EPtalk by Dr. Jayne 5/26/22

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/23/22

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/19/22

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/16/22

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/12/22

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/9/22

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/5/22

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/2/22

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/28/22

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/25/22

This week’s Monday Morning Update discussed an EHR outage at two of Tenet Health’s hospitals in South Florida. Apparently Tenet didn’t like the media coverage from WPTV and suggested that a story about the downtime be removed. The story covered a patient’s concern about potential medical errors during the outage, with Tenet complaining that suggesting a downtime could result in medical errors is “preposterous.” As a physician who has been in the trenches for more than two decades and who has been through enough EHR downtimes that I couldn’t begin to count, I’m speechless at the thought that downtimes aren’t problematic.

I’ve been up close and personal with a downtime-related medical error in my career, and the situation certainly would have been different had the EHR been online. It was a bit of a perfect storm-type situation. First, I was a relatively new hire still getting used to the processes at a new urgent care employer. Second, due to someone calling out sick, I had been rescheduled from my usual location to a different site, which added a baseline level of stress to the day since I was working with an unfamiliar team. Third, due to a pre-existing diagnosis, the patient I was seeing for a fever was unable to contribute to the history of the presenting problem and was combative during exam, which is tremendously stressful.

After my initial attempts at history-taking with family members and a brief exam during which I detected no emergent problems, I ordered some laboratory studies and moved on to see other patients. When I left the patient, he was pacing around the room and showed no signs of being in distress or in pain.

At some point before the tests were resulted, the EHR went down. As a new employee, I was unfamiliar with the downtime process, but knew there should be one. I asked if there was a downtime binder or how we were supposed to handle it. The clinical team lead was resistant to instituting downtime procedures, giving excuses along the lines of “the EHR usually comes back in a few minutes” and “it really makes a lot of paperwork if we try to go to downtime procedures.” Knowing that creating paperwork is the point of a downtime procedure, I pulled some paper from the printer and began writing my own SOAP notes and documenting what I could.

I remember having probably half a dozen patients on the board that I was seeing. I tried to move them through the process while begging for a paper prescription pad so I could write discharge medications and keeping a clipboard with sticky notes on it as a tracking board to help me remember what patient was in what room. Lab results were being printed from the instruments on little slips of receipt paper rather than flowing through the interface to the EHR. The results were in an unfamiliar format, with the individual tests being out of order within a panel and the reference ranges being difficult to read. Despite the downtime, the staff continued to room new patients and expected us to move forward. I was surprised by that – none of the patients were emergent, and as a walk-in urgent care center it would have been within our rights according to state regulations to stop taking new patients.

I was managing patients the best I could and providing written discharge instructions that I was typing in Microsoft Word and printing two copies so we could scan them later. For my patient who had a fever, there wasn’t anything apparent on the exam or on my review of the labs that could have been causing it, so I recommended close follow-up at home and told them what to look for. This was during the usual season for viral illnesses, and in many patients, the illnesses begin with fever but don’t always declare themselves with other symptoms for a day or more. Since the patient couldn’t describe his symptoms and the exam was difficult, I didn’t suspect anything serious.

Every one of my hand-typed discharge instructions included my best recollection of the practice’s standard disclaimer, which would have been automatically applied by the EHR had it been online. It was something along the lines of “Your examination at XYZ Health today is limited by the capabilities of this urgent care facility, which does not include advanced imaging or moderate complexity laboratory testing. If at any time you feel your condition is worsening, we recommend that you be re-evaluated at the nearest hospital Emergency Department.” I reviewed this instruction with the patient (who could not verbalize understanding) and his adult caregiver, who said she understood.

Two days later, I was called before the practice’s owner and yelled at for “letting someone walk out of here with those abnormal labs,” because by that point, the patient ended up having a significant abdominal infection that required surgical drainage. I explained that at the time I saw the patient they had no features of a serious abdominal process and reviewed the examination that I had documented on my handwritten SOAP note. I was then asked to review the documentation that had been keyed into the EHR after the downtime ended. There it was, in bright red — an abnormal lab value. I had missed it when looking at the receipt-paper printout in an unfamiliar format and with confusing reference ranges. It wasn’t a critical value, but it was abnormal enough that it might have made me think about additional potential diagnoses, even if the physical exam didn’t point me towards an abdominal cause for the fever.

In reviewing the patient’s course, he hadn’t been taken to the emergency department for more than 12 hours after I had seen him, which wasn’t a guarantee that the process requiring surgery was yet present when I evaluated him. Usually if patients have a significant infection in their abdomen, they’re not likely to be pacing around the room – they are completely still on the exam table, and you can hardly touch them. Still, I couldn’t help but second guess the factors that went into my care of the patient – the unfamiliar staff, the new location, the downtime, and the patient’s individual characteristics and presentation.

I explained to the now shouting and red-faced CEO that this wasn’t a normal visit under normal circumstances and that I didn’t have the luxury of having the abnormal lab highlighted in red in the EHR during the visit because there wasn’t an EHR during the visit. He seemed surprised to hear that. Even after he admitted that the EHR downtime was an issue and there’s to way to know if my care contributed to the problem, I agonized over the situation. Several peers reviewed the chart and had no additional suggestions, but that certainly didn’t make me feel any better.

The bottom line here is that EHR outages are difficult. They raise the potential for medical errors in a number of ways. They add stress to already overwhelmed staff. They remove safety checks that we’ve come to rely on. They increase cognitive load as clinicians look at data in unfamiliar formats. They reintroduce illegible handwriting to the environment. They also create time pressures when they end and staff is forced to key in data while they proceed forward with their usual assigned tasks.

I’m fortunate that the patient in this scenario had an uncomplicated hospital stay and there were no long-term consequences of the event, either for him or for those who cared for him. However, the long-term psychological impact on me as a physician makes me never want to encounter another EHR downtime again.

What do you think about Tenet’s comments regarding EHR downtimes? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/21/22

Telehealth company Amwell adds two new clinical programs to its platform. Payers can brand the offerings as part of their digital engagement strategies. The dermatology program offers sessions with board-certified dermatologists in an effort to alleviate delays in dermatologic consultations which can be several months in many parts of the country. The press release notes that it offers “most diagnoses returned in just 24 hours,” which makes me wonder if it’s an asynchronous offering versus a virtual visit with a dermatologist. The musculoskeletal program will help payers address challenges with physical therapy access, disrupted productivity, and downstream costs. It will provide patients with a personalized physical therapy plan, telehealth visits, digital sensors for guided exercise sessions, behavioral health support, and patient engagement services.

This article about non-fungible tokens (NFTs) caught my eye since it’s not often that you see them mentioned in the same sentence as “medical ethicists.” It raises important points about the fact that EHR data is being sold without patients being fully aware of it. How many of us actually read the documents given to us at medical appointments such as the Consent to Treat, Assignment of Benefits, and HIPAA Notice of Privacy Practices? The numbers are likely low because we just want to be treated and aren’t going to walk away regardless of what’s in there, for the most part. The last time I was at my local academic medical center, I was asked to sign a signature pad saying I had received the documents despite not having been actually offered the documents.

The premise is that a patient could own an NFT of their medical information, which could be stored in a secure database that would track access requests and approvals. The piece also points out that patients could maintain ownership of their biological specimens, from blood to tissue and even down to the cellular level. When you learn about the cell lines used in research and where they came from, there’s been tremendous injustice. (“The Immortal Life of Henrietta Lacks” is a great read if you’re curious.) Some ethics professionals disagree, saying that ownership of such data is shared between patients and the physicians and health systems who are involved in their care. The article notes that there needs to be a balance between privacy and public health along with greater understanding of why patients might not want to share their data.

There are also sustainability concerns around the creation of NFTs and maintaining the blockchains used to track them, as well as the risks of data making it outside of the public ledger or it moving to the black market. One researcher points out that “you can’t de-identify something with a genome,” reminding us of the uniqueness of each and every one of us. I would settle for greater attention to how patients are informed of the ways in which their information is used, and protections for those who want to opt-out of having their data become part of anonymized data sets that lead to profits for others. I’m not sure what the other potential answers are here, but will be interested to see how things evolve over the coming years.

With as much time as I’ve spent recently with marketing and branding exercises, I was surprised to learn that “debranding” is also a thing. Upon further review, it’s an extension of branding, but with a focus on simplicity and cleaner design. Examples include removing complicated color gradients or shadows in order to make logos cleaner. Increased use of mobile devices is a driving factor, as is a drive towards a more professional appearance. It’s fun to look at certain brands and see how their presentation has changed over time, especially in the consumer space.

A recent KLAS publication looked at the causes of clinician turnover. Although nurses are most likely to leave in the next year, other types of clinicians are close behind. EHR and IT tools are cited as a major cause, along with burnout, chaotic work environment, lack of personal control over workload, and more. I recently joined an online physician forum for EHR issues and have been shocked that the majority of questions are actually operational and management questions rather than technology issues, but physicians are turning to technology hacks to try to fix deeper issues.

I feel like I’m yelling into the void every time I say something along the lines of, “This is an operational issue requiring a policy and procedure to keep your practice staff from dumping on you, not something that needs another macro or preference or configuration in your EHR.” One physician confided in me that her two partners have left because the practice, owned by a large health system, is so chaotic and mismanaged. Rather than hiring a locum tenens physician until they can fix the problem and find permanent hires, the employer expects her to manage a panel of over 10,000 patients by herself with only a front desk staffer and two medical assistants. This is in a semi-rural area, and I’ve seen the complexity of her case mix. She’s to the point where she’s ready to resign if she doesn’t get some help, and the health system doesn’t seem to care. From a couple of decades in practice management and healthcare operations, I’d bet on the fact that better EHR templates and macros to respond to patient portal messages are not the answer. Shame on the health system for letting it get to this point and especially for thinking this is an acceptable solution.

When people are under stress, they turn to different diversions – often during the workday. If my Facebook feed is any reflection, there are many people are into playing the New York Times Wordle game. There have been plenty of imitators as well as specialty games. If you’re looking for some brain-stretching timewasters, I offer for your consideration:

• Worldle – geography themed.
• Wordosis – medical themed.
• Morsle – Morse code recognition.

Ever gotten the Wordle on the first try? How fast can you transcribe Morse code? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/18/22

A client I haven’t worked with in a couple of years reached out to me over the weekend, asking if I had copies of some materials that I had created for them. The project I originally worked on had been shelved because the company decided to take its solution in a different direction.

I wasn’t surprised when the work was mothballed. When you’re working on the vendor side, priorities can change drastically. Sometimes it’s a new regulatory requirement or the need to keep up with a third-party certification. Other times it’s a high-profile client with a contractual request. I’ve also seen projects get shelved when a competing solution turns out to be more work than originally scoped.

As a clinical content creator, you can’t get your feelings hurt when things change and your work winds up on the chopping block. Sure, as a physician you can be offended that your peers aren’t the priority, but it’s the nature of the beast when you’re working in the vendor space.

Fast forward and the company is trying to land a big client who needs content along the lines of what I created. There’s been a fair amount of turnover among the product and development teams, and although they remembered having content, no one could find it on any of their shared drives, SharePoint sites, email archives, or anywhere else. Despite corporate IT policies that discourage it, unless it is expressly prohibited, I keep copies of all my work product, so I was able to find it easily.

A quick glance reminded me that some clinical guidelines have changed over time and it probably needs a good going-over. I asked the representative from the vendor whether they had done any requirements gathering sessions with the prospective client or how they planned to approach the project. Although I don’t have capacity to work on it personally, I’ve got some informatics colleagues who could step in and get them moving.

I was surprised to hear that despite the fact that the client wasn’t able to find my content and therefore really didn’t have a good handle on what it contained, that they were planning to put it in front of the prospect and hope for the best. Apparently the buzzwords used by the prospect seemed in harmony with what was in the project charter (which they were able to find), so they assumed it was appropriate.

Since the product owner who reached out to me knows me pretty well, I shared a couple of thoughts on the idea of putting half-baked content in front of a high-value prospect without doing any requirements gathering. Without really understanding what the customer needs, how can you hope to hit the mark?

Unfortunately, I see this all too often in the healthcare IT industry these days. There’s a lot of tail wagging the dog between sales and product organizations, and ultimately the customer suffers when they have been promised something that doesn’t exist or that is quite a bit farther down the roadmap than they are led to believe. Having been in the CMIO trenches for longer than I sometimes care to admit, I’d much rather have honesty about what might or might not be available than to be the victim of a bait and switch. I know what my priorities are and what things I can bend on if it comes to that, but if the vendor isn’t interested in documenting my needs, I’m not sure why I’d want to be working with them in the first place.

The product owner was sympathetic to my recommendations, but mentioned that she’s under a lot of pressure from her leadership to make it look like they already had this content (even though they couldn’t even locate it). She knows she’s in a bind and is unhappy with the approach, but as we all know, the mess rolls downhill and sometimes you just have to do things you don’t want or like to do if you want to make those above you happy. Particularly if you’re in an organization that’s strongly top-down and feedback isn’t seen as something positive, you can feel pretty stuck.

I’ve spent plenty of time in organizations like that over the years, so I don’t envy her position. I sent her the files and the contact information of a couple of informaticists that used to work for me. Although I hope they’ll do the right thing (not only for the prospective client, but for the vendor’s own future success) but I’m not optimistic. I know my colleagues will let me know if they hear from the vendor, and it should be good for some stories over cocktails if they do start an engagement together.

While I was digging through my file archive, it was kind of fun to have a blast from the past and remember some of the projects I’ve worked on during my wild ride through the clinical informatics world. I think I’ve worked for clients that use just about every major EHR vendor as well as dozens of bolt-on solutions and even quite a few homegrown ones. I’ve worked with some amazing people who would bend over backwards to make sure that their projects delivered maximum benefit for patients and clinicians, and they’ve made even the most difficult projects rewarding. I’ve also worked with people who were only focused on how to make themselves look good and often did so at the expense of their teams and their colleagues. Those are the most difficult projects because even if you’re a consultant, no amount of experience or advice can make a difference unless there’s higher executive stakeholders who are willing to accept the fact that there’s ego-driven nonsense going on.

I also found some hilarious pictures of go-lives, some of which involved themes and costumes. One involved camouflage and a “M*A*S*H” theme and I think that was probably one of my favorites. I had forgotten coming up with IT-themed nicknames for everyone on the project, including General Release, General Ledger, Colonel Memory, Major Cluster, Major Milestone, Major Conversion, Major Problem, Captain Cloverleaf, Captain CCOW, Lieutenant Login, Sergeant Surescripts, Sergeant SAN, Private Practice, and of course Commodore Sixty-Four. One of the project team fired up her Cricut and made frames to go around our ID badges with our new credentials. That client produces stories that become legends, and I’m glad I got to have that experience.

What’s the most fun healthcare IT project you’ve worked on? What kind of things have you taken from it to enhance your current work? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/14/22

I wrote at the beginning of the pandemic about the increased visits my practice was seeing for sexually transmitted disease testing. A recent Washington Post piece covers the increase in syphilis and gonorrhea during 2020, partly attributable to clinic closures and delays in seeking care. Scarce public health resources were focusing on COVID-19 and availability of testing services was variable. I was distressed to see a significant rise in cases of congenital syphilis, which rose 235% since 2016 and hit a new high of 2,148 cases. Pregnant patients who are infected can experience pregnancy loss and infants who are born with syphilis can have devastating health issues.

Other diseases were also on the rise in 2020, including gonorrhea. Surprisingly, chlamydia was on the decline, although that may be due to decreased testing and delays in seeking care. Many infected patients don’t have symptoms and are only diagnosed on routine screening, so a decline in face-to-face visits might also be a driver. With the power of all the data we have in our electronic health records, organizations should be able to do a better job of identifying patients who are eligible for STD screening and can use patient engagements solutions for outreach. Depending on configuration, there may be barriers to outreach because it’s a sensitive topic; but that doesn’t mean we shouldn’t do our best to address an entirely preventable category of illness.

Many of us in healthcare IT cringe when healthcare workers incorrectly cite HIPAA as the reason that they can’t provide patients with their own health information. As a field consultant, I shuddered every time someone claimed a regulation wouldn’t let us configure the EHR in a certain way or modify a workflow so that the site would run more efficiently. The American Medical Association has created a series of articles that debunk regulatory myths. Hot topics that impact our field:

• HIPAA does not explicitly state that physicians can’t respond to online reviews from patients. However, they must maintain privacy, even if the patient has revealed personal information. Responding may however violate community guidelines for review sites, so physicians and practices should do their homework before responding.
• Clinical support staff who perform non-clinical tasks in the EHR are not required by federal or state law or regulation to log out and back in when switching back and forth between clinical and non-clinical tasks. They also don’t have to log out/in when switching back and forth from a scribe role to a clinical support role.
• The Joint Commission does not support or prohibit the use of documentation assistants such as scribes.
• Medicare doesn’t require physicians to re-document information captured by the staff, only to verify it, as long as there are no state or institutional policies to the contrary. This includes documentation completed by medical students.
• There is no federal rule that physicians are the only clinicians that can enter orders via computerized provider order entry. Other members of the care team are permitted to pend or send orders as requested by the physician, as long as state law allows.

One of the most often cited (and incorrect) myths is that The Joint Commission and/or OSHA prevent food and beverage at clinical workstations. I’ve seen dozens of nursing supervisors tell people that the hospital will fail a Joint Commission inspection if there are cups at the nursing station. In reality, The Joint Commission does not address where food or drinks can be located. Even the Occupational Safety and Health Administration doesn’t determine specific locations where workers can eat or drink. They do, however, prohibit eating and drinking in places where one could be potentially exposed to blood or infectious materials.

Hopefully, organizations aren’t allowing blood, urine, or stool specimens at the nursing station, not only because it can lead to contamination, but because it’s simply gross. Employers can make their own rules, and certainly it’s a good idea not to allow open drink containers in areas where a spill would damage electronic equipment or patient records, and people shouldn’t be eating by the computer and dropping crumbs in the keyboards. The reality of healthcare staffing these days is that often people don’t get dedicated meal breaks and sometimes scarfing a granola bar while you’re giving report on patients is the only way you’re going to power through. But when employers decide to put the hammer down, they need to not blame other organizations that have no opinion on the matter.

Speaking of regulations, I’m spending part of this week working on my bucket list. Despite being in a helmet-optional state for the week, I’m glad that my course requires reasonably adequate helmet coverage. I always feel a little squirrely when I participate in activities that have inherent risk since I know that I’m likely the highest trained medical professional available if something goes wrong. I’ll be glad to not have to manage the consequences of failing to protect against head trauma. The weather is looking rather frightful, so I’m hoping for the best.

I ran across a solution today called JustAskEvie. It offers real-time EHR support for clinicians, powered by a network of fellow clinicians who provide peer-to-peer support. Services include coaching on specialty-specific workflows either during a physician’s onboarding process or during their first days using the EHR. Their goal is to be complimentary to the training offered by organizations or as a replacement option for those who might not have been able to attend scheduled training. They also offer go-live and upgrade support as well as after-hours coverage.

The company is hiring “Evies” for a variety of EHRs. I like the idea, but I imagine there might be some challenges when working with organizations who have heavily customized their EHRs. Several physicians who were part of the conversation voiced interest in checking it out as a potential side gig, with two noting that their organization doesn’t offer compensation for those physicians who agree to be super-users or to provide peer-to-peer support. It reminds me of the staffing equation we’re seeing in nursing and elsewhere in healthcare. Rather than pay for in-house resources who know the local system and climate, organizations are willing to give money to a third party to achieve a similar outcome. I understand why it happens, but on some level, it is still baffling.

How does your organization compensate clinician super-users? Or does it expect them to do it out of the goodness of their hearts? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/11/22

I spent some time this week with people who are knee-deep in public health efforts. One of the major topics of conversation was a preprint study that looked at ongoing declines in the US life expectancy. This year’s decline is significantly smaller than what we experienced last year, with us losing about half a year on average in 2021. The overall US life expectancy is now 76.6 years, representing the lowest value in more than two decades. Although the decline is less steep, it causes some less than optimistic thoughts among public health proponents who thought that having a readily available COVID-19 vaccine would help stabilize life expectancy data. Unfortunately, I think many underestimated the resistance to vaccination that we have seen across the country.

A big part of the discussion was the disparity between life expectancy in the US compared to other countries with similar resources, including Austria, Belgium, Denmark, England and Wales, Finland, France, Germany, Israel, Italy, Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Scotland, South Korea, Spain, Sweden, and Switzerland. Researchers felt this was largely tied to lower vaccination rates in the US compared to our peers. Other wealthy nations have seen increases in life expectancy in 2021 to the point where the gap between the US and our peers differs by more than half a decade. In addition to COVID, our numbers are likely impacted by conditions like diabetes, high blood pressure, and obesity that seem to be growing every year.

Another central theme in the conversation was the sheer amount of healthcare spending in the US compared to the outcomes we see. Although there has been a lot of discussion about value-based care over the last several years, we still see plenty of organizations focusing their marketing efforts around procedural subspecialists who can bring fee-for-service cases to their hospitals. Sometimes it feels like patients would much rather spend money for a pill or a scan or a procedure than they would on healthier lifestyle choices. The reality is that public health isn’t sexy and most of the time the general public doesn’t want to hear about it, despite the fact that clean water, waste management, safe housing, and vaccines are all public health measures that have made life better for many people.

The group knows I’m a clinical informaticist and asked me what technologies I thought could be brought to bear to help the life expectancy crisis. There are a lot of solutions out there, but I think we need to focus on a couple of key themes rather than following every shiny object that passes in front of eyes. First, we need to educate our patients. Patient engagement solutions such as chatbots, patient portals, and the like can help deliver patient education so that patients understand their health situation and know what to do to move things in a positive direction. For some patients this may need to be low tech, such as simple phone calls with a health coach or navigator, and those patients shouldn’t be left behind.

Second, we need to help patients track whether the things they’re doing to try to improve their health are making a difference. I’m surprised that readily available home monitoring devices such as smart scales or connected blood pressure cuffs aren’t used more. They don’t necessarily have to have all the bells and whistles, such as sending data to their care team, but need to be able to help patients see a trend and to know if what they’re doing is helping things get better or not. Seeing immediate results can make a huge difference in patient morale as well as readiness for patients to continue an intervention.

Third, we need to make sure that everyone involved in a patient’s care is aware of their health factors. Interoperability is key here to ensure that there’s not only avoidance of duplicative or unnecessary services but to ensure that different members of the care team know all the different conditions a patient has. There are still a number of patients that see multiple subspecialists with minimal coordination, so I think it’s going to be important to continue to invest in infrastructure such as health information exchanges.

Last, we need to continue to spend some of our tech funds on health surveillance, including not only public health analytics to help identify the next pandemic or severe health threat, but also on analytics to monitor the improvement or decline in the overall health of populations and what might be contributing to those changes. With all the computing power available to us, we should be a lot better informed. If we’re going to get health spending in check, we have to measure, manage, and measure again. I do have some favorite vendors in these areas, but I’m interested to see what our readers think and how impressed (or unimpressed) you might be with the solutions your organizations are using.

I spent a good chunk of the weekend helping some young people learn wilderness survival skills in the context of a fictional “zombie apocalypse” that was made more dramatic by the presence of near-freezing temperatures. It was also a team-building exercise, and it was interesting to see how the different groups came up with completely different shelter designs even though everyone started out with two tarps and a ball of twine. Several used the landscape to their advantage for wind and rain protection, and another did some interesting things with old tires that they found dumped in the woods. One less-than-enterprising group tried to just gift wrap a picnic table with their tarps. Although it was probably effective as a survival shelter, it didn’t score well on creativity in the peer voting at the end of the day.

The winning shelter was a simple design. I spotted one of my co-leaders napping in it following the judging, so I hope it earned all the “suitability for sleep” points that it rightfully deserved. Most of the groups spent the night in their shelters with only sleeping bags and I’m sure the excitement of having made it through the night is an accomplishment they won’t soon forget. Certainly none of them were impressed by my zombie antics, so I suspect I’ll just have to go back to being the “boomer” that the youngsters seem to think I am.

Has your company ever done any “extreme” team building? If so, what did you do? If zombies were taking over the world and you had to abandon your living space, do you think you would make it? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/7/22

A bill introduced in the US House of Representatives last week would allow employers to offer separate telehealth plans to its employees, much like they offer separate dental, vision, and medical coverage now. The Telehealth Benefit Expansion for Workers Act bill is a bipartisan effort, and it would also modify HIPAA and the Affordable Care Act to allow all employers (including seasonal and part-time staff) to benefit. It would allow freestanding telehealth programs to be separate from traditional medical coverage.

I haven’t seen any commentary on this from hospitals and health systems, which are probably still digesting how it will impact them if it passes. I haven’t had time to dig into the specifics of the bill, but I suspect the devil is in the details as far as what constitutes a freestanding telehealth program. For organizations that are already offering services but want to be able to capture their piece of the standalone pie, I imagine there will be a need to customize platforms to allow for different types of billing as well as to comply with any other program-related definitions. We’ll see how this bill navigates through the committee process and other parts of the legislative journey. If you’ve got any insider scoop, do tell.

In other telehealth news, the Government Accountability Office urges Medicaid to assess how its beneficiaries are using telehealth and to ensure that they are receiving quality service. The call to action is based on data from five states that showed significant increases in the number of services delivered via telehealth as well as the number of Medicaid beneficiaries participating. There are certainly challenges in delivering high-quality telehealth visits to Medicaid patients, who often have difficulty accessing healthcare in general. Technology may pose additional barriers due to cost, particularly when video is required for telehealth services. It will be interesting to see what types of studies are designed and what the outcomes are. A well-managed telehealth program can delivery high quality care, so let’s hope the studies are completed quickly so we can build upon the findings.

Despite spending the majority of my time on clinical informatics these days, I’ll always be a family physician at heart. With that in mind, I was disheartened to see a recent report from The Commonwealth Fund that showed the US ranking last for women’s healthcare among wealthy nations. Specifically, we had the highest rate of preventable deaths for reproductive-age women, with 200 avoidable deaths per 100,000. The UK was next with 146, followed by 132 in Canada and 90 in Switzerland. The maternal mortality rate in the US was three times the rate of other countries in the report, with high death rates among black women. The US also posted high rates of chronic health conditions, mental health issues, and difficulty paying medical bills. Although many of the people in legislative roles in the US are neither women nor of reproductive age, hopefully they have some family members who might fit into those categories and will consider taking action.

Back when my state’s Board of Healing Arts used to send out a paper newsletter listing its disciplinary actions, I often marveled at the ignorance, recklessness, and sometimes downright stupidity of some of my peers. Now I have to settle for digital snippets depicting doctors behaving badly, and a recent article. The Office for Civil Rights, which is charged with enforcing HIPAA, recently announced findings in a few investigations. Two were particularly salacious: one was a dental practice who provided patients’ protected health information to those running a state senate election campaign and another was a dental practice who disclosed a patient’s information on a website while replying to a negative online review. Seems to me like specialty medical certification boards should consider dropping some of their exam questions that deal with esoteric disease processes and consider adding basics of HIPAA (and being a decent human being).

News of the weird: a man in Germany received 90 COVID-19 vaccinations so that he could sell vaccination card forgeries that included actual vaccine batch numbers. Staff at a vaccination center became suspicious when he presented for immunizations two days in a row. He was found to have blank vaccine cards, and although he was not detained, criminal proceedings are under way. Forged documentation is a hot commodity in Germany, where vaccine passports are needed to enter public venues.

Insomnia is a big problem around the world right now. I attended a couple of presentations at HIMSS that discussed solutions. One looked a prescription digital therapeutics as a potential intervention, while the other discussed a smart pillow to gather data as part of an overall sleep management program. During a recent trip, I had four straight days of poor sleep and felt the effects. I couldn’t control the heating and cooling in my room the way I needed to, and of course there were random hotel noises in the hallway and loud pipes in the bathroom. I’m sure stress was also a contributor, but sometimes there’s not a lot you can do to mitigate that compared to the other factors. With that in mind, I ran across an article discussing a recent study of sleep data that revealed 16 distinct ways that people sleep.

The data was gathered from smart wristbands used by the United Kingdom Biobank. The bands tracked patterns of sleep and wakefulness by measuring arm movements. Clusters of sleep patterns were then divided into five categories with a number of subcategories to total 16. Groups ranged from those waking up mid-sleep to those sleeping well without naps, and everything in between. The researchers also identified disruption that was likely due to shift work as well as those with fragmented sleep. I don’t know where I fall on the continuum other than knowing that my recent sleep has been “a cluster,” but I hope I can get things to reset soon. I’ll be spending several nights in the upcoming weeks sleeping in a tent, which usually does the trick since I crash hard after being active in the outdoors.

Have you found your sleep suffering in the third year of the pandemic? What strategies have you taken to improve things? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/4/22

I spent some time this weekend at a non-healthcare, non-technology conference. It was nice to get away for a few days and spend time learning ways to improve my skills for one of my hobbies.

I’ve been attending this particular conference since 2018, and many of the attendees know about my past life in the emergency department. There were quite a few questions about COVID and whether I think it’s really over. I typically respond that I don’t think it will ever be over, but we’re learning how to cope with it in the US. Because our lives are back to normal, at least in part, many people have forgotten that there are other nations where people still haven’t had adequate opportunities to receive vaccines.

The Our World in Data website is one of my favorites. It shows that a high percentage of people in Africa have yet to receive even one dose of vaccine. It makes you think twice about living in a country where a large number of people still believe that COVID isn’t real and vaccines aren’t safe, despite there having been more than 11 billion doses administered worldwide.

I had some time to kill at the airport, so I participated in an online research study from Harvard University. The study was designed to evaluate strategies to influence vaccine-hesitant individuals to become up to date with the COVID vaccine schedule. Participants were educated on several strategies to try to persuade people to receive vaccines and then were asked to create narrative statements that they felt might work. Messages were to be in response to a patient who was concerned that the vaccine was rushed, that mRNA technology is too new, that fetal cells were used in vaccine development, and that vaccines cause death. The researchers plan to use a natural language processing algorithm to evaluate the messages, and which are best at demonstrating receptiveness. They also gathered data on the respondents’ perception of the concerned patient and whether they would be willing to interact with that person again, which I thought was interesting. I’ll have to keep my eye out for the results of the research in the future.

I also had time to read a study that was recently published and has been regarded as somewhat controversial. The Journal of the Mississippi State Medical Association published the study, “Targeting Value-Based Care with Physician-Led Care Teams” in its January issue. It details findings from Hattiesburg Clinic’s value-based care journey with its Accountable Care Organization. When cost of care was examined, the study revealed that care delivered by non-physician providers who were practicing independently was more expensive than care delivered by physicians. The findings led the Clinic to redesign its care model as well as to publish its findings. Multiple news outlets and physician organizations picked up on the article, leading to headlines about how midlevel practitioners just might not be the answer to the primary care physician shortage at all.

Looking at the organization’s journey, in 2005 it employed a combined total of 26 APPs (advanced practice providers), including nurse practitioners and physician assistants. Today it employs 118. Over the last 15 years, Hattiesburg Clinic had made decisions to expand care teams by allowing these providers to manage primary care patient panels on a largely independent basis. The Clinic has more than 33,000 Medicare beneficiaries and an associated Accountable Care Organization, so it was monitoring its outcomes carefully. The study found that by allowing APPs to operate independently, the organization “failed to meet our goals in the primary care setting of providing patients with an equivalent value-based experience.”

The authors looked at 2017-2019 CMS cost data on Medicare patients who did not have end-stage renal disease and who were not in a nursing home. The data showed that per member, per month spending was $43 higher for patients who had a non-physician in charge of their primary care needs. When applying risk adjustment factors for patient complexity, the difference was $119 per member, per month. Originally, the analysis was to help the organization identify high-cost providers so they could intervene. They didn’t expect the results they identified, including increased testing utilization, more specialist referrals, and more emergency department utilization for patients who were under non-physician care.

They also found that physicians performed better on nine of 10 quality measures, with notable differences in vaccination rates for influenza and pneumococcal disease. Physicians also had higher patient satisfaction scores across multiple domains measured via Press Ganey. Although they concluded that non-physician providers are valuable members of the care team, the organization determined that independent practice was not in the organization’s best interest. They then embarked on a year-long transition that would allow APPs to inform their patients that they would start seeing the supervising physician as well, and that the physician would become the primary care provider of record. Additionally, APPs in specialty areas were restricted from seeing new patient consultation visits except in emergencies or when approved by the referring physician.

There are some interesting factors to note with regard to the findings. First, the Hattiesburg Clinic is focused on value-based care. Their experiences may not translate to organizations that are still operating under a predominantly fee-for-service model. Under the value-based care model, excess testing and referrals cut into the organization’s bottom line, so there’s an inherent level of buy-in for operational changes. In a fee-for-service model, the organization can benefit from certain kinds of overutilization, which doesn’t encourage restricting services. Also interesting is the finding that the patients who had the best quality were those who had alternating visits with both the physician and the APP.

There are also some weaknesses in the study itself, including controlling for years of experience of the APPs compared to years of experience of the physicians, and any variation in the organization’s onboarding and training of different types of providers. Having worked with new and experienced nurse practitioners, physician assistants, and physicians, I’ve seen across the board that inexperience is directly related to the propensity to order increased testing and referrals. When you’ve seen a given clinical presentation hundreds or thousands of times, you’re likely to be more confident in your ability to manage the patient on your own and are also experienced enough to refine testing to the minimum necessary. The published writeup also doesn’t include enough information on the analysis to determine whether some of the differences were statistically significant.

It will be interesting to see if the authors submit their work for the additional scrutiny of one of the national journals and what the findings look like when they are subjected to additional statistical analysis. Although the findings seem dramatic, they underscore the need for critical reading and to determine whether findings are likely to be similar to other situations. There are hundreds of organizations across the country who have the same types of data as Hattiesburg Clinic, and it would be interesting to see whether they reach the same conclusions. We’ve entered an era where there is more healthcare quality and cost data at our fingertips than we’ve ever had, and it’s time to really start using it.

What does your organization think about Hattiesburg Clinic’s findings? Have you looked at this issue yourselves? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/31/22

A recent survey conducted by the American Medical Association found that 85% of responding physicians are using telehealth in their practices. Approximately 60% of physicians agreed or strongly agreed that telehealth enables the provision of high-quality care. I wasn’t surprised by the breakdown of visit types – 93% of them are offering video visits and 69% of them are offering audio-only visits. More than half of respondents say they are motivated to increase the use of telehealth in their practices. Uptake of other telehealth services, such as remote monitoring, seemed low at only 8%. As far as other interesting statistics, more than half of physicians indicated that telehealth had improved job satisfaction. The online survey was conducted anonymously, with 2,000 physicians responding.

A lot of people think that true telehealth services have to include both audio and video, but in my experience as a telehealth physician, it seems that the majority of patients are happy with audio-only services. Physicians have mixed feelings about doing audio-only visits. It’s definitely easier to assess whether people have an increased rate of breathing when you can see them, and you can quickly gauge their overall level of distress. Especially when caring for sick children, I like to see if they are clingy and how consolable they are as part of the evaluation.

For many adults seeking telehealth services, however, observation and other elements of physical examination don’t add much to the clinical picture. Ultimately it should be a balance, taking into account the patient’s preferences and the clinician’s comfort level with different telehealth modalities. There are plenty of studies that indicate that inclusion of audio-only services results in greater telehealth access among underserved populations, older patients, those who seek care in safety net facilities, and some demographic subsets.

Although there’s a lot of enthusiasm about telehealth, other sources look at telehealth from a different lens. One survey commissioned by UnitedHealth Group found that 55% of physicians are frustrated by managing unrealistic patient expectations for virtual visits. About half are also frustrated by issues with audio and video technology. Providers who responded to the UnitedHealth survey were less optimistic about telehealth’s impact on job satisfaction, with only 25% saying it was improved. There was also division on the role telehealth plays with regard to physician burnout – 30% said it increased burnout, while 30% said it reduced it. I’m sure the perceptions are valid at both ends of the continuum since I’ve seen some outstanding telehealth implementations and some that are marginal at best. I do hope that those organizations that plan to continue making it a large part of their patient care strategies spend the time and money to optimize their offerings for both patient benefit and clinician satisfaction.

Henry Ford Health unveils a new brand, dropping the word “system” from its name. According to its press release, removing “system” places more emphasis on the word “health” and broadens the vision. The new logo drops the iconic Henry Ford signature and oval and adds three shades of blue as well as a swath of purple. The purple is certainly eye-catching, but I’m not sure what to think about the different blues. The organization plans to roll out the new branding to its largest facilities first, with others phasing in the new branding over the next few years. Along with the visual branding, Henry Ford Health is launching an omnichannel ad campaign titled “I Am Henry.” It includes stories from the organization’s patients, employees, and from the communities it serves.

The organization’s press release notes that the “new logo clearly transitions the identity from one steeped in the visual history of founder Henry Ford, to a brand expression focused on humanity, backed by a powerful heritage of innovation and drive.” I’m not sure I fully feel that, but I’m willing to play along. On one of my recent projects, I learned an incredible amount about marketing, branding, and how different visuals can evoke specific responses from viewers. Looking critically at the new logo, I find the font rather intriguing. The majority of the letters are strong and uncomplicated, but the leg of the R adds a bit of whimsy. The swooping crossbar of the leading H pulls you into the name, and the trailing H feels downright playful. The purple feels a little too bright compared to the blues, but that’s just me. I’d be interested to hear what the marketing gurus out there think of it compared to my decidedly amateur opinion.

I learned last night that a physician who I worked closely with during my residency took his own life on Monday. He was a few years ahead of me in training . The loss of a young and talented physician (as well as a father and spouse) is tragic. Each year, 300 to 400 physicians die by suicide. Even if we personally are not at risk, the odds are that someone we work with might be struggling. The grief was particularly heavy since Wednesday was Doctors’ Day in the US, which was created to honor physicians for their dedication and their service to humanity. Knowing that some physicians feel there is no way to get through the challenges is heartbreaking, especially since I’ve lost two colleagues this way in under two years.

Judging by the reports in some of my social media feeds, the day was subdued for many, with occasional “snacks in the breakroom” celebrations. One physician reported that their organization gave everyone a book on wellness, which for many frontline physicians has become synonymous with pizza parties and therapy dogs. Another received a heart-healthy cookbook that appeared to be left over from a recent cardiology department open house based on the sticker gracing the back cover. I doubt hospital executives think about the idea that their selections might be posted on nationwide Facebook groups as a humorous counterpoint to those “best places to work” lists. Sadly, some physicians reported receiving no recognition in the clinic at all. With all the work physicians have put in over the last couple of years, I’m hoping that for them Doctors’ Day 2023 will be a better one.

Did your organization do anything to mark Doctors’ Day? Leave a comment or email me.

Email Dr. Jayne.