EPtalk by Dr. Jayne 9/1/22

There’s an often-cited study in the primary care literature that looks at the number of hours a physician would need to spend each day to perform the recommended care for a standard panel of patients. The problem was that it hadn’t been updated in years. Earlier this month, a study was published in the Journal of General Internal Medicine that updates the info and confirms that the situation hasn’t gotten any better.

Researchers from the University of Chicago, Johns Hopkins University, and Imperial College London found that primary care physicians would need to spend nearly 27 hours each day in order to provide all the guideline-based care needed for a hypothetical panel of 2,500 patients. The breakdown includes 14.1 hours for prevention, 7.2 hours for chronic diseases, 2.2 hours for acute care, and 3.2 hours for documentation and wrangling the inbox.

The authors used data from the 2017-18 National Health and Nutrition Examination Survey (NHANES) and the 2020 care recommendations to develop the projections. The statistics seem grim, so what’s the answer? Most agree that team-based care needs to be the norm and not the exception. The authors took the same requirements to see how they could be delivered by a team. That approach would reduce the physician component to 9.3 hours per day, with most of the savings occurring in the areas of preventive care and chronic disease care.

In this model, counseling might be delivered by a dietician, nurse, or other member of the support staff. The authors noted, however, that many practices are already using teams to deliver a variety of pre-visit screenings and counseling, so the ability to improve this might be variable. They went further to conclude that even with team-based care, the requirements would be “excessive.”

Another potential solution would be for physicians to have fewer patients on their panels, although this wouldn’t do much to ease the primary care shortage. Overall, fewer patients generate fewer appointment requests and fewer phone calls. The reality is that many of the organizations that employ physicians won’t let them close their panels to new patients without a lot of weeping, wailing, and gnashing of teeth. I once did a consulting engagement with a group that forced physicians to take new patients until their panels were so large that they couldn’t provide any same-day care and the wait for routine care was several weeks. When physicians work like this, they feel like they’re on a perpetual hamster wheel and that they can never catch up.

Yet another solution would be to shift some of the work to the patients themselves  through self-service programs or outreach. It’s fairly easy for organizations that have implemented certified EHRs to generate lists of patients who need a particular service and queue them up for outreach. Even if you can pick off a certain percentage of the patients by delivering asynchronous education through a patient portal, you’re still helping the practice with workflow. Throw some patient self-scheduling on top of it and that’s a winner.

I’m still baffled by the number of practices that won’t allow patients to self-schedule for routine visits. When I press the issue, they’ll argue with me that self-scheduling doesn’t help the provider. I counter that it can when the FTE employee positions that used to schedule are instead redeployed as more clinically relevant roles such as health coaches, care navigators, etc.

Automation can be a big piece of the solution as well. I’ve seen some very cool functionality recently that allows automated rerouting of patient messages based on their content, so that the most appropriate staff member can manage them as opposed to everything having to come through the physician first. It can also be used to send pre-visit questionnaires to patients to help identify whether they’re doing well with their chronic conditions or whether they’re having issues that might merit another team member helping with the visit, such as a pharmacist, social worker, or health coach. Questionnaires can return data that can auto-populate the visit note, reducing documentation time.

Not all patients will be amenable to reading patient education materials via a patient portal, or to interacting with a chatbot or other virtual assistant, but at this point offices are so congested that any number of patients you can divert from the “same old, same old” workflow is a bonus. There’s often an argument that older patients aren’t candidates for digital engagement, but I call baloney on that. Thinking of the retirees with whom I interact the most, they might have some small struggles with technology, but overall they find their time to be valuable and are willing to try solutions that might allow them to spend more time with their grandchildren versus hanging on the phone with a medical office.

Most of the primary care colleagues I reached out to about this updated research said they feel the drain of all that work directly and on a daily basis. One recently decided to give up primary care because she didn’t feel she could deliver the kind of care she wanted to do, or was trained to do, with the constraints her employer had placed on her. She isn’t able to hire additional team members and is expected to run a full family medicine panel with only one medical assistant helping her, which is ludicrous. Several have closed their panels to new patients, and others are limiting office hours. The only ones that sounded even remotely hopeful for the future were the ones who had transitioned to Direct Primary Care models, where they’re only caring for 200-400 patients at a time versus the thousands that physicians are conventionally expected to manage.

One colleague I spoke with said that society needs to double down on public health education everywhere, not just in the physician office. Patients need to make healthier choices and need to be hearing about prevention regularly, not just during an annual visit. Healthier patients make for much quicker and easier office visits than those featuring patients with multiple chronic conditions. However, requirements for health education have been cut in many schools and we’re certainly not flooding the airwaves with evidence-based health education. I’ll keep doing my part with healthcare IT, advocating for patient engagement, outreach, automation, and increased self-service options. I’ll lobby my representatives to support public health efforts.

What do you think is the answer to the ever-expanding burden placed on primary care delivery organizations? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/29/22

I spent most of last week at the Epic Users Group Meeting and I’m finally recovering. Although I’ve been to the Epic campus on other occasions, this was my first UGM. It was an outstanding experience.

This year’s theme was “Midnight at the Museum.” I can only imagine the amount of work that went into putting it on. Although most vendor user group meetings that I’ve attended have a theme, this was over the top, with many of the Epic staff dressed as characters from paintings, movies, museum exhibits, or as historical figures. Although many paid tribute to a movie of a similar theme — such as cave people, a centurion, and security guards — my favorites were those from paintings such as “American Gothic” and “Girl With a Pearl Earring.”

The theme was even used in unexpected ways, including as an explanation for a last-minute substitution of the conference bags they had planned to give out. It’s important to have a sense of humor when the best-laid plans fail to happen, and I give them full credit for running with it.

After checking in and picking up my badge and the substituted tote bag, my colleague and I headed to the traditional Campfire event, which is also a “Taste of Epic” and a chance for the legendary Epic culinary team to shine. The menu included pulled pork sliders, two kinds of stuffed grape leaves, shrimp with tortilla chips, and fried lotus root. I had never tried the latter and was pleasantly surprised. The campfires are real and there were s’mores stations, but I opted to go for the “deconstructed s’more” approach to avoid getting next to the heat since it was already unseasonably warm. The banana pudding did not disappoint. There were plenty of Epic executives out chatting with attendees.

Monday morning I was up bright and early for the trek to campus because I wasn’t sure what traffic would be like. Although they run buses from most of the conference-related hotels, I decided to drive myself due to some post-conference commitments. It was an easy commute. After breakfast, we dove straight in for educational sessions.

I like the Epic format better than other conferences I’ve attended. The majority of the sessions are 40 minutes in length to allow for a 30-minute presentation, 10-minute Q&A, and then a 20-minute passing period. That’s a good length that forces presenters to be concise and focused and allows for attending more presentations versus being in longer ones. Some of the Epic-presented sessions are longer because they are going more in depth with functionality, but they still felt well paced. Audiovisual setups in the presentation rooms were solid, with most rooms having dual projection of the presenters’ slides.

Lunch was my first trip to “the Tent,” which can only be described as ginormous. There was outdoor seating via picnic tables and high-top tables along with lawn games. Inside was a tremendous amount of seating along with various museum-themed exhibits, photo opportunities, costumed staff, and ample buffet lines to keep thousands of attendees moving. I appreciated the nod to sustainability with refillable water bottles and easily accessible filling stations along with recycling bins everywhere that trash bins were located. The short walk from the classrooms to the tent was a nice excuse to get out and enjoy a little fresh air and the beautiful blue skies.

After lunch, I spent a few minutes perusing some local vendors that were set up in one of the common areas. Vendors were sampling cheese, chocolate, and of course mustard since the National Mustard Museum is located just a short hop from campus.

In the afternoon, I stopped by the exhibit hall, which I really enjoyed. Half the space was full of Epic’s “Meet the Experts” booths, where attendees could connect with developers and other key staff for each of the products. I’ve been to other user meetings where development and product teams all but hid from the attendees. It was great to see so many good conversations and plenty of ideas being exchanged. I look forward to seeing some of the ideas I heard discussed make their way into the software.

The other thing that’s different about the exhibit hall is the vendor space. Each vendor has the same size booth and they are relatively uniform. It’s more about substance than glitz, and the smaller format was conducive to conversations. I had a good conversation with IMO (Intelligent Medical Objects) and enjoyed their customized M&M giveaway as an afternoon pick-me-up. As always, the team from Healthwise was friendly and engaging and I enjoyed learning about the volunteer service that one of their reps does in their free time.

Tuesday morning contained the executive address, which was definitely something to behold. Thousands of clients pack the Deep Space auditorium, and many organizations bring decorated umbrellas, balloons, and signs to allow co-workers to find each other to sit together. All of the presenters were costumed in a way that tied to their presentations, with several teams re-creating famous paintings. Part of the presentation involves introductions of all the new clients, and Epic selects a song for each that ties to their name or location.

I wasn’t surprised to see some of my former consulting clients joining the Epic community and I’m certainly looking forward to collaborating with them on a new adventure. No matter where I’ve worked, the informatics community has been full of people who are willing to share best practices and work together to improve care for our patients and communities.

Dr. Jayne’s “Best in Show” vendor award goes to Nemours KidsHealth, which always has cute giveaways. This year they had mummy-shaped chocolates to match the museum theme. I mentioned their HIMSS giveaway of insulated grocery totes and their rep offered to send one to my teammate, which was sweet. The rep was hilarious and definitely held our attention. The Nemours booth was next to Iron Bridge, whose reps were also engaging and funny. The two of them were doing a little riffing off of each other along with the Nemours rep, which was fun to watch. I’ve staffed the booth at conferences in a past life and it can be exhausting, so kudos to these three for keeping it fun. They were still at the same energy level later in the week, which was impressive.

Kudos also to the Epic customer service desk, which happily produced an ice pack for my co-worker’s aching foot. She had injured it prior to the event and soldiered through the week, although she did take advantage of a cow-print golf cart to get to her car at the end of a particularly long day. I know I walked more than 19 miles and talked with what seemed like a thousand different clinical informatics professionals while learning dozens of things I want to take home and implement. I have numerous presentations to review since there were often multiple interesting sessions running at the same time. Our team did its best to divide and conquer, so we still have to put our notes together and share all the thoughts and ideas.

When I’ve written about visiting Epic in the past, readers comment about the cost of the campus. However, in talking with a couple of friends who work in the marketing and trade show space, being able to host your major events on your own property is a smart play. They’re not paying exorbitant convention center fees year after year, but rather are able to invest those expenditures in their own infrastructure. They’re not flying staff across the country, and their in-house culinary team delivered the best conference food I’ve ever encountered, probably at a fraction of the cost that vendors pay for hotel and convention catering. They’re not paying for big-name entertainment or keynote speakers-for-hire. Everything about the event just screams “good clean fun, and you’ll learn something, too.”

What’s the best or worst vendor conference you’ve attended, and why? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/25/22

This week has been a bit disjointed due to travel. I’m starting to wonder how I survived being a road warrior for so long earlier in my career. I traveled at least twice a month for a number of years and there was a predictable routine to it, unlike today. In the current state, it seems like delays and difficulties have become the norm and a smooth trip is a rarity. Whether it’s due to labor shortages, supply chain issues, or other factors, I’ve grown used to airports where restaurants are closed, amenities are limited, and rental cars are less than plentiful.

I’m working on a project right now to increase accessibility to behavioral therapy services, particularly for patients who are dealing with anxiety, depression, and overall stress. The need for these services far outstrips the supply in some areas, and patients are looking for solutions that they can access during non-traditional hours as they try to juggle responsibilities at work and home. There is a particular need for services targeted towards adolescents, who are experiencing mental health diagnoses in ever-growing numbers.

As I was looking for statistics, I came across this opinion piece from the spring that suggested “It May Be Time to Ban Kids From Social Media.” I certainly know plenty of adults that struggle with social media. Family physicians and pediatricians have been speaking for years about the amplifying effect it can have on already existing social issues in pre-teens and teens.

The author cites a study that was published in Nature Communications that looks at which specific time windows of development have the most sensitivity to social media’s influence. The study, which looked at data from the UK, found that there were distinct impact windows for both males (14-16 years old) and females (11-13 years old), where higher estimated social media user predicts a decrease in life satisfaction ratings one year later. Both sexes also experienced a dip at age 19. He notes that it’s difficult to study these phenomena because of challenges identifying correlation versus causality and that using the one-year lag is helpful in trying to “tease out causality.” The authors of the study noted a feedback loop where increased social media use led to decreased life satisfaction, which led to increased social media use, and so on. The study was unable to separate the different types of social media use or platforms used, which is also a limiting factor.

Mental health issues in adolescents have been on the rise long before the COVID pandemic, and social media seems to be a significant contributing factor for many of the youth I encounter regularly. Gossip that used to spread within a given class grade level over several days at school can now spread to the entire school in seconds. Legislation to prevent children under 13 from having social media accounts has been in place for more than two decades, but I’m constantly encountering parents (including physicians) who help their children subvert these protections due to perceived fear of missing out or frankly giving into peer pressure. It’s interesting and often appalling to listen to the explanations given for parents who know they’re doing something that could harm their children but who don’t feel empowered to say no. Only time will tell how much of a public health threat social media really is, but it seems like we’re already past the point where the genie could be put back in the bottle.

Speaking of the teenage years, I started my medical career in earnest as a Candy Striper in a local hospital. That designation is likely long gone, replaced by “teen volunteer” in the early 1990s in most hospitals where I’ve worked. In a post-HIPAA era, I’m sure there were privacy concerns with regard to underage volunteers, and in many institutions, volunteer roles were significantly impacted by the pandemic. I volunteered with my best friend who wanted to be a nurse and it was a great experience.

Especially if they are considering healthcare, it’s important for young people to take a closer look at the careers they are considering. Our local school district has a health careers program as part of its vocational education offerings, where students can learn formally and build experience while completing their normal high school course work. I enjoyed reading a recent article about what hospitals should consider when hiring teens. One of the executives noted the emotional toll of his own daughter’s employment in the hospital’s food and nutrition area, especially when working with sick patients.

The article notes that Ohio’s Mount Carmel Health System lowered its hiring age from 18 to 16 in September 2021. Initial teen hires are working in environmental services, nutrition services, and patient transportation roles. Earlier this year, the organization created a patient-facing student support associate position and is working to onboard those who are enrolled in nursing or pre-nursing programs. The associates assist with tasks that are normally assigned to patient care technicians, such as taking vital signs, assisting with bathing patients, and helping manage equipment and supplies.

It’s a smart move, especially given the nationwide nursing shortage, since young people who have a positive experience with a given hospital might be more likely to consider a long-term role there once they have completed their training. It’s challenging, however, due to the limited hours that students can work.

It’s nice to see students be paid for the work that we did for free as Candy Stripers. We did a lot of running between our assigned floors and the central supply department, refilled ice and water pitchers, prepared ice packs on the postpartum unit, ensured that linen carts were filled, and sometimes even delivered medications from the pharmacy to nursing units. One of my favorite jobs was working in the hospital gift shop, which was a nice break from using the addressograph machine to apply unique demographics to paper chart pages. Keeping the shelves stocked appealed to my sense of order and helping the adult volunteer who was intimidated by the brand-new electronic cash register might have been the beginning of my career in technology and end-user coaching as well.

Here’s to all of us in healthcare who started as Candy Stripers. If you have a favorite story to share, leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/22/22

In many ways, I’m still recovering from the years I spent as an in-person urgent care physician, especially during the COVID pandemic. The organization where I spent a good chunk of my career was a well-run practice when I joined, but a series of events led to an ongoing downward spiral that resulted in tremendous staff turnover and contributed at least in part to loss of more than one life.

An event that finally convinced me to leave was the acquisition of the organization by a private equity firm and the subsequent chaos that change introduced. My former partners and the PE firm are still suing each other years later and the practice is in shambles. Staff members who were relocated to other states to grow the business by developing new locations were stranded when those sites were put on pause.

I was gratified to learn that there is an organization that keeps an eye on these things. The Private Equity Stakeholder Project (PESP) released a recent report that looks at the impacts of PE firms acquiring urgent care facilities. To be honest, private equity is everywhere in frontline healthcare delivery these days. Ambulatory surgery centers, dermatology practices, OB/GYN practices, and ophthalmology practices are big targets due to their revenue streams.

The PESP issue brief notes how urgent care centers benefit from a lax regulatory environment that allows them to escape the level of scrutiny that is paid to hospitals and other healthcare providers. Only 10 states require facility licenses for urgent care clinics, while in the rest, they operate under an individual physician’s license or a hospital’s license. Not surprisingly, private equity was involved in approximately 50% of all urgent care transactions from 2012 to 2020.

Additionally, the report notes that recent surprise medical billing regulations may provide loopholes for urgent care centers that will negatively impact patients. It’s no surprise that patients are drawn to urgent care centers, which can treat a variety of non-life-threatening conditions more quickly and economically than the emergency department. The brief notes that as of 2019, it was estimated by the Urgent Care Association that urgent care visits counted for 23% of primary care visits and 12% of all ambulatory physician visits. That’s a significant amount of primary care that is potentially being delivered in environments that don’t have the same supports in place as a traditional primary care practice, or by those who are not actually trained in delivery of high-quality primary care. I’ve used several EHRs that are specifically marketed to urgent care practices and those systems lack the content that is needed to manage chronic conditions or to ensure that preventive care is being delivered.

It goes on to note the tactics used by PE firms to improve cash flow, including adding service lines, reduced staffing, expanding the use of unlicensed staff, and pushing unnecessary high-dollar procedures. I’ve had a front-row seat to all of these, and unfortunately, it’s often reinforced by patient perceptions of technology and its role in good care. For example, patients often place more value in a CT scan than they do in a physician’s clinical skill. They specifically ask for laboratory testing and x-rays when they’re not clinically indicated, and physicians who don’t order the studies anyway are often penalized with poor reviews. Technology has become a proxy for experience and skill. That approach not only raises costs, but can lead to worse outcomes when there are slightly abnormal incidental findings on the tests that weren’t needed in the first place, which in turn leads to more testing, patient anxiety, and costs.

Prescription medications and polypharmacy are also part of the equation, especially when clinics are running their own pharmacies and dispensing medications on a cash basis. One urgent care I consulted for actually maintained a metric on their providers, scoring them on how many prescriptions they issued per visit. Leadership dinged them if they sent scripts to an outside pharmacy where patients could use their insurance. This was all supported through elaborate “talk tracks” that the staff was forced to memorize and use.

The process went like this. First, all prescriptions were filled in-house without asking the patient their preference. When the clinical associate went into the room to discharge the patient, they carried the medications with them and walked the patient to the checkout counter with no mention of the fact that the prescriptions had been filled on a cash-pay basis. When the patient arrived at the checkout counter, they were asked to “please sign here to indicate you received your medications” without explanation that the sheet was approval to charge for the medications.

If the patient complained, the checkout team had a speech about “filling the medications here as a convenience” without mentioning that some of the commonly used generics were more than four times more expensive than pharmacies charge cash-paying patients. When you have providers giving four or five questionably-indicated medications per urgent care visit, that really adds up.

If patients still balked, there was a speech about how important it was for patients to be compliant with all the provider’s treatment recommendations, and that failing to do so could place their health at risk. While that’s  generally a true statement, using it to coerce patients into purchasing prescription versions of medications they can buy over the counter or might already have at home is quite a stretch. There were a couple of additional talk tracks that staff could use at that point. 

If the patient still refused, the staff would take the medications and the billing sheet and walk them back to the clinical area to try to find a provider who could send the prescriptions to the pharmacy. The practice refused to install the capabilities needed to legally prescribe controlled substances electronically, so  those had to be manually printed and signed. Patients who had been to the practice before and knew the game and knew their insurance coverage or how to get the cheapest medications in town were savvy enough to tell the provider to preemptively send the prescriptions to the pharmacy versus going through the whole in-house pharmacy charade.

There are times where having a prescription filled in-house is worth an upcharge for convenience. A couple of those situations might include treatment of an infection requiring antibiotics that is diagnosed at 7 p.m. when many pharmacies are closed, or filling a prescription for a harried parent with four children in tow who doesn’t want to deal with lines or delays at a short-staffed pharmacy. Still, it should be the patient’s choice, and for many of us, ethics dictates that they should understand their options before choosing. That takes more of someone’s time at the bedside, whether it’s a licensed individual or a clinical associate, and practices simply aren’t willing to expend those resources.

I’m not sure what the answer is, but the continued growth of for-profit care delivery organizations is only going to fuel more sticky situations. Patients will continue to be left holding the bag, and clinical care will continue to be diminished in the name of profits.

I’m interested in what readers think about this situation. As a patient, how do you feel about being treated by for-profit entities? Are there any advantages? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/18/22

I booked my hotel for HIMSS23 this week, and I think this might be on par with the earliest I’ve ever done it. Still, my preferred dates were already sold out for the hotels closest to the convention center, which means I’ll be doing more walking but that I’ll be better located for parties.

Chicago is one of my favorite places for HIMSS when you consider the after hours scene, with plenty of interesting restaurants in close proximity when you discover that you have three events booked on top of each other. I’ve also loved the ability to just step out into the street and grab a taxi, although that might be different now in post-COVID world and with the rise of ride share services. The last time HIMSS was in Chicago I had one of those “the world is my oyster” weeks, so I have high hopes for the 2023 edition.

Hospitals claim to be running on razor-thin margins, but I still see them waste money on paper processes when they have perfectly good technology offerings ready to assist them. This week I received a letter reminding me that it’s time to schedule a mammogram, apparently without any kind of crossmatch to the fact that not only do I already have a mammogram scheduled but that it’s been on the hospital’s books for more than 11 months, so it’s not like my scheduling process crossed paths with the letter. The letter didn’t mention anything about “if you have already scheduled your study, please disregard this letter,” which made me wonder if there had been some kind of glitch, forcing me to check my patient portal and confirm that my appointment was still there.

The hospital should know that I have opted in for patient portal communications, so that’s a great way to save not only on postage, but on the service contract that I’m sure they have for mailings. They could have sent me a reminder electronically, but even better, they could have crossmatched the “patients who need a mammogram” report with the “patients who have a mammogram scheduled” report, using the magic of the very expensive analytics suite that I know they have. If they’re trying to prevent no-shows, they could use outreach tools to ask me to confirm my appointment.

Especially as a patient who is enrolled in their high-risk program and whose anxiety around the procedure is likely higher than average, I didn’t need the extra annoyance of wondering if my appointment got lost. Due to the need for taking off work since a trip to the high-risk clinic takes a minimum of three hours out of my day, I’d have been seriously irritated if it turned out to be more than just a poorly managed, wasteful, and annoying outreach effort.

Mr. H mentioned an article by physician Danielle Ofri, MD, who describes her journey to telehealth advocacy. I was excited about reading it. Many of her statements resonated with me as a telehealth physician. However, I tripped over the wording a little when she mentioned that telehealth “offers some flexibility to overburdened clinicians, who can do telemedicine from home if they happen to get grounded by a sick child or a COVID quarantine.” Seeing this kind of statement from a fellow physician makes me wonder how much Dr. Ofri actually understands the thin line that many physicians are walking with so-called work-life balance, what burnout is doing to us, or what flexibility really means. Of course, there’s a chance she was misquoted or that her statements were taken out of context, but still I ran it past a couple of colleagues who are parents to determine if I was being overly sensitive. Based on their responses, I was the least riled of the bunch.

The consensus among my colleagues (many of whom are pediatricians and primary care physicians) is that when a physician parent is “grounded by a sick child,” what they need is the same level of sick leave time that many other workers in the US have, not an expectation that they’ll just keep working at home. It doesn’t appear that the author understands what it’s like to juggle a vomiting child, or one with diarrhea, or one who’s lethargic and clingy, with basic care tasks including pumping the child full of clear liquids, doing copious loads of laundry, always having a popsicle at the ready, or watching the thousandth episode of Bob the Builder or some other show because it’s the only thing your child wants to do.

As a family physician, I would like to advocate for a world where sick children are actually cared for by their parents, not pushed to the side and only checked-on in between their parent’s telehealth visits with patients. The myth that physicians are some kind of superhumans who can work through anything (let alone should be expected to do so) needs to go away, once and for all. Of course, this should apply to all working parents, not just physicians, and the fact that families struggle with this on a daily basis shows how far we need to go as a society.

Price transparency remains a significant issue for patients, so this research letter in JAMA Surgery caught my eye. The authors looked at National-Cancer Institute-Designated Cancer Centers and how compliant they were with the January 2021 requirements for price transparency. In addition to publishing their master charge lists, hospitals are required to publish the negotiated rates that they have obtained with health insurance companies. Since cancer care is a huge segment of spending ($200 billion annually), they looked at NCI-designated hospitals to see whether the information was provided and how useful it was.

By examining the websites of the 63 designated hospitals, they found that although two-thirds of them provided some information on negotiated rates, fewer than one-third were fully compliant. Failures in compliance included lack of inclusion of the required machine-readable format and lack of documentation for all of the required price parameters. The authors had some choice commentary about the data that was provided, including a note that one facility used the word “variable” over a hundred thousand times in its documentation. They found the data difficult to use with large files that “required advanced coding and statistical experience to open or analyze.” It just goes to show that some of our best efforts to help patients fall short, and it’s going to take a coordinated effort by experienced technologists to make this information useful.

How is your institution handling the price transparency rule? Do you think patients benefit or are you missing the mark? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/15/22

As clinical informaticists, many of us wonder whether the technology that we are championing really hits the mark. I was excited to see this study that appeared recently in Applied Clinical Informatics. Titled “Health Information Technology Use among Chronic Disease Patients: An Analysis of the United States Health Information National Trends Survey,” it attempted to look at several important factors, including: perceptions of health between patients with disease and those without; usage of health information technology depending on which chronic diseases might be present; the evolution of health information technology over the last half decade; and whether patients with specific chronic diseases are more likely to use specific IT tools.

This is exactly the kind of thing that gets us out of bed in the morning – being able to better understand how people might use the tools we deploy, and whether we can shift what we’re working on to improve how we meet their needs. We all know that chronic diseases are a problem and that the sickest 5% or so of the population are using the majority of healthcare resources. Chronic diseases also kill people, and many of them steal away patients’ productive years and the time they have to spend with loved ones. Many organizations are spending a great deal of technology resources to try to better manage chronic diseases, so it’s important to know how patients are interacting with those offerings.

What did the authors define as chronic diseases? They used a straightforward definition, namely those diseases lasting longer than a year that require lifestyle change and ongoing medical attention. In the US, approximately 60% of us have chronic diseases, with 40% having two or more. In crafting the plan for the study, they also had to identify a consistent description of health information technology: “the electronic systems health care professions and patients use to store, share, and analyze health information.” This includes electronic health records, medication adherence solutions, virtual reality therapy applications, and more.

The authors used the Health Information National Trends Survey (HINTS) with data from 2014 to 2020, comparing self-perceived health factors with health information technology usage and presence of chronic disease. The HINTS database is interesting because it is generated by the results of consumer-facing surveys that are obtained via mail. The survey instrument includes over 120 questions. Controls were put in place for demographics and comorbid conditions. Part of the survey involves questions on self-perception of health, including asking patients to score their health on a five-point scale from excellent to poor. They were also asked about their confidence in their ability to take good care of their healthcare needs.

The authors found that certain patient groups, such as those with lung disease, depression, and cancer, had an increased likelihood of technology use. Patients with other conditions, including diabetes, hypertension, and cardiovascular disease, tended to use technology tools at rates similar to patients without chronic disease. As far as confidence levels, patients with chronic disease were less likely to be confident in their ability to take care of their own health. Patients without any diseases were more likely to be “completely confident” than those with comorbid conditions.

The authors also found that over the time period studied, patients generally increased their use of health information technology offerings. They found that age had an impact on technology usage, with a 3% decrease in odds of using a tool for every year increase in age, even when controls were in place for race / ethnicity, educational attainment, chronic disease, and smoking status. They noted that usability and availability could be motivating factors for technology use and pointed out mental health applications as an example: “Previous review studies have shown the sheer among of online CBT [cognitive behavioral therapy] tools, the wide range in styles of therapy, and the statistically significant improvement in outcomes for patient engaging with these tools. With such effective tools already available for depression patients, it makes sense that more patients with depression are engaging with HIT.”

They concluded that additional study is needed to gain better understand of the specific factors that may influence adoption of health technology and that the knowledge gained from those studies should be used to improve technology offerings and user experience in an effort to improve overall utilization. One summary sentence gave me a chuckle: “…studies have shown that when providers encourage online medical record use, patient usage goes up, but many providers are not encouraging use…” I just had a conversation the other day with an early-career clinical informaticist who was asking for tips on increasing patient portal adoption as a way to reduce the use of laboratory results letters. It didn’t sound like their practice had done any of the basics, such as providing information to patients during the office visit either as discussion, formal handouts, or exam room signs. They had yet to include information on the availability or functionality of the portal on billing statements or other existing communication streams. Given those factors, it wasn’t surprising that adoption was poor. I explained how one hospital I worked with used summer interns in facility lobbies to help register patients. My colleague was surprised that the approach was even a thing.

The authors also noted the need to look at the impact of COVID-19 on technology usage beginning in 2020. They also identified limitations in the HINTS data including its relatively low response rate, the fact that the survey has evolved over time, and that earlier versions of the questionnaire didn’t include questions that could have contributed to the study. HINTS also didn’t include adequate data on newer technologies, such as remote patient monitoring, or certain chronic conditions such as kidney disease or post-stroke complications.

I’ll definitely be reaching out to some of my informatics colleagues as we gather around the virtual water cooler. It will be interesting to see what they think and whether their institutions are doing anything formal to look at these factors. We’re always looking for a silver bullet that will really help us drive the needle and include clinical outcomes, although it’s never quite as simple as we would like it to be.

For the six in 10 of us with chronic conditions, are you doing anything personally to engage with health information technology with respect to your condition? Do you think it makes a difference, or is just another thing that takes up time or falls by the wayside? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/11/22

One of my clients reached out to me for assistance adding information on monkeypox and smallpox vaccines to their EHR. I no longer support systems for the vendor she’s on, but was happy to connect her with another consulting company who can assist.

It brings up a good point, though. In cities across the US, patients who have been exposed are receiving these vaccines. Not only is there sometimes low clinician awareness about the diseases, but also organizations need to think through how to incorporate exposure and vaccine data into their workflows. Fortunately, my EHR has been sending regular updates as the outbreak evolves so I know what to do, but smaller organizations with fewer resources are likely to be struggling.

Governmental organizations are also having to keep up. CMS just issued new CPT codes effective July 26 which will need to be updated in EHRs and billing systems across the country. Hopefully the COVID pandemic led to organizations creating policies and procedures for these kinds of quick changes. I wonder how vaccine registries are handling this and whether they’re keeping current or lagging. If anyone is involved in statewide registries, I’d love to hear your thoughts.

News of the weird. Now that I’m back in the air doing a fair amount of travel, travel stories always catch my eye. I’m glad I wasn’t caught in the holdup at the Springfield, MO airport when a suspicious carry-on item triggered a TSA response. When scanned, the item appeared concerning in that it contained wires and liquid, which can be characteristic of explosive devices. It turns out that the item in question was a urine warmer, which is typically used when trying to falsify a urine drug test. Since my last urgent care role also included occupational health duties, I’ve heard plenty of stories about the things they do when they have “dirty” urine and need to pass a test, but flying with your accessories probably isn’t the best idea.

I had a great lunchtime Zoom with a longstanding colleague yesterday. It’s always good to have those relationships where you can feel instantly connected even though it may have been years. We hit a number of topics about remote work during our chat that were timely. One was “the etiquette of eating on Zoom” and how people feel about eating on camera. Both of us come from backgrounds where we attended working lunches or lunch meetings all the time, and where no one ever questioned whether you should eat in front of others. There’s something about being on camera and watching yourself eating, though, that seems to have made people reluctant to do it.

I noted that there’s also a difference between randomly eating on a call and it being advertised as a lunch meeting or “brown bag” session where people are encouraged to eat their lunches. We both agreed that ultimately each team needs to address the topic as part of a team operating agreement exercise to make sure that no one is surprised one way or another. I’m a big fan of team operating agreements in general, because they help set guidelines for productive work and may be even more important in the virtual world than they were when we were in-person.

Another big topic was “Will you ever go back to in-person?” My colleague comes from an organization that actively terminated leases once they came to the conclusion that COVID was here to stay, and which has significantly reduced its office space expenditures. They have had some increases in stipends for home office – internet, phone, printers, and comfortable desk chairs – but overall, it’s a fraction of what they were spending on rent, utilities, and insurance. Her team has been informed that they will remain 100% virtual and they’re excited about it. Several employees have moved to locations they’ve always dreamed about because they’re no longer tethered to an office.

We also talked about how we see relationships among teams and colleagues when you’re in a virtual company. She noted that she thinks relationships are deeper because there has to be increased communication for teams to be successful. I agreed and added that I think it’s easier to get to know people on a personal level when you get to meet their pets or children on conference calls and can get a sense of who they are in their own environment versus whether they’re adopting a certain kind of persona because they’re going to work in an office setting. It’s also easier and more accepted to share pictures of pets and outside activities, which helps deepen those relationships.

Both of us agreed that remote workers can be more productive. There are also different levels of communication that happen when you’re remote including increased reliance on instant messaging and chat platforms. There is also increased speed of communication. Rather than having to leave my cube, walk around to a couple of people and get opinions, then make a decision, I can simultaneously ask everyone for an opinion and quickly hash out a scenario when it might have taken the better part of an afternoon to solve in person.

Of course, there are challenges with remote work, including rampant multitasking which can lead to inattentiveness and lack of focus. For every person who is energized by the ability to take frequent productive breaks to do things like starting laundry or grabbing a package off the porch, there are also people who become distracted by household responsibilities and family members. Being a successful remote worker involves a certain level of compartmentalization and time management skills that not everyone has.

We also talked about the perils of the hybrid workplace, where some employees are on site and others are either remote or commute intermittently. Not all organizations are good at this. I’ve had exposures to those who had developed a bit of a caste system where workers were treated differently based on the percentage of time in the office. Sometimes it is obvious, such as access to reduced-cost meals and free snacks and beverages for those who are in-person. One company I worked for had a keg of craft beer delivered on Fridays. Other times, hybrid workplace issues are subtle, including concerns about preferential access to mentoring and staff development resources based on work location. Being completely remote can help level this playing field, but companies vary in the strategies they use to mitigate this.

I once consulted for a company that was excellent at this. They deliberately crafted a strategy for their remote workers to mirror what was happening in the office. When it was time for flu vaccines, those in the office could receive a free one over lunch. The remote workers received CVS or other pharmacy gift cards so they could have the same benefit. On days where there was an office party or celebration, remote workers were included with a meal delivery gift card so they could feel like they weren’t being left out. Rather than using the company gym, remote workers could receive stipends to subsidize memberships to their local YMCA or gym.

Of course, there are organizations that don’t see a need to provide parity and will instead spin the office-based perks as something that rewards people who work in person. Especially for a hybrid workplace, a better stance might be defining what perks you think all your employees should have access to and coming up with creative solutions to ensure everyone feels like the company is looking after them.

What do you think about the hybrid workplace? Does your company manage it well or are their opportunities for improvement? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/8/22

In my work with large health systems, some of the projects I most enjoy are those that involve patient-facing technology. In sophisticated organizations, this includes actually bringing patients and caregivers into the product management and development work so that you can ensure that you are developing a solution that meets their needs. A lot of great ideas don’t necessarily resonate in the real world and it’s important to find those disconnects earlier in the process so that the solution can be refined. Otherwise, there is a risk that it will flop when it’s released into the wild. I’ve certainly seen plenty of initiatives go that route.

Healthcare delivery organizations have been in a state of transition for several years as they try to move more care out of the hospital and into the home or other care delivery facilities. Many of these efforts make sense. Getting patients out of the hospital quicker reduces the risk of hospital-acquired infections as well as costs. Patients may recover better in familiar surroundings than they might in an institutional setting. There are numerous other factors and these approaches have been successful for many same-day procedures such as orthopedic surgeries. However, when thinking about these types of programs there is a presumption that patients have family who are not only available to assist but who have adequate health literacy, appropriate physical capabilities (strength, dexterity, etc.) but also the emotional fortitude to assist in caring for a loved one at home.

A friend sent over this piece that was published on LinkedIn, with which I have a love/hate relationship as far as content creation and dissemination. It’s great to be able to share information, but there are a lot of people out there who interpret what they see on social media as being authoritative without fully understanding the background of a given issue. There’s a danger in drawing conclusions from narrow write-ups without fully understanding them or their downstream impacts. I saw this behavior often when working with large health systems that would pounce on an idea that they saw float by regardless of whether it applied to their situation or not. Significant resources were spent researching, evaluating, and assessing before the executive who thought it was a great idea could be convinced otherwise.

The LinkedIn piece is from The Health Management Academy and talks about five barriers to scaling the hospital-at-home concept. It draws in readers by leading with the phrase “digitally-enabled home-based care models” and quickly connects interest in the topic to both the COVID pandemic and to CMS reimbursement allowances. It notes that programs are often small, which makes them somewhat unsustainable, and questions whether programs will be able to continue beyond the pandemic. Below are the barriers the article cites, as well as my comments:

• Low patient enrollment. No surprises here, as patients have to be appropriately referred to the program, which requires time, effort, and coordination. Some organizations only allow patients who are in the emergency department to be referred, and others restrict patients to those who are already in an inpatient unit. This prevents other referrals which might be useful, for example, as an urgent care physician I would love to have referred patients with blood clots to such a program if they weren’t quite candidates to just manage it on their own yet didn’t really need a hospital admission to get started on blood thinners.
• Staffing challenges. This is the universal challenge of all industries right now, from fast food to construction to healthcare. In addition to having healthcare skills appropriate to inpatient care, frontline workers in hospital-at-home programs need other skills, such as managing remote technology and being able to self-support. In talking with several inpatient nurses, they’d be reluctant to give up their current level of predictability for increased volatility and personal risk.
• Provider support. Hospital-at-home workers have to be comfortable going into patients’ home environments, which sometimes have unfriendly living conditions, pets, and people. The article refers to this as “an uncontrolled setting,” and anyone who has ever done home care or rode along with EMS or the fire department knows what we’re talking about. This can be an extremely scary situation and there’s not a good way for those referring a patient for a program to know that Cousin Doug with severe uncontrolled mental illness also lives in the house, or that Aunt Julie has a handgun that she likes to leave on the end table.
• Coordination of services. The article sums this up as transporting providers and equipment along with care coordination. Given the fact that hospital-at-home is often related to a relatively acute situation such as an Emergency Department visit or an inpatient hospitalization, quick and efficient coordination is needed. Having shared the patient experience when a close friend couldn’t get the appropriate durable medical equipment delivered to her home when her surgery had a three-month lead time, I’m not convinced of some organizations’ ability to handle this rapidly. It’s not just equipment, but other medical supplies and services like imaging, phlebotomy, pharmacy, and the care itself that all have to be coordinated effectively.
• Reimbursement uncertainty. To me, this is the largest area of concern. Healthcare delivery organizations aren’t going to invest the resources to build the infrastructure to do all the things listed above if they aren’t convinced that they will be paid for their efforts in the future. Given the state of healthcare spending in the US and the fact that many of these programs are operating under a CMS waiver that provides payment equivalent to inpatient care, it’s unclear how much programs are willing to invest to keep the lights on let alone expand.

The piece the article missed, of course, is the patient piece. Do patients really want this service, or do they feel it’s just another way to get pushed out of the hospital before they are ready? Do they find value in the offering, or do they find it stressful? How do they feel about having outsiders in the home when there are stories every day of scams, theft, and abuse of patients by unscrupulous caretakers? Is the family ready to start delivering nursing and other care? Any health system administrator who is considering this needs to have firsthand exposure to what it’s like to help care for family at home, including assisting with feeding, mobility, toileting, managing surgical drains, and more. Unless a program is going to provide 24×7 support, these tasks will fall to family and friends, and some of them are not for the faint of heart.

What is your organization doing as far as hospital-at-home? How do you feel about it as a patient, and as a family member? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/4/22

Some days are more challenging than others when it comes to finding healthcare IT topics worthy of blogging about, but this week brought plenty of interesting and/or entertaining content to my door. In the category of “hospitals behaving badly,” we have Nebraska’s Bryan, which recently updated its dress code policy. The purpose of the policy change was to remove restrictions on hair colors, but it was delivered with additional commentary regarding “messy buns,” including pictures of rogue hairstyles. Social media is now alive with the hashtag #showmeyourbuns along with plenty of comments about hospitals worrying about the wrong things while they’re struggling to retain staff members. I share my own messy bun pic in solidarity. And yes, those are cocktail picks holding it together.

Also on my list is HLTH, otherwise known as spammiest conference ever. I thought HIMSS was bad with the volume of email it generates, but since I registered for HLTH, it feels like I have something from them every day. Do I really care who the first 200 sponsors to register are, or how great HLTH thinks its hosted buyer program is? Why is every other email focused on topics related to women? What about other groups that are inequitably served by our healthcare delivery systems, such as minorities, children, or the elderly? To be honest, it feels like pandering, and I’ve started keeping track. I haven’t attended previously, but I’m already tired of the conference hyping itself. You already have my money (and a fair amount of it, at that), so dial it down, already.

CMS is looking for public input on improving Medicare Advantage programs. The organization wants to understand how programs are working for Medicare beneficiaries as well as to understand whether the programs are improving outcomes and decreasing costs. For those not familiar with the programs, Medicare Advantage is also sometimes referred to as “Medicare Part C” and involves contracting with private insurance providers that typically offer not only the traditional Medicare benefits, but also coverage such as vision or dental. Most of them also offer prescription drug coverage (Medicare Part D). In general, they function similar to HMO programs with narrow networks in an effort to better control costs. Comments are encouraged from insurance plans, providers, beneficiaries, patient advocates, states, employers, unions, and others who are stakeholders.

I ran across several articles about telehealth services for mental health, and nearly all of them mentioned the shortage of behavioral health therapists, counselors, social workers, and case managers. One article had a profound headline: “Want to Keep People Working in Mental Health? Pay Them More $$, Experts Say.” One expert cited in the piece stated it would take a $13 increase in hourly wages to keep people from leaving the field. She notes the challenges of the new 988 national suicide prevention hotline in that states have to figure out how to fund it. She’s been able to hire less than half the staff she needs and comments that her crisis center is competing with retail and entertainment employers for available workers who often gravitate to lower-stress, higher-paid positions.

The article notes the wide disparity in access to psychiatrists as an example of the workforce challenges, with New York state having 612 psychiatrists per 100,000 people where Idaho might have one psychiatrist for the same population. Other factors causing workforce challenges include greater awareness of the need for mental health services as well as increased numbers of referrals for care. One of my colleagues recently referred an adolescent to the emergency department for suicidal thoughts, and after 16 hours, the patient still hadn’t received a psychiatric assessment. Ultimately the family left the emergency department without being seen after their primary care physician crowdsourced a same-day psychiatric referral on Facebook. It shouldn’t be that way, but it is, and most people are unaware how poorly our systems are running.

There’s also the matter of escalating abuse and violence against hospital staff. The death of a South Carolina hospital mental health technician was recently ruled a homicide as the technician had been kicked by a patient while staff was trying to restrain her. The staffer, Kevin Robinson, had worked at the facility for 11 years and was only 40 years old. Incidents like this are truly tragic and when young people hear about them, it’s no surprise they’re not gravitating towards jobs in the field.

Last but not least, I spent some time with my parents this week and received a crash course in “patient experience with the local Veterans Affairs health care clinic.” Due to flooding in the area, my dad called the clinic to make sure that the staff was able to make it in. The reply he received was “oh, we’re here, come on in, baby,” which made both him and my mom laugh. The staff at his local clinic is outstanding and the veterans are treated with the care they deserve. The information systems they work with are challenging at times, though, and apparently between his last visit and this one he somehow underwent a religious conversion in the EHR without requesting an update. He was surprised at how much time the staff spent with him going through a variety of screening instruments and taking a detailed history, a much longer duration than the staff at his non-VA primary care office has ever spent with him. I reassured him that it was a good thing they’re doing things like screening for suicide risk and fall risk.

They made sure he had instructions for accessing the patient portal and encouraged him to sign up. He’s proficient with MyChart and other online services, so was surprised that it ended up taking several hours to get signed up for the VA’s portal. Part of that was due to authentication and identify proofing. It was interesting to hear a non-informaticist’s explanation of the process. When he was finally able to access the system, he immediately pulled up his visit note, which was a whopping 49 pages. He thought the view / download capabilities were cool and it was nice to see how a patient perceives something like View / Download / Transmit that most clinical informaticists take for granted. His VA has not yet implemented Cerner, so I’ll have to keep an eye out for when that transition occurs so I can see how it goes from the patient perspective.

What topics in healthcare or healthcare IT caught your eye this week? How do you feel about messy buns in the workplace? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/1/22

I’m always excited to read about technology that makes a difference at the point of care or improves the patient experience in a significant way. Two articles with solutions that fit the bill popped into my inbox this weekend.

The first discussed a smartphone app that can help identify skin cancer in older patients. Researchers from Stanford Medicine used an app called SkinIO after seeing that the COVID-19 pandemic had created barriers to patients accessing dermatology services. They noted that for older patients, a 37% decrease in visit volume correlated with a 23% decrease in skin cancer diagnoses.

The SkinIO app helps patients capture photos of concerning skin lesions and routes them to dermatologists. The app doesn’t try to make a diagnosis, but rather highlights lesions that meet certain criteria and lets the physicians know that additional review is advised. The study was small, occurring between November 2020 and July 2021. There were 27 patients enrolled, all of whom resided in senior living communities in the San Francisco area. Researchers visited the sites in person to collect skin images, using a dermatoscope to further evaluate high-risk lesions. The SkinIO app flagged 63% of the lesions as needing further attention, although researchers ruled out cancer in the majority of those submissions. However, three of the lesions were determined to be cancer, leading researchers to conclude that the app can be a helpful resource, although it’s not 100% accurate.

For the average patient who might be able to make a dermatology appointment, the app might not be as useful. But for a patient with mobility impairment or someone in a skilled nursing facility who might require additional services to support an in-person visit, it could be a useful adjunct. It could also be helpful for patients that have numerous moles and would benefit from additional evaluation beyond the traditional full-body skin exam they might receive once a year.

I checked out the SkinIO website to see how they were positioning the solution. I expected it to be marketed to dermatologists, and it is, with additional features such as automated mole-mapping and tracking of changes over time as key points. They’re also positioning it for health systems, perhaps to be integrated into primary care settings to allow greater referral of high-risk lesions to dermatologists within a given integrated delivery network. The angle I didn’t expect was marketing towards employers. At first glance, it might be a good employee wellness offering for industries where the conditions that contribute to skin cancer are present. Examples of workers who might benefit include those in the utility, landscaping, forestry, hospitality, entertainment, parks and recreation, and maritime industries. I’ve added the company to my watch list. It will be interesting to see how they do over the next couple of years.

The second article covered one of the industry’s buzzword topics: precision medicine. There are plenty of people excited about the topic. Being able to figure out the perfect therapy for a patient based on their genetic makeup or other measurable factors is exciting. Who wouldn’t want a treatment that was perfectly tailored for them? It sounds great, but actually making it a reality in our increasingly broken healthcare system is a challenge. For example, I recently implemented a new EHR that has some pretty exciting pharmacogenomic content. Unfortunately, the health system implementing it has not made the decision to store the results of pharmacogenomic testing as discrete data, rendering the content useless. The article talks about such patient-level data as the “fuel” that is needed to power the advanced analytics “engine” that drives precision medicine.

Once the organization makes the decision to incorporate discrete data, other factors need to be addressed, such as ensuring that clinicians know what changes to make based alerts that might appear, and that they trust the system to a level where they’re willing to take action. Clinicians will also need support using the tool, especially if incorporating it makes visits take longer due to the need for additional counseling and education for the patient. A physician who is already trying to cram a 30-minute visit into a 20-minute time slot is more likely to fall into old and familiar patterns rather than trying something new. If they need to research a proposed therapy or read deeper to understand what an alert is trying to tell them, then tailoring a treatment is likely to be a no-go.

The article notes this, and additional mentions that the complexity of our health care system is also a factor. Tailored treatments will also need to take into account patient factors such as symptoms, history, and preferences as well as societal factors such as access to care and impacts from social determinants of health. I’d go further to suggest that insurance coverage, treatment cost, and financial resources are likely to trump all other factors for the majority of patients in the US.

The article uses diabetes care as an example, where additional factors need to be added to precision medicine algorithms that are used for older adults — lived experience, support networks, current living situation, and more. For patients with cognitive impairment, limited social support, or other resource constraints, the situation is even more complex. In my experience, adding culture and personal / family values to the list of considerations is key.

I’ve seen patients flatly reject cost-effective treatments that are standard of care because they are perceived as being at odds with cultural practices or beliefs. I remember one family where the mother wouldn’t consent to a necessary surgery for her child because of a perception that the child would have to live with “mutilation.” Those are the elements that it will be challenging to add to an algorithm, because they’re not readily quantified and often only come to light in a crisis or through a longstanding physician-patient relationship, which is all to frequently the exception rather than the norm.

The authors propose that we need to go beyond the traditional thought of precision medicine as “the right treatment for the right patient at the right time” to incorporate the element of “each patient’s unique context.” I wholeheartedly agree and look forward to additional work as we continue to quantify those contextual factors in ways that allow us to take action at the point of care.

How is your organization approaching precision medicine? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/28/22

I was exited to see a Tweet from my favorite bowtie-wearing crush Farzad Mostashari @Farzad_MD as he shared information about the Aledade FIRST program, which is designed to support medical residents pursuing family medicine. FIRST stands for Fostering Independence, Readiness, Sustainability, and Togetherness. The program strives to better educate new physicians about value-based care and to equip them for successful careers. Aledade will offer the program to up to 20 second-year family medicine residents who will receive additional training in value-based care and practice management while receiving one-on-one mentorship. Residents can also opt to participate in a subsidized clinical experience. In exchange for agreeing to serve for 3-5 years in an Aledade member practice, clinic, or Community Health Center of their choice, residents will receive monthly stipends, signing bonuses, and more. The program is open to those who intend to practice full-time in North Carolina after completing residency. If we truly want to transition to value-based care, we need clinicians who understand the model and how to maximize patient outcomes. I’ll be looking forward to following it over the next several years.

Lately, I’ve been receiving some random faxes intended for other providers, which I can only assume is from crossed wires deep in some database somewhere. My practice has been trying to correct it, but I suspect it will take some time. Given that context, I was interested to see this Kaiser Health News piece about the challenges of inaccurate provider directories. The article’s introduction is painfully true: “If you have medical insurance, chances are you’ve been utterly exasperated at some point while trying to find an available doctor or mental health practitioner in your health plan’s network.”

As an urgent care physician, I saw hundreds of patients in that situation who ended up in front of me because they didn’t know where else to turn after finding out that the wait was too long,  in-network providers weren’t taking new patients, or providers no longer participated in their insurance plans. Many of these patients needed specialty care that we were not equipped to provide, and they became even more frustrated when they learned that we couldn’t help.

Despite regulations that require accurate provider directories, they’re often a mess. The article cites a study from the Journal of Health Politics, Policy, and Law that found that in a best-case scenario, patients could only schedule timely appointments for urgent issues with about half of the physicians listed in a directory. The worst-case scenario was 28%. For general medical appointments, best case was 64% and worst was 35%. The article notes the challenges in getting providers to update their files with each payer, but from experience, even when providers do provide updates, they are often not incorporated.

Case in point – my previous employer sent termination notices to all plans when I left the practice. I was copied on all the communications. Even as recently as last month, one payer sent me multiple notices that I needed to update their directory and didn’t respond to my attempts to clarify that I hadn’t been a participant in well over a year.

The article closes with some good advice for patients who might find themselves fighting an out-of-network charge despite thinking that a provider was in-network. It recommends taking a screenshot of the provider directory showing the provider’s name, calling the physician office to confirm, and taking notes of the name of each person that was spoken to. That’s more work than the average patient is going to do, even assuming they know that it’s a good idea, which most don’t. Despite recent “no surprises” legislation, fighting unanticipated out-of-network bills is still an irksome task even for those with experience.

The American Academy of Family Physicians was on fire regarding healthcare technology topics in the recent issue of its FPM Journal (previously known as Family Practice Management). One article looked at strategies for reducing documentation burden through EHR simplification. It called out the fact that changes to documentation require buy-in from leadership, appropriate resource allocation to make changes, and adequate support for implementing change.

The author provides an example of institutional policies not keeping up with government simplification of Evaluation and Management guidelines. Their project team engaged subject matter experts to identify ways in which documentation could be simplified, used clinician surveys to identify problematic workflows, and worked with technology teams to identify the best solutions. The authors also noted the need for providers to take advantage of basic EHR functionality such as templates or exam defaults, along with time management strategies such as completing notes throughout the day rather than saving them for the end of the day. I continue to see physicians who will complain endlessly about EHR templates that don’t meet their needs, but who are unwilling spend the time to update them to better suit their needs. If the article spurs even a handful of physicians to take steps to improve their workflows, it has value.

The second article that caught my eye listed five administrative tasks where technology could improve physician workflow. The list includes some features that are readily available in EHRs, including the calculation of patient risk scores and synthesis of data needed to facilitate pre-visit planning. The list also features technology-assisted workflows, such as using voice recognition for visit documentation and using digital solutions to assist with prior authorization tasks. Although many practices are using EHRs, I would wager that a minority are fully optimized and there is still much for clinicians to incorporate into their day-to-day workflows.

The third article addressed quality metric reporting and why practices are struggling to rebound from the impacts of COVID-19. It highlights three burdens impacting practices: the emotional burden, the workload burden, and the payment burden. Technology can help with workload through automation and delegation, allowing diverse members of the care team to assist in closing care gaps and recommending services for patients. It can also help with the payment burden through solutions that promote improved charge capture, demonstration of higher quality in the face of risk-based contracts and ensuring that incentives are maximized. As noted in the previous articles, these efforts take time and resources, but it’s important for organizations to understand that making the effort now will pay dividends in the future and to provide leadership to make changes a reality.

How is your organization using technology to bolster struggling primary care practices? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/25/22

This weekend marked the first time in a decade that I took a trip without my laptop. It was weird at first because my backpack felt surprisingly light, but it was good to know that I couldn’t slip into the trap of doing work even if I tried.

Now that the workplace is more mobile, and especially when some companies offer unlimited time off, it’s tempting to blur the lines between the work day and the rest of your life. It was a great opportunity to connect with old friends and focus on spending time together as we crammed as much adventure into 48 hours in the Big Apple as possible.

Of course, since we were a group of healthcare IT people, there were plenty of opportunities to discuss where the industry has gone since we all worked together at a big health system. Several in the group have moved into the non-profit space and payer space, which was interesting to learn about compared to others’ experiences in the vendor and consulting spaces. One person’s resume reads like he’s a job hopper, but in reality, he has been in the same job, but his company has just been merged and acquired multiple times. I’m not sure everyone would pick up on that just looking at his employment history.

There was a lot of chatter about the Amazon acquisition of One Medical for nearly $4 billion. Nearly everyone in the conversation was concerned about Amazon having access to patients’ protected health information, even though the company issued a statement that they don’t plan to share health information to advertise or market other Amazon products without clear permission from patients.

Several of us brought up the point that most consumers don’t read terms and conditions, even when there are limited updates to an agreement, so it’s likely that Amazon could obtain such a consent without patients full understanding what they’ve accepted. Most of us are a bit skeptical about how this is going to play out, so we’re going to have to watch it as the deal moves towards the regulatory approval it needs for closure.

Digital health startups were a hot topic throughout the weekend, and one of my traveling companions sent me an article that caught his attention. It’s from the Journal of Medical Internet Research and looks at the “clinical robustness” of companies in that sector. The background for the article notes that “health care technology stakeholders lack a comprehensive understanding of clinical robustness and claims across the industry.” That phrase caught my eye as well, since I’m constantly seeing companies that make me wonder what exactly it is that they do and why people, including investors, are so excited about them. Certainly there’s a hype factor for a lot of digital health startups, as well as a great deal of marketing, but the meaty information tends to get pretty thin when you start to dig into some of them. The article looked to assess clinical robustness along with the claims made by companies.

The authors used data from the Rock Health Digital Health Venture Funding Database, the US Food and Drug Administration, and the US National Library of Medicine. (It should be noted that three of the authors are employees of Rock Health, although the article states that no individuals involved in investments were part of the analysis.) The authors defined clinical robustness using the sum of the number of regulatory filings and clinical trials completed by each company with each having equal weight. For the companies’ claims, the authors looked at company websites. They looked at 220 digital health companies with an average tenure of 7.7 years.

The average clinical robustness score was 2.5, with a median score of 1. Companies specializing in diagnostics had the highest scores, followed by those focusing on treatment and those specializing in prevention. The authors found that 44% of the companies they looked at had a clinical robustness score of zero. There was no correlation between clinical robustness and the number of publicly made clinical claims or between clinical robustness and total funding.

There were some other interesting statistics in the article:

• More than 1,900 digital health startups have raised more than $2 million in venture capital funding in the US.
• In total, digital health startups have raised more than $77 billion in venture capital funding.
• Multiple studies have shown the need for greater clinical validation.
• Many solutions are not supported by robust clinical evidence.
• Solutions have mixed results on cost savings and cost-effectiveness.

Additionally, the authors noted that there have been examples of misleading claims in the industry, as well as actions by the Federal Trade Commission and state attorneys general. They note the limitations of using publications as a proxy for clinical impact, especially given that there is often a lag in publications. There were also limitations in that they only looked at venture-backed startups in the US that had raised at least $2 million in funding, which may have excluded early-stage companies as well as larger technology companies. They also note the need for deeper research into the effectiveness of solutions.

I found it amusing that the article noted that “all data were stored in Microsoft Excel,” where the calculations were performed. Excel isn’t always the most sophisticated tool, but it’s gotten the job done for me more often than not.

It would be interesting to do a follow-up study to see how many of the startups that the authors looked at are even here in two, five, or 10 years and what their clinical robustness might look like over time. I suspect we may see some significance between funding and clinical strength or between time in the market and clinical outcomes. In the short term, though, it’s often difficult to demonstrate value beyond individual case studies and client profiles. It’s certainly challenging to wade through some of the content on company websites and to truly know how broadly a solution has been deployed or whether clients are happy with it.

What do you think about the idea of measuring clinical robustness for digital health tools? What markers might you use beyond those selected by the authors? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/21/22

As I put together my travel schedule for the next year, I’m looking at various conferences. One that caught my attention in email was Becker’s 8th Annual Health IT + Digital Health + RCM Annual Meeting. The attention-getter was its list of keynote speakers including former President George W. Bush, former professional boxer Sugar Ray Leonard, and professional golfer Michelle Wie. It’s certainly an eclectic mix of speakers and I’m not sure how much they individually have to bring to the digital health discussion, but hopefully someone who is willing to pay the $950 admission fee will clue us in.

The costs for conferences keep rising, and it’s not always clear whether attendees receive the value offered. For comparison, the American Academy of Family Physicians charges between $695 and $895 for its Family Medicine Experience (FMX) conference. The National Association of Community Health Centers charges $1,290 for member organizations to attend its annual Community Health Institute & Expo and $2545 for non-member organization attendees. HLTH is pricing registration for in-person admission at $2,295. Typically, an employed physician might have one conference covered by their employer per year, so there are certainly some choices to be made.

I’ve been working with EHRs and consulting with vendors for more than a decade, so it’s been gratifying to see the improved focus on patient safety and greater movement towards standardization. A Viewpoint article published in the Journal of the American Medical Association last week discussed ways that we can continue to improve EHR safety and usability. The authors note that computer-based records have failed to live up to their promise particularly as related to the support of health care providers’ thought processes and that in fact the EHR creates distractions for caregivers.

They state that “…the term electronic health record” is a misnomer… It is not designed primarily to capture and present a patient’s record as efficiently and effectively as practical.” They go on to recognize what we all know – that “…the EHR has many stakeholders, including physicians, health system executives, educators, regulators, and patients whose needs influence EHR capabilities. In the US, requirements for reimbursement, regulatory compliance, and administrative workflow automation often take precedence over clinical efficiency and effectiveness.”

I don’t think anyone who has been working in the healthcare IT space for any length of time would disagree. We’ve all been stymied by EHRs that won’t let us document things the way we need for the patient in front of us. For example, one EHR I worked with didn’t have the capability for the physician to set a default follow up instruction of “within 24 to 48 hours.” The system’s designers insisted that a date be used, which doesn’t necessarily support what the urgent care physician is trying to say when they want a patient to see a specialist quickly but not necessarily on a certain date. As a result, the physician ends up free-texting what they want on every single patient rather than taking advantage of labor-saving features – which costs much more time and money in the long term. There are also organizational impediments to efficiency, such as when EHR decision makers refuse to let clinicians personalize their workflows because of a fear of increased maintenance or support costs.

The Centers for Medicare & Medicaid Services published a final rule stating that hospitals should review their systems using the Safety Assurance Factors for EHR resilience (SAFER) Guides so that they can evaluate usability and safety of clinician systems. The authors call for greater focus on minimizing the cognitive load created by EHR workflows. When there is too much mental effort needed to complete a given task, user performance suffers. The authors propose a SMARTER Guide to improve EHR cognitive support:

• Synthesizing information and supporting goal-oriented search.
• Monitoring care decisions, taking patient data and care setting into account, and suggesting better alternatives.
• Automating routine tasks.
• Recognizing trends toward or away from idealized patient models.
• Translating important user actions into documentation.
• Exposing contextually relevant data; and
• Reliably and consistently performing these functions.

It will be interesting to see how some of these elements are incorporated into technology over the next few years, and whether technology begins to better serve clinicians or whether it continues to be a distraction.

As an avid outdoor adventurer, sustainability and environmental protection are high on my priority list. I enjoyed this article in the Journal of the American Medical Association that looked at the use of informatics to assess healthcare systems with regard to climate impact and environmental footprint. The authors note that healthcare delivery  — including facilities, pharmaceuticals, and more — accounts for approximately 5% of global carbon emissions and propose informatics efforts to monitor healthcare’s carbon footprint. Other contributors include supply chain (production and transportation of supplies) along with staff travel and waste disposal. The authors propose synthesizing economic activity data alongside life cycle assessment models for products and processes.

Most of the organizations cited in the article are located in the UK or Australia. I would be interested to see how US organizations are looking at the problem. One of the aspects that was mentioned was one that I’ll admit I hadn’t thought very much about in the context of sustainability – wasteful clinical practices. This includes unnecessary imaging, duplicate tests, medication overprescribing, and unneeded surgeries. Many patients in the US feel that greater technology use leads to better outcomes and that medications are a much better solution than more environmentally friendly treatments such as lifestyle modification. Often the decisions made for hospital purchasing are focused strictly on cost without consideration of environmental impact, so there will need to be significant changes in priorities in order to see downstream impacts on climate or the environment.

One of my favorite readers clued me in to this publication on health worker burnout from US Surgeon General Vivek Murthy. He cites Hawaii Pacific Health’s “Getting Rid of Stupid Stuff” initiative as an example of identifying and mitigating workflows that staff felt were unnecessary or poorly designed. The effort led to a savings of 1,700 nursing hours per month across the organization.

A specific example of burnout-generating work is the prior authorization process. Although I understand the need to reduce ordering of unneeded treatments and tests, I’ve long proposed some kind of golden ticket for those of us who order judiciously. In my time as a traditional family physician, I never had an order that failed to be authorized, which meant I was following guidelines. With years of that kind of track record under their belts, why should physicians be subjected to unneeded scrutiny? To be certain, all those unwarranted prior authorization process cost the payers more money than they saved.

Should providers who follow guidelines and control costs be rewarded by reduction in administrative burdens? Would such a move serve as an incentive for clinician behavior? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/18/22

I spent part of the weekend hanging out with some longstanding healthcare IT friends. There was plenty of catching up to do. It was great to hear about everyone’s newest projects and what they think will be hot in healthcare over the coming years. We all used to work together, but now everyone is scattered to the winds at various health systems, consulting firms, payers, and vendors. A couple of have even retired and I enjoyed hearing about their many adventures and how much they’re enjoying not being part of the madness anymore.

Several of us have had experiences helping or parents or other relatives navigate the healthcare system in recent years, so there were plenty of conversations about the usefulness of various patient portals and how our loved ones are or are not using the information available to them. One hot topic was patients having access to their notes from medical visits. Although most of the folks I was speaking with were eager to see their own documents, probably due to the fact that we’ve spent so much of our careers dealing with EHRs and other clinical IT systems, very few of their parents show an interest in reading their medical notes.

The clinicians in the conversation voiced concerns about patients being able to see their notes and “how bad they really are” due to EHR-related note bloat. There were few concerns about patients reading things they would find worrisome or being offended by discussion of hot button issues such as obesity, smoking, alcohol use, or drug use. Nearly all felt that the benefits of transparence outweighed concerns, although one clinical informatics nurse lamented the fact that many of the clinicians that she supports write notes that can be described as “terrible,” including typos, sentence fragments, and disordered thought processes. I certainly feel for that physician’s patients if they try to access their information.

With that conversation fresh on my mind, I was happy to see a link in my email to a recent article in the Journal of the American Medical Informatics Association that looked at the impact of patient access to notes on clinical documentation. The authors set out to examine whether recent rules that require patient access to clinical notes have had unintended consequences, such as increasing physician documentation burden. They used what they describe as “a national, longitudinal data set consisting of all ambulatory care physicians and advance practice providers using an Epic Systems EHR” to specifically evaluate the length of clinical notes and the time spent documenting in the EHR.

As background, the 21st Century Cures Act language that required that healthcare organizations provide access to notes was implanted on April 5, 2021. The authors used “de-identified clinician-week level EHR audit log metadata extracted by Epic’s Signal software” to look at aggregate data from January 3 to May 29, 2021. This data covered over 340,000 unique clinicians for 21 weeks and excluded inpatient data. Analysis models controlled for the number of visits that clinicians were performing each week as well as other factors that might impact individual productivity. The authors also checked their data by looking at only primary care physicians and also by stratifying to compare physicians against midlevel providers. During the initial post-rule period, there was no statistically significant change in note length or documentation time.

Interestingly, providers spent more than 12 minutes creating each note, which is significant given the fact that a large number of visits delivered in the US are scheduled for approximately 15-minute appointment times. In the discussion, the authors acknowledge that they were looking at the potential for short term impacts and that more work is needed to evaluate whether there are long term impacts on having patients access their notes. Although I like how the authors approached the problem as well as their use of a large and available dataset, I wonder how many of the organizations in that dataset were actually releasing their notes at the time of the study. My own health system didn’t start releasing notes to patients for at least six months after the rule went into effect, although they did release content retroactively, which was a surprise to me as a patient.

Now that I have access to my notes, I look at them often. I have found their content to be largely fictional. My last preventive health visit contained two full pages of screening questions that were never asked during the visit as well as exam elements that weren’t performed. There were also inaccuracies in my responses to questions, along with what I find to be a very annoying disclaimer that the documentation “was created with voice recognition software and may contain errors or omissions.” Seriously? I can’t imagine having a patient see that information in one of my notes, and it definitely makes me think less favorably about the clinician I saw, especially since I wasn’t happy with the visit in real time.

I wonder how many patients are actually looking at notes that are available and whether they’re communicating with clinicians when they find problems. I know I don’t have time to deal with trying to get a correction, so I’m going to just let it be even though those inaccuracies will likely propagate themselves across other entries in the future. Even thinking about trying to correct it is tiresome.

I would love to see research looking at how many health systems are actually releasing their notes, how many have communicated to patients that the notes are available, and how many are encouraging patients to use the information to better their health. I suspect that the results of those kinds of efforts would be rather interesting.

The authors note that they are also unable to quantify non-note work that may have increased due to the availability of patient facing notes, such as increased patient phone calls or portal messages. I know that when I put on my CMIO hat to approve patient-facing documentation, I always try to make any default language as clear as possible to avoid creating confusion. However, I’ve seen plenty of notes where clinicians go crazy with free text and create plenty of confusion that I will never be able to influence.

Who’s ready to look at this data again, and see what it looks like 12 to 18 months into the process? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/14/22

I spent some time on Wednesday attending a deep dive on “The Platform Revolution Comes to Healthcare” as part 2022 MIT Platform Strategy Summit, which is taking place in the Boston area this week. The initial speakers, Vince Kuraitis and Randy Williams, spoke to what they described as four healthcare platform megatrends:

• Synergy. Platforms advance (and are advanced by) four key healthcare trends – value-based care, consumerism, interoperability/data sharing, and home/virtual care.
• Investment in digital health is fueling platform growth.
• Platforms are shaping new operational ecosystems.
• Platforms are transforming the competitive landscape in healthcare.

One of the highlights was the keynote fireside chat with Jonathan Bush, who described his experiences in building healthcare platforms. He had an interesting analogy about Dudley Dursley in the Harry Potter books, likening healthcare to Dudley. Healthcare isn’t evil, but it still kills people every year, so “we jack the safety net up so far” that “there’s no ability to move about the cabin” and trying to figure out how to innovate without violating the social safety net.

He refers to his former clients at Athenahealth as “kooks” with great affection. He notes that in healthcare, the demand curve doesn’t function the way that it does in conventional businesses, because there really isn’t a choice to not buy the service and keep the money. He notes two things that have shifted the demand curve – the COVID pandemic, which has shifted acceptance of virtual-first approaches, and the ability to assemble robust tech stacks.

I chuckled when he described in-person care as “lumbering in and taking your pants off and sitting on waxed paper every three months.” Jonathan has certainly mellowed over time, and I always enjoy hearing his thoughts. It will be interesting to see how Zus Health plays a role moving forward.

Speaking of healthcare transformation, we’re approaching the point at which health plans and insurers have to provide pricing information to the public. As of July 1, CMS required those organizations to provide machine-readable files for in-network rates and allowed amounts respective to various medical charges. Starting in 2023, they must also provide online price comparison tools to allow patients to estimate their individual payment portion for a list of over 500 items and services. In 2024, they will have to provide price comparison tools covering all services. Organizations that fail to comply face a fine of as much as $100 per day for each violation for each affected enrollee.

I’m all for empowering patients to understand the costs and options for various services, but publishing this data doesn’t take into account the differences between the same services performed at different facilities. These nuances often inform how physicians order their tests. For example, I am extremely high risk for breast cancer, to the point where I could easily qualify for preventive surgery. Prior to undergoing consultation with an expert, I used to have my mammograms at an independent general imaging facility because it was convenient, the costs were low, and a preliminary reading was provided before I left the building.

However, after having multiple consultations with nationally known experts in the field, coupled with genetic testing, I switched to having my mammograms (and now MRIs) performed at a more costly facility that has subspecialty radiologists interpreting all the studies. The average patient doesn’t understand that subtlety, and with the devaluing of comprehensive primary care in the US, I doubt those kinds of conversations are going to be happening in the exam room.

Speaking of genetic testing, I was excited to see the announcement that Myriad Genetics has partnered with Epic to make genetic testing more nearly seamless for patients and providers. My own Myriad testing several years ago was ordered with a daunting-looking triplicate paper form, where the medical assistant had to transcribe dozens of data points that already existed in the EHR. Results came back on paper, which the office had to scan into the chart. They were supposed to mail me a paper copy, but somehow couldn’t get it out the door, so after weeks of delay and begging on my part, I finally received a PDF version of the scan, minus the pretty color that I’m sure was in the original paper result. Less than ideal, but I’m excited that future patients will have better options for receiving their results and that physicians will be able to fully explore the value that discrete data brings.

Once upon a time during one of my work trips, I became a patient at Mercy. They recently sent an email to patients with “MyMercy” MyChart accounts asking them to take a survey about a new feature. Apparently  they are evaluating the possibility of implementing Epic’s MyChart Bedside capabilities and wanted patient input.

Having been on the health system side of healthcare IT, it’s often difficult to prioritize initiatives unless they are regulatory or otherwise mandated. Understanding how patients would use or not use a potential new feature seems prudent given the limited resources available to most IT teams. Survey participants were asked to rank a list of features based on how useful the participants thought they would be during an inpatient stay. I’m not a regular consumer of care through Mercy, but I did appreciate the outreach. I’ve got some contacts from residency that work there so will be interested to see if I can find out how the results are being used to make decisions.

Former telehealth darling (and now telehealth pariah) Cerebral tried unsuccessfully to recruit me before its fall, but I’ve ended up on one of their mailing lists. The company is conducting an all-out messaging campaign to explain its new focus on clinical quality and its vision for comprehensive mental health care. Putting on my primary care hat, I’m unimpressed by their messaging. It’s going to take a long time for them to overcome the perception that they have been prescribing controlled substances like someone giving out candy at Halloween.

Since I care for children, another physician recently asked me for my thoughts regarding the “right” age for her personal child to get a cellphone. This is often a hot topic around the neighborhood as well, with every child seemingly stating that “everyone else has one but me.” There’s a growing body of data demonstrating that mobile devices are harmful to mental health. One physician I refer to stated that smartphones are little more than “dopamine dispensing slot machines.” Discussions  at the recent Endocrine Society meeting highlighted issues with smartphone-associated behavioral issues, sleep disruption, and obesity.

Most adults I know don’t have the ability to separate from their phones, so it’s not realistic to think that the relatively underdeveloped brains of children would make it any easier for them. The article links to a number of publications in the medical literature regarding cell phone and screen use. If you’re a parent of children or adolescents, or if you are concerned about your own dependence on mobile devices, it’s worth a read.

Do you think that constant smartphone access and the prevalence of social media is making the world a better place or consigning us to a dreary future? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/11/22

I missed the initial announcement last month, but the US Department of Health and Human Services has issued guidance on “How the HIPAA Rules Permit Health Plans and Covered Health Care Providers to Use Remote Communication Technologies for Audio-Only Telehealth,” which will apply even after the Office of Civil Rights “Notification of Enforcement Discretion for Telehealth” no longer applies. Audio-only telehealth is important for populations that don’t have adequate broadband access or who can’t access video visits due to disability, cell coverage, or other factors.

Seeing telehealth patients over the last four years, I found that nearly half of the patients I treated preferred audio-only visits, for a variety of reasons. There are some interesting details in the document on the use of traditional landline phone services as compared to electronic communication technologies such as internet-based phone services, cellular service, and Wi-Fi. The HIPAA Security Rule applies to the latter technologies, but not the POTS lines, although I’m not sure how many covered entities still use copper wire for their communications.

Most large healthcare organizations are trying to forecast what their use of telehealth services will look like in a post-pandemic world. In speaking with CMIO colleagues, it seems like their ideas on the topic run across a pretty wide spectrum. There are quite a few who feel that telehealth has provided substantial benefit for patients and providers and therefore plan to continue it. Those organizations are increasing telehealth budgets, working on staffing strategies, and more.

One health system that I follow is doubling down on virtual primary care, standing up virtual clinics and virtual patient panels. From a technology perspective, it feels like they’re just replicating their in-person workflows in the virtual world, complete with staff performing intakes and then referring patients to go visit the hospital lab and pharmacy at the end of the visit. They’re not yet approaching things like home phlebotomy or medication delivery. Other than not having to leave the house, the visits are pretty much business as usual, so they should seem familiar to the patients.

Another system I’ve consulted for in the past is retreating from telehealth somewhat. They’re adding additional capacity for nurse practitioners and physician assistants to offer same-day acute visits and are reducing the options for telehealth visits with primary care physicians so that the physicians can focus on patients who need to be seen in the office. That approach likely provides less convenience for patients who have grown accustomed to telehealth, and also potentially requires more real estate square footage since they’re going to have more providers and increased foot traffic in the offices. They feel that telehealth is impersonal and that their patients want a level of care that can only be given in person. As a patient, I’d argue that in-person care also brings a level of annoyance that many of us are trying to avoid.

We’ll have to see how it plays out and whether their capacity forecasts are accurate or whether they see patients defect to the health system across town since it’s still offering plenty of telehealth availability.

A recent survey from the Associated Press-NORC Center for Public Affairs Research and the SCAN foundation asked 1,000 US adults for their thoughts about what their lives will be like after the pandemic. While 48% said that telehealth was a “good thing” that should continue to be available, 52% responded that they’re not likely to use virtual care in a post-pandemic world. The breakdown of responses by age was interesting. For adults over 50, a mere 16% said they would continue telehealth visits. Looking at a younger crowd, 22% of adults under 50 said they would opt for virtual care. Not surprisingly, respondents with concerns about being infected with COVID-19 had a higher likelihood of wanting to continue with virtual healthcare. Most of the patients I see are in the under-50 age bracket, so I think it’s fairly likely they’ll want to continue with current telehealth options.

Looking more generally at the responses, only 12% of adults felt that their lives are the same today as they were before the pandemic, where 54% feel that life is somewhat the same and 34% feel their lives are not yet the same. Still, many adults in the US have resumed their pre-pandemic activities, including socializing with friends, dining out, visiting older relatives in person, travel, and worship. Only about half plan to use public transportation, which I find surprising given the rising cost of fuel (survey responses were gathered May 12-16, 2022).

Despite increasing COVID in my community (at least according to sewer shed data, since testing numbers are no longer reliable), the majority of people seem to be going about their business without masks, even though they’re recommended. I’ve had a combination of allergies and a cold for the last week, complete with eight negative COVID tests, and am convinced that since I haven’t had a cold in the past two years that I’ve forgotten how miserable it can be. Of course, it might just be undetectable COVID, but based on the negative tests and narrow symptom profile, I’d be surprised. No one I’ve been around has reported being sick either, so it’s a bit of a mystery if it’s something beyond just some wicked allergies. I engage in most of my pre-COVID activities, although most of them tended to be outside or with small groups of people and are fairly low risk.

I’ll be increasing my risk tolerance in coming weeks, as I have a couple of leisure trips coming up. I’ll be masking on the plane and in the airport and anywhere that seems like it doesn’t have great ventilation. One of the events I’m attending promises to be a reunion of sorts with lots of healthcare IT people I’ve worked with in the last decade, so I’m excited about that, as well as the ability to spend some quality time with one of my favorite healthcare personalities. I did some checking on the places I’m headed, and it looks like some of the entertainment venues still have mandatory masking. It will be interesting to be somewhere that’s a little stricter than home as far as preventive measures. I’ll be traveling with a stash of COVID test kits just in case, although I’ll be keeping my fingers crossed that I won’t need them. Hopefully during my travels, I won’t need any telehealth services, although I know where to find them if I need them.

Have you had to use telehealth while on vacation, and what was your experience? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/7/22

I’m back in the swing of things post-camp and am grateful that all was quiet at my day job. Now I’m wearing my blogger hat and wading through several hundred emails trying to figure out what happened in the healthcare IT world while I was gone.

There were the usual press releases, government updates, emails from my professional organizations, and what seems like more than my share of messages that should have been flagged as spam yet were sitting in my inbox. I had links to a handful of interesting journal articles, some clinical updates, and of course the latest and greatest about monkeypox (which is apparently still awaiting a new name courtesy of the World Health Organization).

The first article that caught my eye looked at using data from Twitter to better understand how the public thinks of FDA-approved versus off-label use of medications to treat COVID-19. The authors used natural language processing to evaluate 600,000 tweets that originated in the US between January 2020 and November 2021. They examined content mentioning four drugs that received a lot of attention during the pandemic. Both molnupiravir and remdesivir were FDA-approved treatments for COVID, where hydroxychloroquine and ivermectin had only anecdotal evidence for their use.

Not surprisingly, the authors found that the unapproved agents were mentioned more often, especially during pandemic surges. They also found that Republicans were more likely to support the unapproved agents than Democrats. Individuals with healthcare backgrounds opposed the unapproved agents more than the general population. The authors concluded that “social media users have different perceptions and stances on off-label versus FDA-authorized drug use across different stages of COVID-19, indicating that health systems, regulatory agencies, and policymakers should design ‘targeted’ strategies to monitor and reduce misinformation for promoting safe drug use.” This certainly becomes more difficult in states where governmental agencies and the courts took steps to promote or protect the use of unauthorized drugs. It will be interesting to see how this continues to play out now that we’re no longer in the most explosive phases of the pandemic.

The next article that caught my attention was about decision fatigue. The term refers to “a state of mental overload that can impede a person’s ability to continue making decisions.” Whether they’re small decisions or more significant ones, decision fatigue can leave individuals feeling “overwhelmed, anxious, or stressed” and can interfere with ongoing decision-making ability. According to the psychiatrist featured in the article, individuals make over 35,000 decisions during the course of a day, consciously or not. The COVID-19 pandemic has added stress for physicians as we navigate decisions in an increasingly complex healthcare environment. She notes that physicians have “had to make decisions we never had to make before, and we’ve had to manage the anxiety of our patients.”

Many of us have also had to manage the anxiety of family members as well as their healthcare needs, from helping them schedule vaccine appointments to making sure they can navigate through the web of in-person versus virtual visits over the past two years. One member of my family postponed a joint replacement during the pandemic and was just able to have surgery last month, which was a great relief. Decision fatigue can leave people feeling tired, drained, or with foggy thoughts. People are also likely to engage in unproductive processes as a result, via procrastination, avoidance, indecision, or impulsivity. We’ve all seen enough pandemic buying to explain the latter, and I’ve definitely seen the first three among my friends and colleagues as well.

Strategies for overcoming decision fatigue include creating daily routines, making lists to help avoid random decisions, simplifying repetitive processes through services such as automatic bill pay, and reducing tasks and activities that don’t provide value. The psychiatrist notes that “research shows that the best time to make decisions is in the morning” which is a time “when we make the most accurate and thoughtful decisions, and we tend to be more cautious and meticulous.” It makes sense to me – I know that by the end of the workday, my brain is pretty much fried.

The third item that caught my eye was an ONC blog that talked about health equity by design. It summarized some of the findings of ONC’s Health Information Technology Advisory Committee (HITAC) as it looked at creating equity in data collection, interoperability, artificial intelligence, bias, and crossing the digital divide. Since data collection is important to understanding outcomes and measuring change, it will be important to capture information on race, ethnicity, sex, language, disability, sexual orientation, gender identity, and social determinants of health. Although many organizations are doing a good job capturing these elements, I often see charts where many of the fields are blank.

Bias is important especially where artificial intelligence is concerned. There have been numerous articles in the last several years looking at how particular models perform when factors are different from the data set on which the model was trained, such as when a particular demographic isn’t adequately represented in the data set. There have been significant changes in how we manage certain laboratory values based on evidence versus old ideas that race is more of a factor than it should have been.

One example of this is kidney function. In the past, race was used to set different reference ranges for certain lab values. Scientists have realized that using race can be problematic since it doesn’t necessarily represent a specific genetic makeup or group of underlying biological characteristics. I’m excited about efforts to deliver healthcare in a more equitable manner, and especially initiatives that use technology to ensure quality care for all. I’ll definitely be watching to see where some of these efforts go.

Speaking of excitement, it’s July, which means the beginning of Internship year for many newly minted physicians as well as residency promotions for other trainees. My medical school recently reached out to me asking for help inspiring the incoming MD class, who will be receiving their white coats in a ceremony later this month. I trained at a time when there wasn’t any ceremony and we just felt lucky to get a coat that fit (and many in the class didn’t, which resulted in a lot of swapping after the fact) as we raced into our third year of medical school.

New students receive theirs in the first year after several orientation weeks, and they’re not only sized properly, but are embroidered with their names and the school crest. I’m sure it instills a sense of pride and accomplishment, although based on the state of healthcare today, I’m not sure I have any inspiring thoughts for those entering a system that seems more dysfunctional than it did even a few short years ago.

What do you wish you had known when you started your journey in healthcare or healthcare information technology? What would you tell today’s entering medical students? Leave a comment or email me.

Email Dr. Jayne.