assistants or medical office staff? It feels like they would always be at risk for being taken advantage of or committing some kind of regulatory offense simply out of ignorance.

I was glad to be able to spend a couple of hours taking them under my wing and explaining the concept of being an empowered physician. I stressed the need to spend a little time trying to fully understand the healthcare landscape well enough to be able to make good choices. I was glad to be able to share some information about how to push for better EHR usability and improved clinical workflows. I’m not sure how much a difference our time together will make for their progressive burnout, but it felt good to at least try to make things better.

What does your organization offer to better educate early-career physicians on the non-clinical aspects of working in healthcare? Or does the teaching stop after HIPAA or Fraud, Waste, and Abuse modules? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/19/22

May 19, 2022 Dr. Jayne 3 Comments

A friend clued me in to an article about the state of patients’ ability to schedule their own healthcare visits. It points out all the industries that have migrated from scheduling via human interaction to scheduling online: airlines, restaurants, and fitness programs are examples. The authors note that some demographic groups want to avoid making phone calls “like the plague” and go further to comment that “there’s no better way to forcibly eject younger generations from your onboarding and acquisition process than by putting them on hold.”

The article provides a great summary of the difficulties in allowing direct scheduling, including pre-visit requirements, insurance requirements, and varying lengths of appointment slots. For some specialties, there’s also the risk of rescheduled or bumped appointments due to emergencies or operating room delays. They dig into issues around physician preferences and control as well.

When I worked on my first EHR implementation, it also involved conversion of the practice management system. We reviewed well over 1,000 different appointment types that physicians had demanded over the years and winnowed them down to about 70. We analyzed past performance and found that the physicians who had the most rigid scheduling rules often had unused appointment slots, while those with more flexible “open access” schedules had more consistent use of their schedules.

It’s difficult to wrest control away from physicians who have little business training and who aren’t encouraged to challenge the status quo. It’s even more challenging when their office staff members have developed a culture of shielding the providers from change.

I’ve found that practices can benefit even if they only allow a small subset of visits to be directly scheduled, such as allowing only well visits, since they tend to have longer time slots, or same-day sick visits, which would be shorter time slots that are sometimes worked in to the schedule. One of my personal physician offices allows only same-day sick visits to be scheduled via the patient portal, and they are usually gone by 9 a.m. As long as the technology lift isn’t too heavy, sometimes even a small benefit can give both staff and patients a bit of a morale boost. If your office hasn’t considered making the change, I would strongly recommend starting to dig into the pros and cons.

Speaking of shaking things up: CNBC has published its 2022 Disruptor 50 list, which includes a number of health technology companies that I’ve followed over the years including Medable (distributed clinical trials), TruePill (virtual pharmacy), Maven Clinic (virtual women’s health), Ro (virtual pharmacy and diagnosics), and Oura (wearable ring for fitness data). My favorite addition to the list is Biobot Analytics which uses wastewater to detect disease. In an era where people can skew population health data by specifically opting out of testing, that might be the best way to go in order to determine where the COVID-19 pandemic is going.


Telehealth startup Cerebral has lost its CEO with the departure of Kyle Robertson. The company has been under scrutiny for some time, but experienced increased criticism around its prescribing processes in recent weeks. Cerebral is accused of excessively prescribing stimulant medications such as Adderall. It has received a grand jury subpoena from the US Attorney’s Office for the Eastern District of New York as it investigates possible violations of the Controlled Substances Act. Cerebral has stated it would largely stop prescribing controlled substances, which is likely to create some interesting care-seeking patterns in the brick and mortar world as patients have their refills curtailed.

The changes occurred following a board meeting which included other leadership changes. President and Chief Medical Officer David Mou will take over, COO Jessica Muse will become president, and clinical advisor Thomas Insel will join the board. Cerebral has tried to recruit me as a provider several times, and the way they conduct their recruiting gave me the heebie jeebies as it felt like they were basically trying to rent my license so that they could generate as many prescriptions as possible.


I always enjoy hearing about different EHR vendors and their client conferences. A regular reader clued me in that CPSI is holding its National Client Conference in St. Louis this week. The conference schedule has a number of interesting offerings and wrapped early enough in the evenings for attendees to take advantage of the city’s food scene, including Italian, Vietnamese, and Bosnian offerings. The customer appreciation event featured the Anheuser-Busch Brewery Experience, complete with brewery tours, a biergarten, and of course the Budweiser Clydesdales. Sounds to me like a great way to cap off a conference.


Other things I enjoy hearing about: the intersection of science with one of my favorite treats. The American Institute of Physics journal Physics of Fluids recently explored Oreology, which it defined as “the fracture and flow of milk’s favorite cookie.” Researchers looked at the failure mechanics involved in twisting an Oreo apart, including the variables of filling amount, rotation rate, and flavor. They assessed a stress-strain curve as well as “postmortem crème distribution” that was typically unequal. Researchers went as far as creating an “open-source, three-dimensionally printed Oreometer powered by rubber bands and coins” in order to encourage “higher precision home studies to contribute to new discoveries.”

Little did I know that Oreo filling could be characterized as having “complex or non-Newtonian viscosity” or the many ways in which science impacts the processing of different foods – from using fractional calculus models to evaluate cheese structure to using physics to improve chocolate quality. Although sections of the paper seemed to be bordering on sarcasm, I thoroughly enjoyed reading it and look forward to discussing it with my favorite physics students when I see them over their summer break. The authors note the need for further research on other varieties of sandwich cookies, custard creams, macarons, and ice cream sandwiches, although I’m particularly intrigued by their mention of the physics of Nutter Butters since they were a special childhood treat.

What’s your favorite variety of Oreo? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/16/22

May 16, 2022 Dr. Jayne 4 Comments

With the rise of telehealth, there’s a lot of discussion about “web side manner” and the strategies that physicians and other clinicians should use when evaluating and treating patients via telehealth.

I’ve worked for a variety of telehealth employers, some which require their clinicians to wear a white coat and others who are fine with what they discuss as a “professional” dress code. For many years in the hospital culture, white coats were considered a symbol of being a physician or physician in training. Typically, medical students wore short coats and those with their degrees wore longer coats. However, over time, many other clinicians began to wear white coats both short and long, including pharmacists, nurse practitioners, physician assistants, and more.

The use of the white coat also evolved at the department level. At the hospital where I primarily trained, medical students wore short coats and residents, fellows, and attendings wore long coats. Except, that is, for the surgery department, where interns and first-year residents were further hazed by being required to continue to wear short coats.

However, the policy in the operating suites was that if you were wearing surgical scrubs and needed to leave the area, you were required to put on a long white coat or a “cover gown” to protect the surgical scrubs from non-OR contacts. However, the surgery interns knew they’d get in trouble if they were caught in long coats, so if they left the OR and there were no cover gowns available, they’d have to change back into street clothes and then don new scrubs when they returned. They detested the fact that students could wear the long coats in that situation, but they couldn’t.

The surgery interns were further hazed by being required to wear ties if male, and not being allowed to eat or drink anywhere but the hospital cafeteria or a break room. Where the rest of us could scurry away from the cafeteria holding a to-go cup and finish it in the elevator on the way back to our duty assignment, the surgical residents had to either chug it in the cafeteria or remove the straw to make it look like they weren’t drinking it until they got to their destination. There were a lot of other elements of hazing in those programs, and needless to say, they were a turn-off for a lot of students rotating on the service. This was also long before COVID, when masks changed how we handle food and drink in hospitals.

Since the white coat is no longer a definitive indicator, quite a few of the hospitals that I’ve worked at have taken to other methods to make sure patients know the credentials of different members of their care teams, including oversized name badge frames or backings that contain prominent credentials such as MD or DO or RN written in bold font that is nearly an inch tall. Still, there’s often confusion about who is caring for the patient, as noted in this recent Medscape article.

Despite all our advances in patient engagement and consent, the use of whiteboards, bedside technologies to track the care team, and more, patients are still confused about who they’re talking to. Some of that can have situational influences since hospitals are strange and unfamiliar places with routines that don’t often make sense. Patients may be less perceptive than usual due to illness or being overtired, since we know that hospitals aren’t great places to get rest.

Following the emergence of COVID-19, those bold credential nametags became even more necessary as many of us ditched white coats (which were largely used for their pockets anyway) in favor of scrubs that we could change before going home. Neckties all but disappeared as we tried to understand the nature of this novel pathogen. Other countries had previously moved away from white coats and neckties due to the infection risk, but the US has been a holdout. When I spent some time in a healthcare institution in the UK many years ago, no one wore sleeves of any kind below mid-forearm to allow for better hand hygiene, and neckties had also been voted off the healthcare island.

Still, there’s the question of how clinicians should dress for telehealth visits. The reality is that our world has become much more casual since the start of the pandemic. Plus, there’s no need for those white coat pockets when you’re sitting at a desk and can use a laptop, PC, or phone to access references rather than having to tote around a “Washington Manual” and a “Pocket Pharmacopeia.” However, there’s still that association of the white coat with professionalism.

The article cites research done at Johns Hopkins to look at patient preferences. Nearly 500 adults were surveyed in the spring of 2020. They were asked about various types of dress, including white coats, scrubs, and fleece or softshell jackets with the institution’s logo. They were also asked to rank photos of models in various attire to identify their level of experience, professionalism, and friendliness. Those models in white coats were seen as experienced and professional, while those in softshell jackets were seen as friendlier. Responses varied by age of those surveyed as well as their geographical location. The white coat seemed to be favored by older respondents as a mark of professionalism.

Another study conducted at NYU Grossman School of Medicine in 2018 surveyed over 4,000 patients at 10 academic medical centers. Those patients preferred formal dress and a white coat, but it would be interesting to see what a study of that size would show in the pandemic-era and whether the results would hold across different encounter settings including inpatient, outpatient, and telehealth visits. At least for the majority of patients receiving telehealth services, they’re not being seen by a whole team of people, so I would hypothesize that the white coat is not necessarily helpful to avoid confusion on what type of provider is present.

Personally, I prefer not to wear the white coat while conducting telehealth visits. I wore it only intermittently in my solo practice, mostly because I had no need for the pockets and everyone knew I was the doctor. In the emergency department, I wore it for the pockets, but ditched it when I went to urgent care. I did bring it back for COVID, partly because my employer couldn’t provide adequate gowns and it was one more layer of protection, not to mention I didn’t want a stethoscope around my neck given our initial lack of understanding about COVID transmission – pockets made much more sense.

Still, I wear it on certain telehealth visits when a particular employer requires it, even though I don’t like it and I don’t think the patients really care. It will be interesting to see how telehealth culture evolves over the next few years and whether the white coat becomes more or less of a requirement.

What does your institution think about white coats and telehealth? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/12/22

May 12, 2022 Dr. Jayne No Comments

There is always a lot of buzz around wearables and using them to boost patient engagement. This Bloomberg piece caught my eye with its discussion of the “nocebo” effect. Where a placebo can make patients feel better, a nocebo that’s providing negative data could make patients feel worse. The article points out that not everyone “will truly benefit from 24-7 monitoring, arbitrary goals served up by an algorithm, and regular notifications telling you that you’re stressed, tired, fit, or simply ‘unproductive.’”

I definitely see this with my patients, who are frustrated by what they’re seeing with their bodies because they don’t understand it. For example, the patient starting a new workout plan who is frustrated due to weight gain might not understand that this is because they are building muscle.


During the course of the COVID-19 pandemic, many clinical informaticists have learned more about public health informatics than they ever imagined. The Strengthening the Technical Advancement & Readiness of Public Health via Health Information Exchange Program (STAR HIE Program) provides support for public health agencies who need to exchange health information during times of emergency. Although the program was initially funded by the CARES act in 2020, it was expanded in 2021 to further support efforts to increase vaccine data sharing between local or regional Immunization Information Systems and HIEs. Various projects have involved: improved delivery of COVID-19 test results; improved reporting among providers, hospitals, and public health agencies; providing accurate lists of non-vaccinated patients to improve vaccination rates; improved case reporting; and creation of new connections between HIEs, hospitals, and correctional facilities.

For those who think “COVID is over,” here’s another example that it’s not and we’re all in this together. Due to COVID-19 lockdowns in China, there is a global shortage of contrast dye that is needed for CT scans. This has resulted in some medical centers rationing CT scans. Organizations are used to having to message patients to reschedule appointments due to physician emergencies or illness, but having to cancel imaging procedures due to lack of supplies is a bit new, so I imagine there’s new reports and new outreach campaigns being created by IT teams. Much like the shortage of intravenous fluids that happened after a Hurricane Maria devastated Puerto Rico, the supply chain is weakened by having too few locations for the manufacture of critical supplies. The shortage is expected to last a few more months and hope this leads manufacturers and distributors to rethink their manufacturing strategies.

Quest Diagnostics releases the results of its 2022 Health at Work survey. They queried 800 workers at companies that had at least 100 employees about what kind of health plan benefits would encourage them to stay with their companies. They were also asked to weigh in on at-home healthcare. Although the majority of respondents (nearly 90%) believe health screenings and wellness initiatives are important benefits, they had concerns about privacy and how much their employer might be learning about an individual’s health. More than two-thirds of workers didn’t want their employers to know the results of health screenings, and more than half had concerns about employer involvement in patient healthcare. Employees are enthusiastic about at-home testing including biometrics and felt they would take advantage of more screenings if they could do them at home. A majority said that telehealth was a desirable benefit.

Remote monitoring is an exciting technology, but a recent article in JAMA Internal Medicine questions the outcomes of remote monitoring in managing heart failure patients who have been discharged from the hospital. It should be noted that the study was small – 290 men and 262 women – and the mean patient age was 64.5 years. The participants were randomized either usual care or to remote monitoring of medication use and weight management with financial incentives for adherence. The primary outcomes were time to hospital readmission and death. Researchers found that there was no significant difference in outcome scores over 12 months.

Personally, I’d like to see some slightly different research. For example, what does the data look like for using remote monitoring to prevent hospitalizations in the first place? Is the data different for patients in different parts of the country since this study was done regionally? I’d also be interested to understand how much patient involvement was present in the remote monitoring, and whether outcomes are better if patients have to be more or less involved in the monitoring.

The best article I saw this week was this: “Effect of Genre and amplitude of music during laparoscopic surgery.” Researchers proposed that since music is often present in the operating room, they’d like to examine the effect of different types of music and different volumes on surgical performance. The research subjects were “novice surgeons” who were measured on their performance of laparoscopic surgical techniques. Music was either soft rock by the Beatles or hard rock by AC/DC and was played at medium or high volume. Surgical task performance was measured on speed and accuracy. Those hearing soft rock at medium volume were faster and more accurate than doing those tasks without music. When the soft rock was played at high volume, the improvements were lost. Hard rock at medium volume led to faster precision cutting compared to no music. Hard rock at high volume also led to increased speed. The authors concluded that “our data reveal that the effect of music… might depend on the combination of music genre and amplitude. A generally well-accepted music genre in the right volume could improve the performance of novice surgeons during laparoscopic surgeries.” I discussed with my surgical colleagues and they would like to understand whether outcomes are different for experienced surgeons, but no one is ready to draft a research proposal just yet.


Shoes of the week: This sassy shoe-sock combo was spotted a conference tweet. They look very comfortable and I’m a sucker for sparkles, so if anyone has the details on these, I’d love to know where I can get a pair.

What’s your go-to slip-on shoe? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/9/22

May 9, 2022 Dr. Jayne 1 Comment

I spent a good chunk of the weekend outdoors, enjoying some quality lakefront time while spring is here. Despite the copious pollen, it was still much more enjoyable than when summer hits and you’re debating whether the humidity or the mosquitoes are more oppressive. Still, when I got home, my tent needed a full wash to get the pollen out, and my quick air out took a little more time than planned. Waiting for it to dry before I could finish packing up all my camping gear gave me an opportunity to complete the Continuing Medical Education evaluations that are required for me to get credit from my recent conference attendance, and to try to wade through all the email that accumulated while I was away last week.

I also spent some time today with my extended family, who wanted me to explain what it really is that I do for work. They know I don’t see patients in person right now, but think I see patients on Zoom, which is good enough for me. They don’t really get what a CMIO does though, or what clinical informatics is, and sometimes trying to explain that is difficult. I try to give examples of the kinds of projects I work on, but I think even those are sometimes hard for people to really understand.

The one thing that usually resonates is when I talk about coaching physicians how to better use computers when they’re seeing patients. That understanding is usually accompanied by one of two stories. The most common story used to be that their doctor spends too much time looking at the computer and not at them. That’s becoming less common, which is a good thing. Now I hear a lot more stories about people’s experiences messaging their physicians through patient portals, which is good as far as portal adoption.

I actually had a conversation about that topic a couple of weeks ago with an EHR colleague. We were talking about the ways that different healthcare organizations approach the idea of encouraging patients to sign up for their patient portals. Some organizations bend over backwards to get patients to sign up. They may have staff in common areas who use a kiosk to try to get patients enrolled, or they may initiate an activation process during the rooming activities in the exam room. If organizations have highly developed process for portal utilization, they benefit from having more patients activated. This could be a financial benefit through reduction in paper billing statements, reduction in the time it takes for patients to pay bills, or reduction in staff costs due to telephone volumes for patient messages and appointment scheduling.

Other organizations however are less aggressive, and it feels like they are just hoping patients will stumble upon the patient portal and decide to sign up. A third group of organizations seems to just want to make it easy for the patients to do the workflows that a patient portal brings to the table but doesn’t necessarily want to require patients to sign up for an account.

Although I totally understand wanting to make things easy for patients, I think that approach will ultimately undermine patient adoption. Why? Because I see it in other industries. I know plenty of people who will go online every month and pay their utility bills, but won’t take the time to complete the process of signing up for automatic bill pay. Having a streamlined monthly process reinforces the customer’s action and they’re willing to do it again. But they’re not making the logical leap to understand that they could spend five minutes once and never have to go to the website again, versus spending two minutes each month for the rest of their lives paying that bill.

Not to mention that by not starting to fully embrace the use of the patient portal, they’re not able to use features such as those that might help with health promotion and disease management. They may also be missing out on the bells and whistles of being a registered user, such as being able to serve as a proxy or delegate for the accounts of children or elderly relatives, which generally aren’t available in the more freestanding workflows. Every EHR vendor handles these workflows in a slightly different way, but I see quite a few moving in the direction of “portal-lite” functionality to try to streamline patient access.

One hospital administrator I spoke with a few months ago tried to justify the fact that his organization isn’t spending any money on portal enrollment or activation efforts by saying that “our patients won’t use it because of XYZ reason, so we don’t want to waste the effort.” I think he is sorely mistaken for a couple of different reasons. First, many of the reasons that are often cited are not necessarily valid. People often think that older patients won’t be willing to use patient portals and for those tech-savvy elders, nothing is farther than the truth. If a patient is following their children or grandchildren on social media, in my experience, they are likely to be willing to use a patient portal, especially if it makes communication with their physician faster or easier.

People also think that not everyone has access to a computer or smartphone, and although that’s true, the percentage of patients who have access to those devices is climbing. Looking at 2018 data from the US Census Bureau, 92% of houses had at least one type of computer and 85% had broadband internet. Smartphones were present in 84% of households where 78% had desktops or laptops and 63% had tablets.

When thinking about the access argument, the truth is this. You don’t need to have 100% adoption to have a successful patient portal initiative. Even if you can get a percentage of your patients to enroll, and a percentage of those enrollees become active patient portal users, everyone can benefit. Patients can take advantage of self-scheduling workflows, which frees up office or call center staff. They can receive test results quicker, which often reduces phone call volumes as patients try to follow up on results. They can access visit notes, patient education materials, and care plans, which can not only reduce phone calls, but might also contribute to improved clinical outcomes.

With all that potential, it’s difficult to understand why organizations are slow to push for patient portal adoption.

What is your organization’s current patient portal strategy? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/5/22

May 5, 2022 Dr. Jayne 12 Comments


Those that follow me on Twitter know what I’ve been doing this week as I traveled to the rolling hillsides of Verona, Wisconsin. Epic’s Expert User Group (XGM) meeting was in its second week, with a heavy focus on clinical topics. It was great to catch up with some old friends, most of whom I worked with on other EHR systems across the last two decades. Each hospital and health system has certainly had its own healthcare technology journey, but it’s clear that for quite a few of them, all roads have led to Epic.

I’ve attended a variety of user groups across most of the major vendors and there are quite a few elements that set Epic apart as far as meetings. Rather than having to rely on hotels or conference and convention centers for meeting space, Epic’s purpose-built facility makes things incredibly easy for attendees. Presentation rooms are interestingly named, amusingly decorated, and full of light – unlike the cavernous spaces divided by portable walls that many of us are used to when we go to meetings. The meeting area also featured booths from various local vendors selling various kinds of cheeses, chocolates, locally produced soaps, and more. I enjoyed seeing everything Wisconsin has to offer and from the number of sales transactions, it appears others did as well.

Another thing that sets Epic apart is its outstanding culinary team. I’ve had plenty of questionable meals at conferences, but the menu selections at XGM were truly over the top. There’s a definite “farm-to-table” feel with lots of healthy offerings. Goat cheese and asparagus options appeared at several meals, which made me very happy, as I like them but don’t often cook them. Attendees were even able to download a 95-page document with recipes in the event they wanted to replicate the experience at home. I’ll definitely be availing myself of the recipe for scones.

Many attendees toured the campus, although rain on Tuesday put a small dent in that. It’s been great meeting other physicians involved in clinical informatics work, especially in disciplines that I haven’t worked in for a while. I enjoyed learning about different groups’ approaches to trauma-informed care and how to use EHR tools to better support patients. One of my favorite presentations was by UCLA Health, which has been using Natural Language Processing to identify patient portal messages that contain high-risk topics. It allows clinical care teams to address those messages more quickly, which hopefully will lead to improved outcomes. The team acknowledged the impact that the COVID pandemic has had on its work, and I know there was a lot of sympathy from audience members whose own projects may have been sidetracked or even canceled as a result of changes in organizational priorities.

It’s always a challenge to balance what’s going on at your day job with attending a conference, and I had a couple of conversations with physician informaticists who were reacting to the idea of a Supreme Court decision overturning Roe v. Wade. My OB/GYN colleagues are noting increased patient demand for appointments to place long-acting contraceptive devices as well as those to discuss prescriptions for emergency contraceptive medications. With several states having laws in place that would go into effect immediately upon the event of an overturn, I understand their desire to be proactive. There have been requests to alter physician schedules to add procedure slots as well as to create outbound patient portal messaging to try to reduce the number of phone calls the offices are receiving. Life as a clinical informaticist is certainly never dull.

The COVID-19 pandemic changed the landscape for virtual contraceptive services, which were offered by the majority of clinics surveyed for a recent article. Pre-pandemic, only 11% of those surveyed offered telehealth consultations for contraception, with the number rising to 79% after March 2020. Apparently, 22% of those surveyed had drive-through contraceptive clinics. Although I don’t recall hearing about any of those in my area, it’s a great idea. I found it interesting that 20% of people closed their in-person clinics and only offered services via telehealth. The study had a relatively small sample size of around 900 respondents. It will be interesting to see what happens to this landscape in coming months.

In speaking with other attendees, behavioral health continues to be a hot topic. There are too few providers to meet demand and organizations are looking to creative offerings such as teletherapy and self-service interventions for patients. Staffing challenges were also a common theme, and organizations are looking to use pre-visit questionnaires to help gather data prior to the visit so that the patient rooming process is more efficient. Automated alerts to let patients know when their care teams were running late are gaining traction. Many of the solutions presented by clients focused on shifting various tasks from the staff to patients. Although those moves can definitely support patient engagement, they’re also ways to help mitigate staff burnout. Many organizations are still struggling to hire office-based nurses, medical assistants, care coordinators, and patient care technicians, so they’re looking for whatever efficiency boosts they can find. It sounds like there are a lot of optimization projects going on, with hospitals trying to fit that work in before a potential next pandemic wave.


On Wednesday, which happened to also be Star Wars Day, a couple of presenters included Star Wars references in their slide decks, and I spotted several attendees in costume. I closed out my meeting experience with a trip to “Xtra Hour,” which was advertised as a social event for food and fun at the end of the day. The event featured a variety of food and drink, including a lovely crab and leek appetizer and sparkly galactic-themed lemonade. I heard the mini cupcakes were good as well as the mini meringue desserts. Attendees had the chance to take part in several activities including craft projects and giveaways, and of course there was plenty of good old-fashioned socializing. Then it was back to the hotel to put my feet up and to pack so I can head home in the morning. Overall, it was a great experience and I’m heading back with a notebook full of ideas and thoughts to make life better for my end users and their patients. I was also happy to be able to have in-person encounters with many of the people I work with regularly. Building relationships is always one of my favorite parts of these events.

What is your favorite part of a user group meeting? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/2/22

May 2, 2022 Dr. Jayne 1 Comment

Today is truly a cleanup day. I’m plowing through 2,300 unread emails. Some days you just can’t make things up with the stories that are out there.

The US Department of Justice announces that a Long Island cardiologist has been charged with crimes related to a COVID-19 healthcare fraud enforcement action. He is alleged to have defrauded Medicare and Medicaid of more than $1.3 million in payments related to COVID-19 testing as he submitted claims to those payers for office visits that were not performed in conjunction with COVID-19 testing. The defendant’s practice had mobile testing sites across Long Island, and apparently some of the billed office visits occurred when the defendant wasn’t even in the state. The prosecution is part of a larger effort by the Department of Justice to crack down on those exploiting the ongoing public health emergency. Criminal charges have been filed against at least 21 defendants for COVID-related healthcare fraud and total nearly $150 million in false claims. The overall Medicare Fraud Strike Force, which was formed in 2007, has gone after more than 4,200 defendants who fraudulently billed Medicare for over $19 billion.

Just a little over a month ago, medical students across the US learned where they’d be doing their training as a result of the National Resident Matching Program. This article about a participant who didn’t match caught my eye. Travis Hughes completed both MD and PhD degrees at Harvard and had a lengthy curriculum vitae with numerous publications and four patents, yet still didn’t match into his desired field of dermatology. More than seven percent of fourth-year medical students in the US failed to match, so he wasn’t alone, although his qualifications likely make him unique. Rather than lament his situation, Hughes used the experience as the push he needed to move towards a career in healthcare technology.

I’m often contacted by people in similar situations looking for advice on moving into healthcare technology or clinical informatics. Not only do unmatched graduates reach out, but those who are in their last year of medical school and who have decided that clinical practice is not for them.

I’m supportive of people finding their bliss in medical careers that don’t involve seeing patients, but have some advice for individuals in this situation. First, just because you graduated from medical school doesn’t mean that you understand what it takes to become a board-certified practicing physician. There’s a lot that happens during the three to seven years of residency training and no amount of reading about it or having friends who are in residency is going to help you become equivalent.

Second, if you’re going to try to find solutions for practicing physicians, you need to understand what happens once you are in practice. Learn what a RVU is or how physician compensation is influenced by patient satisfaction scores and clinical quality metrics. Learn how hard it is to keep a medical practice staffed to a level that provides high quality care but runs as cheaply as corporate employers require.

Third, please don’t talk to practicing physicians like you’ve been in their shoes. Over the past two years, I’ve had many patronizing encounters with physicians who have gone the start-up route. I don’t want to hear about how you dropped out of a surgical subspecialty residency the year before graduation, yet you think you understand what it feels like to be a practicing family physician or an emergency physician dealing with COVID. Sure, you can talk about how you understand the market forces and the pressures we’re under, but you certainly haven’t been there or done that. Also don’t talk about patients like they’re numbers or widgets, because those of us who really treasure the patient/physician relationship aren’t likely to warm to that strategy. If you want to impress us, make sure we feel like you understand that those patients are someone’s mother, grandfather, sister, or child.

Finally, if you’ve decided to take a different path in your career, get some training. If you want to go into clinical informatics, maybe you should join the American Medical Informatics Association. Consider taking one of the 10×10 courses that they offer in partnership with Oregon Health & Science University. Do a fellowship in clinical informatics. Don’t post on physician-focused Facebook groups that you’ve just decided to go into informatics and ask how to get jobs with no experience and no training. Definitely don’t demand that people call you and give you career guidance because you’re too lazy to spend some time on the internet figuring out what it takes to be qualified in the field.

I do wish good luck for all those who are contemplating career changes or who did not match. Much work is ahead and it’s a difficult road. Hopefully, this advice might provide a small amount of insight for those walking it.

I’m doing a fair amount of work with various vendors and have been invited to participate in multiple vendor user group meetings for the upcoming season. While some vendors are going back to their tried-and-true pre-COVID meeting plans, others are using the opportunity to make changes to format and desired attendee profiles. There have been a few recent in-person meetings since HIMSS, and by report, the attendance has been less than previous years. Epic kicked off its XGM Expert Group Meetings last week in Wisconsin and they continue through the end of this week. The American Telemedicine Association meeting is also happening this week in Boston. I’d love to hear from attendees as far as their boots on the ground experiences as well from others who have decided not to attend conferences right now. At least one major health system that I interact with has continued to restrict business travel for the remainder of 2022. They’re not saying employees can’t travel, they’re just refusing to pay for any of it, blaming it on COVID.

Although various states, jurisdictions, and businesses have collectively decided that COVID-19 is over, it’s starting to make a return in my area. Several schools are hitting the thresholds for which students and teachers have to resume masking. I’ve got a couple of flights this week, and despite the airlines’ movement to a mask optional arrangement, I’ll be sporting a KN-95. Even though the COVID infections that most people are getting now are relatively mild, we’re starting to see much more long-term data that shows that even people with mild infections are at higher risk for cardiovascular and other complications. I’ve dodged it so far and am hoping my luck holds.

From a patient care perspective, it’s the school and sports physical season as young people get ready to go away to camps or to prepare for fall sports. Our state has instituted a special process for return to play in youth who have had COVID, and we’re finding quite a few athletes who aren’t as healthy as they thought they were before we started asking some very pointed questions.

Is COVID-19 still playing a role in your habits or travel plans? Is your employer still requiring any mitigation strategies or is everyone back to the office as usual? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/28/22

April 28, 2022 Dr. Jayne No Comments


Half a dozen people sent me this article about Teladoc’s stock woes following recent statements on its outlook. Based on the comments of company leaders, it seems their customer acquisition costs are higher than anticipated. They also cited lengthy sales cycles as a barrier to growth.

Having been on both the health system side and the vendor side of the process, everyone underestimates the length of the sales cycle. My former hospital employer locked in budgets in July of the preceding year, and if you wanted to buy anything that wasn’t previously budgeted, you had to figure out how to fund it from your allocated bucket. Even if you were replacing a system with something newer and more efficient, you better not cross the red line with implementation or consulting fees. This ultimately led to a glacial experience for vendors trying to bring new solutions to the organization.

There have been some interesting articles in the telehealth literature of late. One looked at rates of antibiotic prescriptions for acute respiratory infections and compared performance by hospital-employed physicians to that of third-party contractors. There was a higher rate of antibiotic prescriptions by the contractors. Although the conclusions have received a lot of publicity, I think the results demonstrate that additional analysis is needed. The study looked at telehealth visits for health system employees and dependents between March 2018 and July 2019. The study was controlled for patient age, day of the week, and overnight visits. It only looked at 257 telemedicine encounters for acute respiratory infections.

In my experience as a telehealth provider and CMIO, the study didn’t look at some variables that can influence prescribing patterns. Number of years post-training can indicate whether the physician’s formative years occurred in the “less is better” era of antibiotics. There have been a lot of semi-retired physicians in my telehealth groups who might not be as close to current evidence as we’d like. Importance of patient satisfaction scores is another factor, and I’ve seen plenty of prescriptions issued in both the telehealth and in-person arenas by physicians who didn’t feel empowered to say no because of the potential impact on patient satisfaction scores. Method of compensation can also be an influence when physicians are paid on volume – it takes more time to explain why you’re saying no, which means lower wages for those providers versus those who are being paid a shift rate or who are compensated using other variables.

It also didn’t note whether the physicians were practicing on the same EHR system or whether the telehealth vendor had its own platform. I’ve practiced with three national telehealth vendors and none of them had the same level of clinical decision support that I’ve had in a health system or large practice EHR.

Last, it didn’t look at the presence or absence of quality metrics and reporting. In my health system-employed jobs, I’ve received a monthly quarterly metrics package that directly impacted my pocketbook as well as my understanding of my behavior. In my telehealth-only gigs, quality was only addressed robustly by one vendor and two of them didn’t deliver reports packages to me at all. None of the telehealth-only organizations offered bonuses or penalties tied to quality. I suspect that even if you had third-party physicians, if they were practicing on the same EHR and received the same quality measures reporting, compensation structure, etc. that the numbers would be similar.

It would also be interesting to look at data from the post-COVID world, when most organizations made significant leaps forward in their application of telehealth. Systems used in 2018-2019 were fairly rudimentary compared to what we have today, not to mention that physicians’ experience with telehealth visits has grown exponentially. Hopefully someone will do research to look at the impact of the rest of these factors as I suspect there is more to the story than meets the eye.

Telehealth also took a hit in this JAMA Network Open piece looking at follow-up patterns for acute conditions compared to chronic conditions. For acute problems, patients who had an initial telehealth encounter were more likely to have a follow-up encounter, including emergency department encounters and inpatient admissions. For patients with chronic problems, patients who had an initial telehealth encounter were less likely to have a follow up encounter. The authors note that there are some potential problems with uncontrolled confounding bias. They provided the example of the bias in deciding whether to deliver an encounter via telehealth or in person. They also noted the need to look at other clinically important factors, such as frequency of laboratory testing and prescribing or adjusting of medications. The study was limited to commercially insured patients and didn’t include subjects with Medicare, Medicaid, or no insurance. We know those patients often have significantly different care experiences that would be worth examining.

Thank you to all who reached out regarding my recent post on EHR downtime and medical errors. Many of you had gut-wrenching EHR downtime stories to share. I appreciate the stories but am saddened that we are all part of this club we never wanted to be a part of. Several readers noted the need to have ongoing downtime education – not just when people join the company or at the same time of year that everyone has to churn through annual HIPAA, Compliance, and Fraud / Waste / Abuse training. Others suggested practice downtime events to make sure people know when and how to declare a downtime, as well as where materials and supplies are located. Both strategies would certainly help, so thanks for bringing them front and center.


I’ve been having difficulty sleeping since the recent time change, which was confounded by multiple trips from one coast to another. I’m not into pharmaceuticals and even some popular supplements like melatonin have fallen out of favor. It’s been a rough couple of weeks, so I’m back in pastry therapy. For your consideration, I present a new take on the classic pineapple upside-down cake. With the right amount of brown sugar and butter, you really can’t go wrong.

What’s your favorite stress-relieving pastime? Leave a comment or email me.

Email Dr. Jayne.

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  2. "Ascension Via Christi sent several ICU nurses home after they raised concerns about inadequate staffing." Nice. That'll show em.

  3. Thank you for sharing the full HIStory file. What a great tribute to Mr. Ciotti. “Those who cannot remember the…

  4. "Epic will roll out a “patients like this one” type tool to its users in Indiana this summer. It will…

  5. I don't see Cerner winning employee satisfaction surveys. I can't see VHA pivoting to Epic. It's going to be some…

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