EPtalk by Dr. Jayne 12/1/22

There has been a lot of discussion in the patient engagement world, as well as around the virtual physician lounge, about the announcements of some health systems that they are going to start to charge for patient portal messages that involve medical advice.

Most physicians I’ve spoken with agree that the surge in patient portal messages during the last three years is contributing to burnout, not only among physicians, but with staff. EHR vendors have been hard at work helping their clients understand the types of messages they are receiving so that clients can work on optimization efforts. At least one vendor has even gone as far as working to filter out messages that contain little more than “thank you” in an effort to reduce the sheer volume of messages in clinician inboxes.

The elimination of the thank you-type messages is fairly controversial. Some clinicians like them and see them as a small bright spot in the drudgery of the inbox, but others see them simply as an annoyance.

Despite the information that is available to organizations about the types of messages they are receiving, quite a few organizations I’ve worked with aren’t even taking the basic steps needed to help tame the inbox beast. Let’s take medication refills, for example. In some systems, this is a good chunk of patient portal requests. I don’t see people looking deeply at why patients are asking for refills via the patient portal. For years, even going back to the world of paper, practice management experts have advocated for providers who treat chronic conditions to issue up to a year of refills during the chronic condition visit. People still don’t do this, and when I shadow in physician offices, I hear statements like “just call us when you need a refill,” which is absurd in this day and age.

As organizations moved to EHRs, there was a migration to have refills requested through the pharmacy, where the transaction could come electronically and be vetted against the patient’s existing medication list for a quick refill. That workflow led to tools that were deployed on top of the EHR (one of the best ones I have ever seen was homegrown at a New York provider group in the late 2000s) that would evaluate certain metrics such as recent lab results and past visits and give the nursing staff a red-yellow-green indicator on whether they could issue refills through a standing order or a delegated refill policy. Other solutions followed, but organizations still didn’t fully embrace them.

Now the pendulum has swung back to where we were in the 1990s, which is the patient asking for a refill in narrative form via a patient portal message. This is the equivalent of calling the office and speaking with someone or leaving a message on a voice mail “refill line.” Patients aren’t even being asked to select a medication from their current medication list, but instead are typing it out. They may not have the name or dose correct, which increases the work for the practice as well as the risk of medical errors. Often there are better tools within the patient portal, but they simply haven’t been deployed yet because leadership feels they are not a priority.

Fast forward to every day in a primary care physician office, where everyone is at their breaking points. Physicians are spending hours each day, often at home, handling refills and messages. Two decades ago, we thought this was infrequent and somewhat subjective, but now our sophisticated EHRs can deliver reports about provider work after hours and it’s clear that a good portion of the workday is occurring in places other than the clinician office.

Often that after-hours work involves what we traditionally define as patient care, which includes explaining or re-explaining things to patients, looking through charts for information to send to a patient, coordinating referrals and follow-ups, and more. This is uncompensated work and it makes sense that clinicians are pushing back against it, leading organizations to consider hiring staff to assist in managing the inbox. Thse resources cost money, hence the move to charge for what has largely been uncompensated care. I say largely uncompensated because in value-based care models, compensation for these non-visit efforts is included in the payment equation in other ways.

In looking at some of the health systems’ documentation on how they plan to charge for patient portal messages, most of the approaches are well reasoned. Organizations are clearly saying that they will charge if a response requires the medical expertise of a licensed provider and requires more than a few minutes of time. Looking at one institution’s website, I found some details. Messages are primarily being billed to health insurance, with varying charges being passed on to the patient. For most Medicare patients, those messages will have no patient cost or a small charge ($5 or so), but for Medicare Advantage plans, it might be up to a $20 co-pay. Medicaid resulted in no charge to the patient, and private insurance ranged from a standard office visit co-pay up to a full $75 charge if the patient has not yet met their deductible.

That particular system is using the CPT codes for online digital evaluation and management, which are time-based. The codes can be billed cumulatively every seven days, so if a message generates a lot of back-and-forth responses, the work can generate a higher level of service. The websites are typically clear on what kinds of conversations will generate the code, including a new issue or symptoms requiring clinical assessment or referrals, medication adjustments, flares of chronic conditions, and requests to complete forms. The latter is a huge time suck for primary care offices and many practices have been charging for completion of forms for years, so I’m not surprised at all by that one. Refill requests or conversations that lead to a scheduled visit aren’t charged, nor are follow-ups related to a surgery with a global billing period.

This type of process is going to be an adjustment for patients because they are used to not having to pay the full value of the services they’re receiving. The presence of insurance in our society has led to a general lack of awareness of the value of provider and staff time, as well as the cost of truly delivering care. Consumers are already used to seeing surcharges on restaurant bills and other invoices for work that was previously free, so at this point, it shouldn’t be as much of a surprise as it feels like. Everyone’s just trying to stay afloat, and it will be interesting to see how the use of these charges plays out over time.

Is your organization charging for certain services delivered via the patient portal, and how is it going? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/28/22

I mentioned last week that I was getting ready for an outpatient procedure, and I’m happy to report it went without a hitch. I was impressed by the professionalism of the surgery center staff as well as their efficiency.

One of the nice touches was a card that was apparently with my patient folder. Each staff member signed the card and indicated the role that they played in the procedure. The card was included in my discharge packet.

I was looking forward to recognizing some of them individually via the patient experience survey that was almost certain to follow. Unfortunately, the link that was texted to me later in the day didn’t work, and the review site’s help functions were of little help, which was disappointing. Knowing that physicians are often graded on patient reviews, I felt bad about not being able to contribute in a positive way.

Mr. H mentioned this JAMA opinion piece last week, which questions whether the focus on patient satisfaction measurements might be harming both patients and physicians. The authors note that “patient satisfaction is an integral element of care, and scholars have argued that positive patient experience represents an important quality dimension not captured in other metrics.” However, they note that many survey instruments were created nearly two decades ago, and “Measures can lose value as they age, and just like the Google search algorithm, patient satisfaction measurement strategies need to be updated to remain useful.”

Unfortunately, many organizations don’t seem too interested in updating their surveys. I’ve experienced this with clients who can’t seem to make updating their surveys a budgetary priority. I’ve also experienced it as a patient, when I was asked how the office performed on aspects that weren’t relevant to the visit. For example, asking about COVID precautions following a telehealth visit, or asking about procedural elements that weren’t part of a given office visit.

My biggest pet peeve about patient experience surveys is when they don’t offer an answer choice for “not applicable,” “did not experience,” or something similar. All clinical encounters don’t contain the same elements, and if you don’t allow me to opt out of a question or respond that it wasn’t applicable, then the data you’re going to get is skewed. When confronted with something they didn’t experience, patients might rate it low, high, or neutral depending on how they interpret the prompt.

Another pet peeve about such surveys is how certain organizations use the data. At one of my previous clinical employers, anything that was less than an overall four-star review generated a “service recovery” call from administration. Since our surveys were constructed in a way that a score of three meant expectations were met, this created a lot of focus on visits that were generally acceptable in the patient’s point of view but didn’t meet the criteria of being exceptional.

In the event that a patient responded with a low score, such as a 2, the immediate assumption by administration was that the physician had done something wrong, even if the low score was a result of the provider giving good care. For example, not providing an unnecessary antibiotic or being unwilling to provide controlled substances without a clear medical need. Administrators always called the patient first, which often led to an accusatory call to the physician, who was on the hot seat to explain the situation.

Having practiced in urgent care and the emergency department for 15 years, I have a pretty good sense of when a patient is dissatisfied with a visit. I make sure to put a lot of detail into the chart note about the visit, what was discussed, the patient’s response to the care plan, and more. It’s easy to read between the lines and see that I already sensed there was going to be a problem and took proactive steps to address it. Still, it felt like our leadership never even looked at the chart and we were always put in a situation where we were on the defensive, which isn’t ideal.

Patient satisfaction surveys aren’t inherently bad. Studies have shown that high satisfaction is associated with lower readmission rates and lower mortality. It should be noted that an association doesn’t mean something is causal, a fact which is often missed by healthcare administrators. The authors also mention a well-known study “The Cost of Satisfaction,” which demonstrated that patients who gave the highest ratings often had higher costs and mortality rates.

One of the specific data elements mentioned in the opinion piece was advanced imaging for acute low back pain. Although such services drive higher costs of care and have little clinical benefit  — to the point of being featured on several prominent lists as things that physicians shouldn’t order — they also yield higher mean patient satisfaction scores.

The authors also mention that many of the survey tools in use were designed to measure aggregate performance and weren’t intended to evaluate individual physicians or care teams. They go on to explain that some instruments in standard use result in skewed data, where a physician can score highly but because of the distribution of responses be considered to be in the bottom 50% of performers. When everyone is high performing but some will be penalized regardless, it creates a continuum of responses with complete withdrawal on one end and something akin to “The Hunger Games” on the other.

The piece also notes that small patient populations or small response rates can create a disproportionate impact on a physician. In my past life, when I transitioned from full-time to part-time practice, this became readily apparent as I spent more time working in clinical informatics and less in the primary care office. Patients were also disappointed that I wasn’t as accessible as before and this showed in satisfaction scores, regardless of the quality of care that patients received. It certainly was a contributing factor in my decision to leave primary care and transition to the emergency department, since I didn’t want to spend half of every visit discussing why I was only there one day a week and the fact that patients refused to see my partners.

While the authors note that patient satisfaction scores are an important component of quality, their use in a “high-stakes” environment “renders them at best meaningless and at worst responsible for physician burnout, bad medical care, and the defrauding of health insurers by driving up use.” They call on payers to reconsider their use in determining quality and payment factors. The authors ask the Medicare Payment Advisory Commission to annually evaluate measures currently in use to make sure they are still fit for purpose.

Although I agree, I know that it’s always easier to keep the status quo, so I’m not hopeful for significant changes. There have also been a number of studies looking at elements of bias in patient satisfaction surveys, and how physicians of certain demographics perform less well than others regardless of outcomes. Until those issues are addressed, patient satisfaction scores will continue to be controversial.

What do you think about the incorporation of patient satisfaction scores in the determination of quality bonuses and payments? Is there room for meaningful transformation? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/21/22

I’m back in the patient trenches again, getting ready for an outpatient medical procedure and loathing the process. I’m an active patient of the physician who will be performing the procedure, with an up-to-date chart at the practice. The ambulatory surgery center where the procedure will be performed is owned by the physicians (although it’s a separate legal entity than the practice) and I’m also considered an active patient there due to a previous procedure.

Even though it would have been perfectly easy for the performing physician to send an appropriate History and Physical document to the surgery center (and for all I know they might have done so), I received an enormous “snail mail” packet to complete that basically treats me like a brand-new patient. Once could claim that it was an artifact of trying to keep the surgery center separate from the practice entity, but all the paperwork has both entities’ logos on it, so that claim doesn’t hold water.

The surgery center called me on Wednesday to pre-register me for the procedure, which is pretty typical. Unfortunately for me, I was still in Las Vegas, so the call came in at 6 a.m. local time and my grogginess was probably entertaining for the registrar. The staffer basically asked me all the information that is already on my chart, although it was from the perspective of confirming existing information rather than being from scratch. I asked about the paper packet, and she indicated that it was mailed from the practice side of the organization rather than the surgery center, and that I should plan to complete it.

I enjoyed answering the COVID screening questions, since I was at a conference with probably 8,500 unmasked people compared to the few of us who might have been masking when we could, and certainly I was exposed to someone with COVID. Another great question was whether I have a Healthcare Power of Attorney, but they didn’t seem interested in knowing who my personal representative is or having me bring a copy. The call took less then five minutes, though, and I was able to get another half hour of sleep before I needed to get ready to head to the airport.

As I went through the paper packet today, I noticed the addition of a new form that might actually be useful to patients, especially those who might not have a lot of experience in our fragmented and messy healthcare system. The page listed out all the different entities that will be involved in my care – including the physicians, the surgery center, the anesthesia group, and the pathology group. Each column had the name of the entity, a description of how they fit into the procedure, the services they provide, and the fact that I will receive a separate bill from each group.

Although it fully illustrates the absurdity of healthcare in the US, I appreciate the fact that they’re trying to educate patients prior to their having a procedure so that there are fewer surprises down the road. I found it interesting that only the surgery center requires payment of my portion of the estimated co-insurance in advance. If I recall correctly, the anesthesia group waited until just shy of the timely filing deadline to submit their claim, so any hopes of wrapping up the procedure and payments will likely be delayed until well into 2023.

I’ve been keeping it low key since I got back from HLTH, partly to avoid having a COVID-related reschedule for the procedure. I’ve heard from two colleagues who brought COVID home from the HLTH conference as an unwanted souvenir, although based on the notifications from the contact tracing app, I suspect there were more cases than we will ever know.

It’s been a good opportunity to catch up on email and some of my virtual water cooler venues. The hottest topic seems to be Amazon’s foray into message-based virtual visits. Most of the physicians I’ve connected with aren’t impressed by the offering, since it’s more of a marketplace than a cohesive service. They’re concerned about the further fragmentation of patient care since these records won’t be making it back to primary care physicians, and the fact that patients may end up receiving care from multiple providers or practices as part of the marketplace arrangement without fully understanding the concept.

There were also some concerns about the business model and how it makes sense for the physicians who are part of the offering. The fees are low, which is good for patient access, but are set at a level which drives physicians toward high-volume processes in order to make it tenable as a major source of income. The virtual visits also include the ability to “message your clinician with follow-up questions at no additional cost for up to 14 days” which further lowers the desire to participate for many physicians, who want to practice telehealth urgent care in a “one and done” type model. Several colleagues guessed that the provider organizations are likely using considerably greater numbers of nurse practitioners rather than physicians.

The main patient-centric concern that was voiced was that of clinical quality, but given the fact that this is Amazon we’re talking about here, I also have concerns about patient privacy. The Amazon Clinic site has a lot of information on how they use Protected Health Information. Things I didn’t like included the fact that patients are asked to accept an authorization for disclosure of contact information, demographic information, account, and payment information, and “my complete patient file” to Amazon.com Services LLC and its affiliates. It notes that “information disclosed pursuant to this Authorization may be re-disclosed by the recipient, and this redisclosure will no longer be protected by HIPAA.” Although I’m not an attorney, it sounds like a bad idea to me. The FAQ page says this authorization is voluntary, but if patients want telehealth services but to not sign the authorization, they will need to reach out to the healthcare providers directly. I’m betting (as I’m sure Amazon is betting also) that patients will just click through the fine print. Patients are exhausted and often just want to get care in the quickest and cheapest way possible, and no one likes to read a wall of text.

What are your thoughts about Amazon Clinic? Will it revolutionize healthcare or just further fragment the patient experience? Leave a comment or email me.

Email Dr. Jayne.

EPtalk with Dr. Jayne 11/17/22

HLTH Recap

After leaving CHIME last week, I had just enough time to swing by my home base, run a couple of loads of laundry, and repack for a climate that was 20 to 30 degrees cooler than San Antonio. Many of the people in Las Vegas were complaining about the cold, but there wasn’t any snow like I had at home, so I was happy with the temperatures.

This was my first year attending the HLTH conference and I wasn’t sure what to expect. Registration Sunday was crowded, with lines snaking throughout the halls of the conference center. There were plenty of staffers helping people find the end of the line and it moved quickly though.

Sessions on Sunday were standing room only. It felt strange being packed together like sardines given the social distancing of the last couple of years. I was one of the few people masking during the conference, although I wasn’t able to do it as consistently as I would have liked. Still, I figured that if I can reduce the risk of being exposed by even 50%, it was worth a shot. I have a lot of reasons to not bring COVID home, including the fact that next week is Thanksgiving and I have elderly and immune compromised relatives, and also the fact that I’m scheduled for a long-awaited medical procedure and don’t want a COVID-related cancellation. In some of the conversations I had, however, I felt like I had to explain to people why I was masking, which seemed strange.

Walgreens was offering COVID and flu vaccines onsite, but I didn’t see any mention of testing. I did, however, see multiple people buying COVID test kits at the local pharmacy. Several people I spoke with wished that HLTH had encouraged people to be vaccinated and to test prior to departing for the conference. Within the first day, I received four notifications from the local COVID-tracking app letting me know that I had been exposed. Although I’m glad to get the notifications, it was disappointing to receive so many so quickly.

The exhibit hall opened on Monday. I was initially a bit underwhelmed – there wasn’t the kind of energy I’m used to when HIMSS or another big show has its opening day. This improved as the day progressed, and I think perhaps people just took longer to settle into their booths than expected.

I liked the way that HLTH handed meals, with multiple locations serving food that was included in the price of the conference. I also liked having the “grab and go” options available throughout the day, including a bagel box, sushi lunch, breakfast burritos, a protein box, and more. The only downside of the grab and go stations was the lack of beverages, so unless I had a full water bottle in my bag, I had to trek somewhere to find a drink.

The exhibit hall was set up in a hub-and-spoke configuration rather than a grid structure, although there were grids within the various spokes. While standing near the supersized maps of the hall trying to find booths, I heard many comments that people didn’t like the configuration. The center of the hub was a giant HLTH-emblazoned moon suspended from the ceiling, with a darkened space with bean bag chairs inside.

The wi-fi at the conference center went down a couple of times during the week, and the HLTH app advised attendees not to use personal hotspots as they were contributing to the problem. There’s nothing quite like spotty wi-fi at a healthcare tech conference.

I spotted these cute shoes on Monday at a panel on maternal health that featured Jaime Bland, DNP, RN from CyncHealth, Mandira Singh from PointClickCare, and Thomas Novak from the Office of Policy in the Office of the National Coordinator for Health IT. I don’t think people realize that pregnancy in the US is a risky condition. The panelists did a great job reviewing the challenges of interoperability and how to best let people know at the point of care that a patient is or has recently been pregnant. To paraphrase one of the panelists, you can’t just go around asking every woman if they’ve had a baby in the last 90 days. They discussed efforts happening to improve the situation in Nebraska, where many individuals have to travel an hour or more to receive prenatal care or to give birth.

These less-than-cute and decidedly orthopedic-yet-platform shoes were spotted at Zara, across the street in the Fashion Show Mall.

Speaking of shopping, one of the reasons I chose to stay at The Palazzo was its proximity to the meeting, as well as the fact that you can connect through the Grand Canal Shops and avoid walking through the smoky casino. One of the downsides of that path was that the folks working the cosmetic and bath products shops would stand in the doorways and hassle you as you went by. They didn’t seem to understand “no, thank you” and became increasingly aggressive as the week progressed. I have to say I’ve never made a purchase at a shop where people yelled at me from the door, and I’m not about to start.

Also spotted cutting through the shopping area was this person with a rescue-style backboard. She entered the Atomic Saloon Show theater and didn’t seem to be in a hurry, so I hope it was simply an in-service training session.

Solutions for tired feet were available at this handy vending machine at the Venetian.

Only in Las Vegas do people throw paper money in the fountain in addition to coins.

Although the food options in the exhibit hall were solid, finding dinner in the complex without a reservation was tricky. Many of the restaurants were not operating at capacity, presumably due to lack of staff. Others were packed. I successfully dodged being gifted an alcohol-filled guitar at a place where we stopped for a quick burger. On Monday, I would have enjoyed a nice glass of wine with a friend in the late evening, but we were stymied by the combination of restaurants that close at 10 p.m. and bar/lounge areas with a steep per-table minimum.

Cool things spotted on the floor:

• Caption Health offers Caption Care, which they describe as a “turnkey, end-to-end echo program” for heart failure with the ability to perform exams in the home or office setting. They offer “AI-guided ultrasound” and emphasized the ability to detect disease earlier.
• Kahun had a presence alongside a number of companies from Israel. Their digital clinical reasoning engine helps identify patient symptoms and connect them with clinical insights, including citations of peer reviewed studies upon which clinicians can rely. Some recent enhancements include the ability to order labs alongside the clinical information being provided.
• A blood drive was held Tuesday and Wednesday. Thanks to all who participated.

Hinge Health had plenty of giveaways and there was nary a rep in sight.

I spotted these reps in sperm hats several times, but couldn’t figure out which fertility company they were from.

A colleague of mine was on a panel Tuesday that was titled “Sexual Healing.” That should have been a great attention-getter, but I was disappointed to see so few people attending, especially since this is an important topic that more people should know about. It became busier as the session progressed, and most people stayed for the entire session. Sexual health can be an indicator of overall health and is impacted by many conditions, from depression to vascular disease to pelvic floor dysfunction and more. Often these conditions aren’t covered in medical school, residency programs, or physical therapy programs and it was great to hear this dynamic group trying to cut through the “shame and stigma” that they see in their patients and clients.

Carine Carmy, co-founder and CEO of Origin, noted that they are engaging patients through welcoming environments and “using wellness as a veneer for healthcare.” They are positioning their physical therapy services more like a consumer brand than a medical establishment because that’s what gets attention right now in the US. Lyndsey Harper MD, founder and CEO of Rosy Wellness, Inc. talked about their platform, which offers curated materials to help patients along their sexual health journey.

Tuesday night was party night, and I hit a couple of gatherings including one sponsored by SteadyMD (fresh off the announcement of their participation in the new Amazon Clinic telehealth offering) and Zus Health. Jonathan Bush addressed the audience towards the end of the evening, and although it was entertaining, his speech was tame compared to those he delivered at the HIStalkapaloozas of old.

From there it was off to the Ludacris performance, which was packed. I have to admit I left early, partly due to the crowd but partly due to the volume, which could literally be heard across the street at Caesar’s Palace.

After one more trip past the Bellagio fountains, it was off to bed to rest up for the early flight home.

What things did you think were the best and worst of HLTH? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/14/22

CHIME Recap

Since leaving CHIME, I’ve been dodging sketchy airline schedules, some urgent priorities at home, and snow. I finally have a few minutes to reflect on my first CHIME meeting, which overall was successful in my book.

The general conference vibe was laid back. Most of the non-vendor attendees have substantial healthcare IT experience under their belts and didn’t seem to have anything to prove, so that may have been part of it.

Sunday and Monday were the inaugural “Innovation in Clinical Informatics” sessions, which were great for learning about the challenges that other clinical informaticists are facing. A couple of thoughts stuck in my brain:

• One participant noted that they have concerns about their ability to function during a downtime event, in part because younger staff members don’t read cursive. Several people in my part of the room were unaware that schools stopped teaching cursive more than a decade ago, with the advent of the Common Core State Standards. The concern is real and should be addressed as part of downtime procedures.
• There was a lot of emphasis on asking “why” when solving informatics problems. Finding the ultimate upstream “why” can often lead to different solutions than just taking a request for change at face value. I’m a huge fan of the Five Whys tool, and if you’re not using it with your team, I would ask yourself why.
• Behavioral health was a hot topic. Several speakers noted that patients prefer to have these visits at home. Medical outcomes are better when behavioral health issues are treated, and if organizations aren’t offering adequate behavioral health services, they need to work on their strategies.
• There was good discussion about whether secure chat messages should be considered telehealth.
• UCHealth’s CT Lin presented the “Swiss cheese model of successful innovation,” explaining that all the holes have to align for projects to deliver maximum value. He used it as an admonition about the importance of clinical informatics, because clinical informaticists can often see the problem through different lenses and see how the holes need to align. They can also recommend how to make the connections and avoid pitfalls.
• Clinician burnout was a common theme, as was the importance of culture compared to strategy.

One final thing really caught my attention, and that was discussion about the need to deliver “delightful” patient experiences. Based on my recent adventures in healthcare, I’d settle for “decent” or “passable” rather than the “awful” experiences I’ve been having. That imaging result that was supposed to be released within 24 hours actually took six days to release via the patient portal, and when I returned home, I found a paper result waiting for me that had been mailed the day after the study and arrived two business days later. Something is wrong when you get your results via snail mail faster than via the patient portal.

During the conference, participants had the chance to paint a panel that will form a mural to be hung in a multi-assistance care center providing collaborative care and centralized services for individuals with special needs. The painting project was sponsored by CDW.

Tuesday was the opening keynote, with a celebration of CHIME’s 30th anniversary and an early morning champagne toast. Following awards and recognition, the guest speaker was introduced. Sophia is an “advanced humanoid” robot who was advertised as being able to wow audiences with “her superhuman intelligence and advanced ability to read faces, empathize with emotions, understand the nuances of language, and communicate with thousands of facial expressions. Unfortunately, Sophia seemed to encounter a glitch and the audience was asked to take a 15-minute break while they tried to get her back online. One can only presume that while we were out of the room, they tried turning her off and back on again. She wasn’t much better after the break, using mostly what seemed like canned segments of speech. Based on her performance, I don’t think we have to worry about robots taking over the world just yet.

The rest of the day and into Wednesday was a mix of engaging sessions, meet-ups with colleagues, and a couple of focus groups. Although generally the focus groups provided an opportunity for good discussion and learning about what other CIOs and CMIOs are facing in their organizations, one session became challenging. I couldn’t believe I was watching one participant troll another by making snarky comments about an organization’s challenges, knowing that the leader of the struggling organization was sitting right next to him. It just goes to show that it there’s a lot of variety in leadership skills. I hope that particular individual plays nicer with his colleagues at home than he did in the focus group.

The San Antonio spirit was strong as staff worked on the setup for Tuesday night’s reception and dinner.

For those of you looking for wardrobe and shoe reviews, in general the mood was subdued. Lots of jeans and blazers, but since this was my first time attending, I’m not sure if that’s usual for this conference or if it had something to do with the fact that emails were sent telling folks to bring their jeans and boots. The League of Women session had some fine shoe options including sassy espadrilles, kicky boots, strappy sandals, and “trust me, I mean business” pumps. I opted for some low-key loafers, although I did pull out the boots for the Wednesday night event.

The event was held at the Knibbe Ranch, which is about 30 minutes from the conference center. Not only were cowboy hats and western boots out in full force, but there were also several people wearing Woody costumes from “Toy Story.” As guests stepped off the buses, they had the opportunity to have a photo taken with genuine Texas longhorns. Dinner had a distinctly cowboy flair and was served from buffet lines that contained more cast iron than I’ve seen in one place in a long time (and I’ve seen a lot of cast iron). The bars were serving several Texas beers as well as the usual libations, and dessert of course included pecan pie. Attendees had the opportunity to relax with games of horseshoes and cornhole, along with a campfire.

The main event of the evening included an honest-to-goodness Texas-style rodeo, courtesy of the Lester Meier Rodeo Company of Fredericksburg, TX. In talking with some of the attendees from the UK, they’ve never seen anything quite like it. The rodeo opened with the traditional grand entry and flag processional, followed by bull riding, barrel racing, more bull riding, and of course rodeo clowns. Having spent several years in Texas and having attended a variety of professional and amateur rodeos, I have to say this was some of the wildest bull riding I’ve seen. I think only one or two contestants managed to stay on the full eight seconds, and several looked like they needed medical attention after having difficulty releasing their grips after being thrown or dismounting.

Often a rodeo will have an event called a calf scramble, where children compete to try to catch a calf with only a rope and their wits. I strongly suggest a CIO calf scramble for future rodeos, with proceeds to charity. It would definitely add a healthcare IT twist to the festivities. The rodeo concluded with a fireworks display and guests moved back to the dance hall for music, dessert, s’mores kits for the campfire, and plenty of line dancing.

I headed home Thursday morning, missing the final keynote but making it back in time to take care of some afternoon meetings, run a couple of loads of laundry, and begin packing for HLTH. It’s warmer in Las Vegas than it is at home, and I’ll have the opportunity to connect with friends I haven’t seen in years, so I’m looking forward to the bit of travel.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/10/22

I’m glad to see healthcare delivery organizations putting their proverbial feet down when it comes to patients treating staff poorly. Mass General Brigham is one of the more visible examples, as they release their patient code of conduct. The policy has zero tolerance for “words or actions that are disrespectful, racist, discriminatory, hostile, or harassing.” Patients can be asked to seek future non-emergency care elsewhere if they are found to exhibit a list of behaviors, including sexual or vulgar words or actions. Disrupting another patient’s care or experience is also on the list. Patients who violate the code will be asked to explain their point of view prior to decisions being made about future care at the institution.

Next week’s HLTH conference will include the “Patients at HLTH Impact Program,” which has been designed so that patients and patient advocates can be engaged as “equal partners in care design.” The track offers opportunities for health tech leaders to interact with patients. Since nearly every employee of every organization in the US has been a patient at some point in their lives, I’d suggest that execs don’t need to go far or to spend money on conferences to get input. One of the panels being offered is around “What do digitally-savvy, empowered consumers want?” and although that is certainly valuable, we need to not overlook the non-digitally savvy and non-empowered patients who might need our help even more than the other group. I’d like to see health tech execs troll the waiting rooms and cafeterias of any hospital in the US. They would certainly get an earful, and it would be cheaper than a trip to Las Vegas.

Addressing physician burnout is always a hot topic, so I was interested to see this piece from the American Medical Association on helping physicians reduce “pajama time” and have “more great days.” For those who might not have heard the term, pajama time refers to the time that physicians (and sometimes other clinicians) spend working outside of normal working hours. Although a lot of people think this phenomenon started when EHRs became more common, it definitely happened in the paper world. In my early days as a physician, I had a couple of colleagues who were constantly being reprimanded for taking charts home and sometimes forgetting to return them to the office. However, I was disappointed to see the suggestions made in the article. They’re not at all revolutionary:

• For medication refills, a recommendation was made to renew maintenance medications at the annual visit and to provide the maximum number of refills. This was standard of care in family medicine in the 1990s and appears several times in the literature, yet physicians still can’t incorporate it into their practices. I heard the best description of this workflow at CHIME this week, when UCHealth CMIO CT Lin referred to it as “90 by 4, don’t bother me no more” meaning that patients should receive 90-day prescriptions for their medications with four refills, enough to get them through their next annual appointment. It doesn’t apply to just primary care — anyone performing chronic care can do this and EHR preference lists or favorites make it easy.
• A physician was frustrated by having to walk to the printer to grab after visit summaries to hand to patients, so they installed printers in each exam room. Why are these not being sent through a patient portal for those who have accounts, so that they can become enduring materials accessible to the patient forever versus a piece of paper that can be lost? If the patient isn’t enrolled in a patient portal, why not have a medical assistant or checkout person print them?

I’ve spent a good portion of my professional life helping organizations address policy and procedure issues. Sometimes it’s a gap and new policies and procedures are needed, while other times there are changes needed to keep up with advances in EHR use, medical group governance, office practices, and more. Policies can be a blessing or a curse depending on what they contain, and the latter is addressed in a recent piece in JAMA Health Forum. The authors address the idea of harmful hospital policies and propose that they should be classified along with other “Never Events” such as wrong-side surgery. The authors list five particularly harmful policies:

• Aggressively pursuing payment from patients who are unable to afford their medical bills.
• Spending less on community benefits, such as public health or indigent care, than what is earned through tax breaks due to non-profit status.
• Noncompliance with federal requirements to be transparent about cost of care,
• Paying employees less than a living wage.
• Delivering racially segregated medical care by underserving surrounding communities of color.

They note that other entities, such as insurance companies and medical device makers, are also responsible for harms, but find that given the fact that the majority of hospitals exhibit at least one of the above behaviors, that hospital-associated harms should be addressed in a priority fashion. In addition to calling on hospital leaders to address them directly, they call on the Centers for Medicare and Medicaid Services to deny payments to hospitals engaged in these practices. They also call on state legislatures to require reporting in these areas and state attorneys general to investigate hospitals that are taking advantage of their non-profit status. The article is a quick read and should be mandatory for leaders of healthcare organizations.

Michigan Medicine has fallen victim to a phishing scheme that may have compromised the information of 33,000 patients. The health system learned of the attacks in August, but some patients didn’t receive the breach notification until more than two months later. At least four employees provided credentials that allowed hackers to access their email accounts. I feel for the employees who apparently disregarded their cybersecurity training, for the IT teams that had to investigate and work on the cleanup, and of course for the patients whose information was compromised by individuals who can’t follow the rules.

I feel like I’m fighting a battle on two fronts with email volume right now. At work, I’m getting multiple daily emails from HLTH which don’t always go to their designated folder since I was forced to take a recent Outlook update. In my personal email, I’m inundated with pre-Black Friday emails from retailers. I guess now that the Christmas shopping season actually begins before Halloween, it makes sense for Black Friday to begin November 1. I’d love to see the data on how various retail trends have changed over the years and see what the migration of the start dates for shopping seasons looks like. I’m sure there are big data folks in retail and marketing, so if someone has a connection to the data, maybe you can hook a girl up.

What do you think about the increasingly early start for holiday shopping? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/7/22

There has been a lot of discussion recently about practices that send patient portal questionnaires for existing patients to enter their medical histories. Certainly as a patient, I don’t want to enter information that already exists in my chart, and as a physician, I don’t want to have to reconcile a bunch of information that might already exist in the chart against patient-provided information that may or may not be accurate. Some patients are great at knowing their histories, others are less so.

Once a year, I have an appointment at a major academic center’s high-risk breast cancer program. This year, I was pleasantly surprised that for the first time, they didn’t ask me to provide information that they already had in my chart. The check-in process was quite streamlined even though three separate appointments were involved, so I was looking forward to a smooth visit.

The visit itself was great, with speedy access to an exam room, an upgraded exam gown (flannel with satin trim, if you can imagine), and a short wait for the physician. From there I went to the imaging center waiting room. Although the technician was apparently looking for me in the wrong waiting room (they have three), they ended up locating me quickly enough to get me to my imaging appointment early.

My technician was personable and efficient, making me feel like a valued patient and not like just another patient in a long line of tasks for the day. From there it was back to a different waiting room, where I received preliminary imaging results and met with another physician.

After discussing the care plan, they mentioned that a final radiology reading would be available to me via patient portal within 24 hours. They also explained that due to their current patient mix, they were asking some patients to schedule with a midlevel provider rather than the physician for their next visits. Knowing what I know about healthcare economics and physician staffing, I understood what they were trying to do in making sure the physicians have capacity to manage the patients who need active management of breast cancer and who are planning surgeries in the near term. As a patient, you put a certain level of trust in a leading academic institution to have appropriate physician oversight when you’re seeing a midlevel provider, and as a physician, I know how to advocate for myself if the need arises.

The visit hit a glitch during the checkout process, since there was no one to staff the checkout desk and everyone was being sent to the waiting room. There was quite a line since most patients needed multiple follow-up appointments for imaging, biopsies, or additional clinical appointments. I had plenty of time to read the Patient Bill of Rights they had posted on the wall, which specified that patients might see a physician assistant or a nurse practitioner as part of their visit. It also spelled out that patients have the right to see the physician if they prefer, although that might result in the rescheduling of their appointment. It’s standard stuff, and I didn’t think too much of it until the patient in front of me began to check out.

She handed over her check-out instruction sheet and began asking questions about the providers listed on the board behind the receptionist, as well as their credentials. She was asking which were breast specialists and which were other types of surgeons since it’s a mixed office. The receptionist was describing them, and when she got to the nurse practitioner, she said “Oh, she does everything,” to which the patient responded asking, “Why didn’t she go to medical school then?”

My ears perked up at that and I knew it was going to get interesting. It’s not hard to overhear things when you’re literally three feet apart, and apparently the patient had been given the same information that I had about not seeing the physician at the next visit and wasn’t aligned with the plan. She was shopping for a different surgeon rather than see someone she stated had less education. Having just read the Patient Bill of Rights, I wondered how the office would handle it. The receptionist said she would go and check with the physician.

While she was gone, the patient — with whom I had exchanged pleasantries about my cute tote bag while we were both in the imaging waiting room — turned to me and mentioned that she knew what the answer would be since the doctor had already told her she had to see the nurse practitioner. She went on to say that she was a cancer survivor and that she is scared to not see her surgeon, who knows her the best. I nodded empathetically and waited to see what would happen.

The receptionist came back and announced that she had spoken to the physician and the answer was still no – she would need to schedule as directed. Clearly that didn’t align with the posted Patient Bill of Rights, and honestly if the organization isn’t going to follow it, they need to take a good look at either modifying it or removing it from the office while they reconsider.

I was able to get my follow-ups scheduled and headed home, eager to get my final reports and try not to think about the whole situation for another six months, which is sometimes the best way to approach it as a patient. I buried myself in work the rest of the day, waiting for the familiar notification from the patient portal app that my result was available.

Unfortunately, the notification didn’t come. Nor did it come the next day, or the next, or the following one. I was busy with work and didn’t have a chance to call and wanted to also give a little benefit of the doubt since I know healthcare is in crisis. But now we’re in the weekend, and I’m relegated to wondering where there is a backup in radiology, whether my study was missed, or whether I’m going to get a callback to come back for more images. I know the system’s EHR and how it’s configured to handle release of test results to patients. Once radiology images are final, they release to the patient. The question then becomes whether something is wrong with the EHR and portal systems, or with the test itself.

Since it’s the weekend, I guess I’ll sit and wonder for a few more days, which is never a position a patient wants to be in.

Thinking about the situation as a whole, I think the practice needs to do some introspection around its messaging. In addition to the Patient Bill of Rights issue, they need to provide additional instructions on what to do if imaging results don’t come back. I’m a physician and know to track it down when Monday comes, but a lot of patients might be from the “no news is good news” generations, or don’t have patient portal access, and wouldn’t know to follow up a missing result. In the mean time, I’m off to a conference, so I will rely on my calendar to remind me to make the call.

Does your organization’s patient summary give instructions on what to do when results don’t return? Do you honor your posted Patient Bill of Rights? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/3/22

I’ve experienced an uptick in email solicitations over the last couple of weeks. It’s been fascinating to see the different content and how marketers are trying to use various strategies to get the reader’s attention.

Quite a few of them are going for the friendly-sounding approach, with short sentences and colloquial language. One of the repeat senders is further trying to build on the familiarity by mentioning the local weather and a nearby restaurant, which is fascinating but a bit odd since it’s in an adjacent town. I wonder what the algorithm looks like that says, “hey, let’s pick something close, but not creepy-stalker close” and throw that into the email. They even go so far to mention “location inferred from your company” regardless of the fact that my “company” is located hundreds of miles from the town they mentioned.

I strongly suspect that the emails are stemming from mailing lists related to the conferences I’m attending in the next couple of weeks. It’s one more way for meeting organizers to increase conference revenue, even though it’s annoying for the attendees. I don’t recall seeing any kind of “don’t sell my information” opt-out checkboxes during the registration processes for either of them, but there’s always a chance that I missed them along the way (although from past experience, it’s more likely that the conference didn’t give attendees the chance to opt out). Much like the weeks following HIMSS, I’m sure I’ll be spending quite a bit of time creating new email filters and wading through various pieces of junk email.

I do have to say that I’m a little nervous about my upcoming conference attendance, especially since flu cases are on the rise. The US has already seen more than 880,000 cases of lab-confirmed influenza, and that number doesn’t include the patients who are tested using in-office test kits at physician offices and urgent care centers or those patients who don’t present for testing. Physicians who care for children are concerned, since more than 75% of pediatric hospital beds are full. The leading viral strain at present is H3N2 influenza, which has in past years been associated with higher severity of illness for older adults and children.

Based on what I’ve seen during recent travels, I’m betting I will be one of the few people wearing a mask in crowded situations. I have to admit that I did enjoy the first HIMSS post-COVID, when a good number of people were masking, because I used to nearly always return from HIMSS with a sore throat, runny nose, and generally feeling of cruddiness consistent with a respiratory virus. Especially if you’re not going to mask, now is a great time to get a flu vaccine if you haven’t already received one. I know that lots of people are tired of thinking about contagion after the last couple of years, but the basic tenets of public health are always a good idea.

Speaking of vaccines, while some organizations have kept their vaccination requirements static, several leading universities are requiring students to receive the new bivalent COVID boosters. Schools requiring the new boosters include Harvard University, Yale University, Tufts University, Fordham University, and Wellesley College. Pushback is expected, and the comments on the article are all over the place. Uptake of the new booster has stalled in my community and my urgent care and emergency department colleagues are still exhausted, so some of us are dreading what might happen over the coming months when people move their activities inside and begin gathering for the holidays.

After a recent medical visit, I was flipping through my health system’s patient portal to see how various kinds of documents were rendering and whether there were any changes after the recent updates to requirements for release of information to patients. I found a visit from a few months ago that now had a visible visit note when it didn’t previously have one. I’m confident I would have remembered seeing a note previously based on the last line of the document: “This dictation was done with voice recognition software and may contain errors and omissions.” That’s certainly far from a vote of confidence for the treating provider. Maybe I’m old school, but I can’t imagine putting something like that on one of my notes or signing a note without proofreading and correcting it. I know that everyone in healthcare is stressed, but I’d be embarrassed to allow that in any of my patients’ charts. I had already decided to look for a new physician in this specialty and this just confirms my decision.

It’s common for researchers to create catchy names for their studies, so I was excited to see COSMOS, otherwise known as the COcoa Supplement and Multivitamin Outcomes Study. It’s a randomized clinical trial looking at cocoa extract supplement in comparison to a standard multivitamin with respect to cardiovascular risk reduction. A sub-study, COSMOS-Mind, will look at whether the cocoa extract supplement improves cognitive function and reduces the risk of dementia. Of course, I’m a big fan of chocolate (although usually in baked goods rather than in a capsule) so I’ve been keeping an eye out for the study outcomes, which finally came out this week.

The results were exactly opposite of what was expected. The multivitamin, rather than the cocoa supplement, was found to be more closely associated with improved cognitive function in older adults. The benefits were greatest in patients with a history of cardiovascular disease. Since nearly 90% of the study participants were non-Hispanic whites, the authors note that additional work is needed to confirm the findings, in particular with a more diverse patient population. Halloween passed in my neighborhood with only a small number of trick-or-treaters, so I’ve got plenty of cocoa on hand. I’m looking forward to the mood boost even if it’s not going to prevent dementia.

How was the Halloween traffic in your area? Will you be nibbling chocolates for weeks to come? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/31/22

I spent a good chunk of time this weekend preparing cranky correspondence to send to organizations that can’t seem to figure out that I don’t work for them any more or that I’m no longer a participating provider with a given payer since leaving the practice. Since I resigned from these organizations anywhere from six months to three years ago, I’m tired of dealing with the continued messages and requests for information. The off-boarding processes were variable across the different organizations, so it’s not surprising that there’s still a bit of a mess to tidy up. Still, one would think that with part-time or contractor physician positions, they would have their act more together.

Let’s take my most recent in-person employer for starters. I was a part time W-2 employee and resigned more than one calendar year ago. Apparently I didn’t get terminated properly with a couple of payers, who continue to reach out to me asking me to update my provider file with copies of my license, Drug Enforcement Agency registration, and state control substance documentation. I’ve sent multiple emails informing them of my last date of employment at the practice, and although a couple of them eventually stopped sending me reminders, there are a couple that are persistent. It’s tempting to ignore the communications, but I want to make sure all my provider files are closed out properly in the event that I join a new practice down the road. It’s always good to have definitive closure, but let’s hope it doesn’t take another 12 months to get it.

Then there’s one of my telehealth side gigs, where I only saw patients for a couple of months before determining that not only was the platform horrendous, but they could never seem to figure out how to pay me correctly. Despite having given ample notice that I was leaving and would not be seeing any patients during my notice period, they went ahead and signed me up for multiple insurance plans after I tendered my resignation. It’s likely a case of the right hand not knowing what the left hand is doing, but I’m tired of getting correspondence from various state-specific plans that can’t seem to understand I’m no longer participating in the provider group or planning to submit any claims.

This same platform continues to text me about high patient volumes despite my trying to opt out of the texts by following the included instructions. I’ve also tried sending emails to various individuals within the company with no response, which leads me to think that either those individuals have moved on or they don’t care. Since I no longer have access to the platform, I can’t look up any additional email addresses or contact information than what I have, so I’m sending my correspondence directly to the CEO and CMO of record as well as the head of the physician group, in hopes that they will respond and point me in the right direction.

There’s also another telehealth side gig, where I signed up but never saw a single patient. After watching them exhibit some unseemly behavior with colleagues, I decided not to engage with them. They followed up on my resignation letter by sending me an administrative termination of their own several weeks later, which I thought was somewhat overkill. They’re still sending me regular emails asking me to complete required training and given their track record with others I want to make sure my provider file is entirely closed out.

My favorite target of cranky correspondence is Illinois Medicaid, which is the “undead” of administrative healthcare organizations. I haven’t been a participating provider since 2014, but every now and then, some computer system somewhere goes haywire and decides that I need to update my provider records. The letters come on paper to my home, I always reply on paper because it seems to work, and I don’t hear from them again for a couple of years. I don’t want to wind up published in a directory as someone who is participating because it has the potential to lead to a lot of phone calls and wasted effort for patients who are just looking for a primary care physician and will keep working their way down the list until they find someone whose patient panel isn’t closed.

We’ll see if this batch of letters and emails is successful at tidying up loose ends or if I’ll still be dealing with them in 2023. It seems like there ought to be a better way. I know there are services out there, but the last time I looked at them, they were fairly pricey. Maybe I can find a retired medical practice manager who is looking to make a little cash on the side and enlist their help to get it done. With the number of people fleeing healthcare employment, it’s not a farfetched idea.

I also have a former employer in the tech space that can’t seem to figure out that I don’t work there even though it’s been more than four years. Not only do I get correspondence from the company proper, but also all of their vendors, including health insurance and more. They just sent me notice of the upcoming open enrollment period for health insurance and encouraged me to sign up quickly and not wait until the last minute. I wonder what would happen if I tried to register for a health plan – might be a good project for next weekend assuming an adequate number of cocktails beforehand.

Speaking of cocktails, I’m prepping to attend back-to-back conferences with CHIME and HLTH and the social event invitations have been trickling in. I almost spit my drink when talking to some colleagues about the latter, which they referred to as “the conference with no vowels.” There’s a lot of discussion about the utility of the HLTH conference and whether it’s worth the money. This will be my first year attending, so I’ll have to let you know in a couple of weeks. I’m looking forward to some warmer weather in San Antonio and Las Vegas, respectively. I’m not looking forward to being in crowded indoor spaces and potentially bringing home COVID, influenza, or some other respiratory illness, so we’ll have to see how it goes.

Any recommendations for a first-time attendee at HLTH? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/27/22

Hospitals and health systems are often sponsors and supporters of various sports teams. Although I understand the reasons and how marketing works, I’m always annoyed since deep down all that spending is fueled by patients.

One of our local surgeons, who is frankly embarrassed at his organization’s sports sponsorships and luxury suites at the local ballpark, shared this piece about a shakeup in stadium naming rights for one of the newest Major League Soccer teams. Health insurer Centene has backed out of a deal to be the naming sponsor for the newly constructed stadium in St. Louis, where the aptly named St. Louis City SC is set to play. The stadium will now be called Citypark while the team hunts for a new naming sponsor. Centene had previously inked a 15-year deal for the naming rights, but a recent statement to local media said it would be realigning partnerships to create “long-term, tangible value for local communities.”

Millions of taxpayer dollars flow through Centene every year via government programs such as Medicaid, so I’m glad they’re reassessing the use of their funds. Not to mention that recent reports indicate that their Medicare Advantage quality scores have been worse than expected, which places its 2024 revenues at risk. The organization recently announced it plans to hire a chief quality officer. I’d much rather see money spent on that role than to name a sports facility. At the same time, Centene noted that quality improvement will be “a compensation metric by which all employees’ performance will be measured this year.” I hope they set things up to truly incentivize the employees as opposed to making it a way to squeak out more cash for the shareholders.

I admit that I’m suckered in by clickbait headlines as much as the next person, so I felt compelled to click on the recent Medscape feature on “Physicians Behaving Badly: US vs. UK.” I had literally just come off a call with a colleague where we discussed various patient misadventures, including misdiagnosis, failure to receive informed consent prior to a procedure, fraudulent patient care documentation, and more. The survey looked at 2,800 physicians in the US and UK. In case anyone is curious, the US ranked higher in several unseemly behaviors, including being verbally or physically aggressive; disparaging others; using racist language; and bullying and harassment. UK physicians ranked higher in public intoxication. “Making unwanted advances” was a choice in the US survey but not in the UK version, and conversely sexist behavior was a choice in the UK but not in the US, so it was hard to compare the two.

When faced with physician misbehavior, US physicians were more likely to complain anonymously to the employer or human resources, where UK physicians were slightly more likely to do nothing. For both groups, the leading demographic for misbehavior was age 40-49, with men outnumbering women twofold. As far as how those surveyed think physicians should behave, data was almost identical for both the US and UK, with two-thirds thinking that physicians should be held to higher standards than the general public due to their role. I dislike seeing healthcare professionals behaving badly, regardless of their title, role, or geographic location. I’ve seen more training programs addressing professionalism in their curricula, so let’s hope things improve.

If primary care physicians spend more time in the EHR, does that lead to improved clinical outcomes? A study published this week in JAMA Network Open looked at this question. Researchers performed a cross-sectional study of 300 primary care providers at two large academic health centers. They found that each additional 15 minutes of daily use of EHR messaging led to improvements in glucose control for diabetic patients, improved management of hypertension, and higher breast cancer screening rates. Of course, that amount of time sounds small, but over the course of a year, 15 minutes a day adds up to an additional week and a half of work for a clinician who is more likely than not to already be burned out and stressed.

The authors noted that “these results underscore the need to create team structures, examine PCP and office workflows, and enhance EHR-based technologies and decision support tools in ways that enable high quality of care, while optimizing time spent on the EHR.” Since so much of EHR messaging work is not part of a clinician’s visit-based, revenue-generating work, they also note that “the associations we have identified between increased in-basket time and enhanced ambulatory quality of care highlight the importance of continuing to develop and expand value-based reimbursement systems that adequately reward outside-of-visit care delivery.”

They note that both academic health systems in the study have dedicated population health teams that support primary care physicians in tracking quality performance. They’re also both located in the same geographic area that has a relatively heterogeneous patient population, and as such, they may not represent the majority of primary care physicians in the US.

My favorite quote from the piece is this: “Our findings suggest that although increased EHR time, particularly after hours, has been associated with increased emotional exhaustion and burnout, it may represent a level of thoroughness, attention to detail, or patient and team communication that ultimately enhances certain outcomes. This finding is consistent with recent research reporting a trend toward better outcomes for measures of health care use for family physicians who reported some level of burnout, suggesting that the extra attention given to clinical problems and extra communication that may occur during additional time spent by PCPs may be valuable for patient outcomes.”

Primary care physicians are living in a way that most are counseled against. Time and again, we have seen their willingness disregard the phrase about “not setting yourself on fire to keep others warm.” In the US, they’re among the most hard-working of physicians with the best opportunity to intervene in chronic conditions and lifestyle issues, yet they’re at the bottom of the pay scale and often with the least support staff. The failure of policymakers to align payments in a way that will best serve patients and reduce overall costs will continue to haunt us for decades.

Do you have a primary care physician, and can you actually get a timely appointment? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/24/22

I’ve used a GPS watch to track my hikes and other travels for almost a decade. Recently, some of the features on my trusty Garmin Forerunner 25 have become erratic and had me looking for an upgrade. I’ve had it for seven years and it has served me well, but I was annoyed after the GPS went rogue a couple of times and the sleep tracker started showing the same pattern whether the watch was on my wrist or on the bathroom counter.

After extensive troubleshooting with Garmin, they couldn’t come up with a remedy and offered me a discount, but only if I stayed within the Forerunner line. I wasn’t thrilled with the options and had been casually looking at other models when a friend clued me in to a sale, spurring me to make a decision.

Wearables hold an interesting place in the hearts and minds of patients. I have plenty of friends that are obsessed with “closing the ring” on their Apple watches to the point where they are almost a servant to the technology. I’ve taken care of patients who take their daily activity tracking data seriously, to the point of messaging their physicians asking about what the slightest blip in their numbers might mean.

I’m not training for half marathons anymore, so I don’t need a lot of the training or coaching features that are out there. I wanted something with decent battery life, both as a watch and in GPS mode, as well as something that looks a little more stylish and a lot less rubbery than my current device. I settled on a watch from the Garmin Venu line.

Garmin’s packaging has become more streamlined since my last purchase. However, the setup process was considerably more complicated. Although I already had the Garmin Connect app on my phone, I couldn’t get it to pair with the watch and had to update the app. It still didn’t work, so I thought I would set up the watch manually then try the Bluetooth piece later.

Garmin is apparently confused about sex versus gender and how biological sex is more aligned with physiologic parameters than gender and only gave a choice of two genders. I picked the stereotypical pink icon with the ponytail, but hope someone at Garmin gets educated about the difference between sex and gender.

The next step was trying to set the watch via the GPS, which didn’t work. I’m assuming the GPS wasn’t working well inside my house, but since you’re supposed to have the device plugged in with the USB cable and charging while you do this, I was just following the directions. I’m not sure how many people have USB ports in their driveways.

I also ran across the menstrual tracking option on the device, which I promptly turned off. Most people don’t realize that HIPAA does not protect this kind of data when it’s being sent to an organization that is not a HIPAA-covered entity, and especially given the political climate, I have no plans to share that via a wearable.

During this process, the watch fell on the floor no less than three times due to the short USB cord that was connected to my floor-dwelling PC, coupled with the fact that it hooks perpendicularly into the back of the watch, making it unable to be placed flat on a surface.

The next step was to apply a system update to my phone, which for some reason took several hours. I tried several more times to get it to connect without any luck. Ultimately, I used Garmin Express to connect it directly to the PC, after which it forced a firmware upgrade to the watch. I was hopeful that would do the trick, but it didn’t. However, while the watch was connected to the PC, I was able to connect it to my wifi network, so at least that was something.

After disconnecting the watch, I had to take care of some household tasks and noticed that the watch wasn’t counting steps. It was counting heart rate and respirations, which I find less useful, and not doing the one task that was most important to me. After lots of fussing about with the menus, I tried a system setting to see what version the firmware was on, and it said that an update was needed. I tried to connect it back to the PC, but it wouldn’t pick up, and after plugging it in and unplugging it way too many times, it finally connected and the Garmin Express software showed that despite the recent status of “update complete,” three more updates were now needed.

Each time an update completed, I had to do a manual sync to get the next update to register, and also restart the watch. Meanwhile, Garmin Express kept telling me that the watch wasn’t connected, while the watch showed that it was.

I was asked no less than three times during the process to set up wifi and went through the entire process to have no change in the user experience. I went back to the main Garmin Express menu and was now told that I had 37 updates available even though the previous screen had said, “You’re up to date!” There is nothing worse than a confusing user interface that doesn’t tell you what’s going on or what you really need to do.

After two more unplug-and-restart cycles, the update counter disappeared and and miraculously, over 4,000 steps appeared on my watch. There’s no way they’re legitimate considering I was only wearing the watch for a couple of trips to the laundry room and back. After some digging, I figured out that somehow the steps on my old watch had been ported onto the new watch, which was definitely unexpected.

Fast forward to nearly a week worth of intermittent attempts to connect via Bluetooth. I gave up on it. I can pair the watch to someone else’s phone and pair my phone to other devices, but can’t pair the watch to my own phone. Without the Bluetooth, you lose out on several valuable features – music, alert notification for falls or incidents, and a couple of other things. I’m still able to sync the watch with my PC like I was the previous model. I hadn’t planned to allow it to display text messages or emails, so I resigned myself to being a little retro with my connectivity. I’m hypothesizing that the battery life will be much better without the connection, but I’ll know for sure in a few more days.

It’s snazzier than my previous device. I like its subtle coloring and low profile versus the chunky black model I’ve been wearing for years. For the first couple of days, the synthetic material watch band had a particular smell to it, which probably wouldn’t mean much to the average person, but to me smelled like an operating room. Although it brought back some fond memories, I was glad when it dissipated.

Overall, I’ll give this particular Garmin a solid B. It’s better than my last one, but not as great as it could be. The price was right.

What’s your favorite wearable, and how do you like (or dislike) its features? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/20/22

I went to look at the pricing and deadlines for the HIMSS23 conference earlier this week and it looks like they’re doing a little bit of a cash grab in switching up their pricing. It used to be that the basic conference pass, at the lowest price point, included access to the session records. Now you’ll have to pay an upcharge of nearly $300 for that privilege.

In addition to the recordings, the middle price point also includes access to the pre-conference forum as well as admission to the Thursday night special event. The highest price point adds on attendance at the CXO experience and the Executive Summit / Reception. I haven’t done my registration yet, so I can’t see whether there are a la carte offerings for the different items as well, but hopefully I’ll get around to that soon.

Within the last couple of years, I worked for a couple of telehealth companies. Over the weekend, one of them began texting me about surges in patient volume, despite the fact that I haven’t worked for them in months. For a while I was wondering what kind of activity happened on their system that my phone number has come back from the dead, and then it occurred to me that maybe they’ve just had a slow summer and they’re starting to see an uptick in patient requests due to the increase in cases of influenza and other viral illnesses. Regardless of the reason, texting STOP made them requests go away, which dramatically increased my provider satisfaction.

Speaking of satisfaction measures, I recently received a survey from a vendor who knows I’m extremely dissatisfied with their service. I tried to dodge it by ignoring it, but I kept being peppered by requests that appeared to be from the individual service rep, who is well aware of my dissatisfaction. I know about statistical sampling and the need to have an adequate number of responses, but it boggles my mind that they would continue to beat down the door of a disgruntled customer to the point where I felt like providing an even more negative response than I had intended to deliver. I slept on it for a couple of days then finally sent it over, trying to be as fair as possible. I hope I’m tagged in their customer relationship management as being in remediation, and that based on my very pointed feedback, that they reconsider how they’re sampling customers for routine surveys.

One of my friends reached out to ask my opinion on a medical billing situation. Apparently his insurance only covers vaccines when they’re administered in a physician’s office as opposed to covering them when they’re given at a retail clinic. At least in my community, pricing at Walgreens, Target, and CVS are all cheaper than a vaccine at a physician office and are often more convenient for the patient. I tried calling for a flu vaccine for a family member at their own primary care provider’s office, and after several weeks of trying to get through and continuing to be placed in voice mail purgatory, I gave up and took him to Costco for a quick and convenient vaccine. Fortunately it was covered by his insurance, but it just goes to show how off-kilter our current healthcare delivery system is.

Quote of the week: I loved this quote on the recent Monday Morning Update: “It’s a good lesson for vendors who think AI/ML is the universal hammer for all healthcare nails – Epic has 40-plus years of experience working with the best health systems in the country, so if it can mess up a clinical algorithm, imagine the clinical damage your cool startup and its team of former beer-ponging Facebook engineers could do.” I’ve worked on several AI and ML projects in a variety of settings, including academics, startups, and with startups that were spun off from academic medical centers. I’ve found that doing AI/ML the right way is almost universally harder than people think it is, especially if you want to ensure that you’re training your models in a way that avoids bias and works for diverse populations. If you’re like some of my former colleagues who jumped from retail IT to the clinical space and thought they knew it all, I hope you’re employing experienced clinical informaticists to save you from yourself.

This week included some adventures in healthcare, with weirdness on both the clinical and revenue cycle fronts. I had an annual visit with one of my subspecialists, who uses a scribe. Usually I find that it makes the visit more efficient, and this visit was no exception. Since we’re in the era of unbridled data sharing, I couldn’t wait to see what my visit note looked like. At this clinical office, they never take my co-pay and I always wind up receiving a bill, so I tried to pay the co-pay at checkout. They told me I didn’t have one, and I insisted that I did and offered to show them my card that said so. The clerk said she would check in the system and figure it out, then came back with a “definitely no co-pay” verdict. I asked her to check the practice management system, where she’d clearly see my annual visits and the subsequent copay being billed and my payments, but she refused. This is the only office I’ve been to that refuses cash at the time of service, so I’m not sure what era their billing team is living in.

The weirdness continued when I returned home and looked at my visit note, which was already available. Imagine my surprise when I saw the documentation that the patient had completed a questionnaire, including a comprehensive review of systems, and that I had discussed it with the physician, since neither of those events occurred. The templated documentation also noted that the document was scanned, which is interesting because I’ve never completed anything like that at this office. This is the second time this year I’ve been confronted with erroneous visit notes and I’m still wondering what the best way is to handle them. In this case, it doesn’t impact the outcome of the visit or my future care, so I’m not that excited about bringing it up. In the other case, there were material errors in the chart, but I still don’t know the best way to deal with them. I’ve decided to leave that provider’s care anyway, and the errors aren’t anything that are going to impact future care or payments or anything else, but they’re just annoying.

Have you had errors in your visit documentation after seeing a healthcare provider? How did you handle the situation? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/17/22

When I speak with physicians who don’t have a lot of experience with using telehealth for urgent care patients, they’re always concerned about quality. Many of them aren’t aware of some of the different techniques you can use to assess patients, or the ways you can instruct a patient to perform different maneuvers to help in that assessment.

It seems kind of funny at times, because in medical school we were always encouraged to remember that the patient’s story often provides the majority of information needed to narrow the options for diagnosis. Despite what we might think in a world of high-tech diagnostics, it’s not always about doing a lot of tests or even about performing hands-on examination techniques.

In my time as a “fast track” physician in a high-volume emergency department, I’ve seen a lot of patients who did not truly need emergency services. As telehealth expanded during the COVID pandemic, hospitals were looking at different ways to manage increasing emergency volumes and figuring out different ways to care for patients who didn’t need high acuity care. Some organizations turned to telehealth, adding phone booth-style cubicles where patients who met certain triage criteria could consult with a physician. Others moved to a “physician in triage” model to help expedite care, although that occasionally backfired when patients left after being triaged but were still stuck with a bill since they were seen by a physician.

With that in mind, I was excited to see an article last week in NEJM Catalyst that examined this phenomenon. Titled, “Converting an ED Fast Track to an ED Virtual Visit Track,” the case study looks at the Stanford Health Care experience as it substituted remote consultations for in-person visits in the emergency department. The effort started in December 2020, as the organization accelerated an already-approved plan to add virtual visits into the ED’s offerings. As we’ve seen with a number of technology initiatives across the US, the challenges posed by the COVID pandemic led to many different advances in care delivery capacity.

Historically, the goal of a fast-track area within an emergency department is to be able to treat low-acuity patients faster, since higher-need patients will always be prioritized. Typically, the fast-track area has dedicated physicians and nursing staff who can quickly evaluate and manage a variety of non-emergent problems, such as cough/cold, sore throat, ear pain, rashes, nausea, vomiting, diarrhea, low-grade burns, minor lacerations, sprains, lower-acuity fractures, and the like. On any given shift in the fast track, I’d see kids who were sent home from school too late to get an appointment with their primary care physician, people who were injured at work, and those who might not have a primary physician or other access to healthcare but who had run out of prescription medications or had other care needs.

At my hospital, the fast track was staffed by family physicians since the majority of patient complaints were the kinds of things we see in our offices day-in and day-out. That freed the board-certified Emergency Medicine physicians to manage more complex cases, including strokes, heart attacks, major traumas, gunshot wounds, serious burns, etc. It sounds like Stanford’s fast track unit was a lot like mine, with its own physicians, nurses, and ED technicians. However, due to COVID surges, Stanford implemented a Virtual Visit Track in place of its fast track, adding the offering to both adult and pediatric emergency departments. In that program, a physician is seeing low-acuity patients from a remote location, while dedicated support staff in the emergency department provide services that must be done in person.

In the Stanford program’s first year, 2,000 patients received virtual care through the offering. The volume of patients has been sustained, with around 1.5 patients per hour being diverted into the virtual visit track during an eight-hour shift. This metric was tracked closely since 12 patients per shift was the break-even point for the resource investment. The wait time for patients in the virtual track was around 1.9 hours compared to 4.2 hours for patients seen in-person for the same level of care.

Additionally, researchers looked at the quality of care being delivered, comparing virtual care to the standard in-person care normally available. The virtual care was found to be non-inferior. Research also showed that virtual patients had a lower median return visit rate than in-person patients, although the numbers were not statistically significant.

It’s great that this type of research is being performed so that we know whether the interventions we’re applying to the healthcare system are actually effective or if they’re just another shiny object that we thought would make a difference but didn’t. We’ve all seen plenty of the latter over the years, as hospital administrators brought back ideas from conferences and did a lot of “transformation” work without knowing for sure it would work.

I remember when my hospital jumped on the Disney Institute bandwagon back in the mid-2000s. A lot of money was spent on educational in-services, culture promotion, institution of dress codes, and uniformity across patient care units. I’m not sure any of it did much to drive patient outcomes or to retain staff. Frankly, as far as the latter, I think re-engineering the hospital cafeteria’s late-night offerings did a lot more to boost morale than the Disney principles ever did.

I was involved in a “virtual first” offering with one of my clients a couple of years ago, and it was an interesting experience. I know how my visits went, but when we looked at the work of all the clinicians on the panel, there was a lot of variety. Unfortunately, the program was slow to grow, and during my time there, we never had enough visit volume to get to the point where any research would have been statistically significant. Seeing this article makes me want to reach out to my successor and find out what their volumes have been since I left and if they’ve been doing any quality work. It would be gratifying to know that something I helped get off the ground was making a difference.

Has your organization done any work looking at the quality of virtual offerings compared to standard care? Is it a case of the newer offering being merely “non inferior” or does it really shine? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/13/22

The HLTH conference team has announced the headliner for its Industry Night celebration. Let’s just say nothing celebrates digital health and transformation quite like Ludracis.

The American Telemedicine Association shifts the dates of its ATA2023 Annual Conference & Expo. The conference moves from a mid-week placement to begin on Saturday, March 4 and will run through Monday, March 6. The organization notes this is to accommodate busy schedules and to ensure that “even more frontline providers and virtual care practitioners” can attend in person. The meeting remains in San Antonio and two of the evening events have “Celebrity Mixologist” in the title, so it looks like it will be entertaining as well as educational.

The National Center for Health Statistics releases provisional life expectancy estimates for 2021. It shows that from 2019 to 2021, US life expectancy dropped by 3 years for men and 2.3 years for women. The new values – 73 years for men and 79 for women – are the lowest since 1996. Approximately 75% of the drop was attributed to COVID-19 deaths, with the remainder including overdose deaths, suicide, chronic liver disease, and homicide for men. Women lost years due to COVID-19 as well as heart disease, stroke, and chronic liver disease. Losses were not as high as they could have been, however, since they were somewhat mitigated by reductions in deaths due to influenza, pneumonia, and other respiratory diseases.

Mr. H recently posted a poll to assess “Which of the following items did you earn after age 35 that has been most valuable in your career.” Although there were some good choices, including master’s degrees, doctorates, professional degrees, and more, the list didn’t include my personal pick: my Clinical Informatics board certification. As a relatively home-grown clinical informaticist, most of my training was of the on-the-job variety and a good chunk of the learnings were through the school of hard knocks. I didn’t have the opportunity to do a fellowship in the discipline, but worked my way through the major texts of the specialty through grim determination and the Interlibrary Loan system.

In second place, I’d put vendor-specific certifications. I don’t know how much they’ve really helped me with my career, but they’ve definitely helped me do the day-to-day aspects of my job better. Even though I’m in a leadership role, having the certifications allows me to speak the same language as my analysts and better understand the different features and functionalities that we’re implementing. It’s also entertaining when people discover that although you’re a physician, you have certifications in the practice management and billing portions of the application. Not to mention that I’m always happy to talk about EDI and Coordination of Benefits over a cocktail or two.

The Medical Group Management Association, in conjunction with Jackson Physician Search, releases a report on physician turnover in the US. The sample size was small at 326 physicians, but the data is recent since it was obtained in August 2022. Among the most interesting findings: 51% of physicians have considered leaving their healthcare employer in the last year, with 41% considering leaving medical practice and 36% contemplating early retirement. I wonder what percentage of those who are considering leaving medicine could be mitigated if care delivery organizations were willing to create more novel practice arrangements.

For example, I have several friends who have left medicine in the last couple of years because they didn’t want to work full time as primary care physicians. There’s a perception that having part time physicians is difficult or creates scheduling or administrative headaches, so they would rather let people leave. My former medical group was unsupportive of job-share arrangements. Although there was one highly successful physician pair who was tolerated due to their seniority, no additional arrangements were allowed. Assuming the right contractual language and appropriately paired physicians, there’s no inherent reason why a physician job-share wouldn’t be successful.

In the last two decades, I’ve been let go by two emergency department staffing groups because they made the determination that they didn’t want to contract part-time physicians. They can’t use administrative burdens as an excuse since both of them allowed part-time nurse practitioners and physician assistants, who are actually harder to schedule than physicians due to supervisory requirements in my state. Those of us who were let go each time concluded that the motivation was largely financial, although staffing groups would never admit to it.

Several of us started doing our own variations of an in-town locum tenens gig, where we provided supplemental coverage for acute ambulatory visits at peak times such as Mondays or Friday afternoons. We would also cover vacations, maternity leaves, and time off due to FMLA. There was good uptake on our services by individual physicians, but we could never quite get the big health systems in town (or their affiliated medical groups) to consider making us part of their teams. I guess they would rather see physicians scramble for coverage on their own, or worse for morale, just not take time off.

I’d love to get back to seeing patients in person and would be happy to work evenings and weekends if someone were looking for a part-time doc. Unfortunately, the only place willing to hire someone for fewer than 12 shifts per month is my former urgent care, which I wouldn’t touch with the proverbial 10-foot pole.

The MGMA report has a whole section on burnout and summarizes the results of a May 2021 look at burnout. At that time, 86% of healthcare leaders said they didn’t have a formal plan or strategy to reduce physician burnout. By August 2022, the number of leaders who admitted not having a plan had dropped to 66%. Although it’s a move in the right direction, every organization should have a plan in place to address burnout not only of physicians, but of all members of the clinical care team.

We’re living in unprecedented times and everyone is stretched to the limit. Case in point: the charge nurse in the emergency department at St. Michael Medical Center in Washington called 911 because the department’s five nurses were overwhelmed with 45 patients in the waiting room. She requested that firefighters come assist and they did, taking vital signs and helping turn over rooms between patients.

What is your organization doing to help with burnout? Or are they just keeping their collective heads in the sand? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/10/22

I spent the majority of this weekend on staff at my favorite outdoor classroom program, which focuses on teaching a variety of outdoor skills to adults. Fall has definitely arrived, with frost on the tents the first night and ice the second night. Even though I’ve been doing this a long time and have a good routine to make the experience as comfortable as possible, my body seems to be greeting those early mornings with an increasing number of creaks and groans as I depart my nice cozy sleeping bag. It’s worth it, however, to see people learn new skills and become comfortable with spending time in the great outdoors.

This time around, I was also the designated health officer and was extremely glad that the weekend had zero incidents requiring my professional skills. The only casualty was a box oven that caught fire in a fairly spectacular fashion but was quickly extinguished.

People are always curious when they find out I’m a telehealth physician and wonder how much we can really do without laying hands on a patient. One attendee was shocked that we’re “allowed” to diagnose anything when we’re not seeing someone in person. I explained that a diagnostic process involves a good amount of history-taking and listening, and once you frame it in that fashion, people start to remember that their own physician might not do much more of an examination than listening to their heart and lungs at an office visit. I also was able to explain some of the technologies that are available to assist physicians and patients. People tend to forget that home blood pressure cuffs and scales can provide data for diagnosis and management as well.

Of course, people also tend to ask for medical advice. This weekend’s hot topics included what I think of the new COVID booster along with what I think is the optimal timing of the flu vaccine.

Generally, I tell people that I’ve already had the new COVID vaccine and have no concerns about giving it to loved ones, and there’s not much more discussion. On the flu vaccine, however, it seems like everyone thinks there is some kind of secret to the best timing. Historically, influenza tended to peak somewhere between January and April, so getting a vaccine in early fall was ideal. There have been a lot of changes to the patterns of various viral infections since the COVID pandemic and there’s a chance our predictions for this year’s flu season might not be as accurate as they’ve been in the past, so my strategy is to recommend people get it as soon they are able, particularly if they are high risk, and to take common sense precautions to avoid infection – like washing their hands and staying away from sick people.

We had some staff members who were unable to participate this weekend due to COVID infections, so I am doubling down on the recommendation that if someone has an important event they’d like to attend, it’s a good idea to up their masking and distancing game if they want to improve their odds of making it happen. Many of the members of our instructor team are IT professionals and are now working from home permanently, so there were a couple of good conversations around the new normal of working when you’re sick along with strategies for juggling work commitments when you might have a sick child at home. People reported a wide range of ways they handle this depending on workplace culture. It seems like more organizations are expecting people to work while sick because they’re remote, even if they have designated sick time.

This conversation led into a follow up discussion of “the perils of unlimited PTO,” which seems to be increasing in popularity among tech companies for a variety of reasons. Workplaces definitely vary in how they’ve implemented it. Some still track time off but it’s unlimited, which doesn’t help much with managing administrative overhead. Others leave it up to supervisors to track their teams’ time off and intervene if there are issues. Another strategy is to not track time off at all. The people in the discussion felt that not having any tracking at all made them more likely to not take an appropriate amount of time off, because they didn’t have any kind of visual indicator of what they had taken or any way to judge where they are in comparison to their peers.

I’ve worked in a couple of unlimited PTO organizations. They have also had extremely flexible work hours, which when combined can be a recipe for working way more hours than one might normally do in a traditional time management structure. My advice for those moving into this model for the first time is to track your hours and your work pattern for a period of time and find out how many hours you’re really working and whether you’re doing more than you think. Having been a consultant and needing to quantify my time in various increments – some as small as six minutes – I know with good accuracy how long many tasks take. People who are working flexible hours and tend to answer emails “here and there” after hours often underestimate how long those take and those minutes add up. I recommended a time tracking exercise for one of my mentees recently and he found that his new position with unlimited PTO and a flexible remote schedule actually had him working 25% more hours than he previously worked.

This drifted into a conversation about so-called “quiet quitting.” It was interesting to hear that those in non-healthcare tech positions were seeing similar manifestations of the phenomenon as those of us who are in healthcare IT. I think at times we think that there’s something particularly challenging about being in healthcare or having been impacted by the pandemic, that we think we’re worse off than everyone else. However, it seems that everyone is similarly burned out and looking for solutions to live a more balanced life. I hope that spending a couple of days in the woods provided some food for thought about the need for balance as well as some strategies for getting more enjoyment in the outdoors. If nothing else, the participants should have gone home with a sense of accomplishment after spending the night in a tent in freezing weather.

Does your organization have unlimited PTO? Do you feel like workers take enough time off to recharge? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/6/22

CMS has released a Request for Information on the idea of a national directory of health care providers and services. The announcement notes that such a compilation might “help facilitate care coordination, health information exchange, and data reporting efforts.” They note, “We envision that an NDH [National Directory of Healthcare Providers and Services] could serve as a centralized data hub for providers’ directory and digital contact information, which would contain accurate, up-to-date, and validated data in a publicly accessible index.” On the surface, this seems like a good idea, until one realizes that there have already been efforts to attempt to create a master database.

My current CMS provider records contain a practice address where I haven’t worked since 2011 despite multiple attempts to update it, so I’m not optimistic about efforts to maintain yet another database. It would also be difficult to account for the information for physicians and other providers who work part time at different institutions, which can be common for certain specialties or classifications of physicians. For example, faculty physicians at my academic medical center might have separate practices (complete with separate billing and communications information) at the faculty practice, the residency practice, the hospital service, and the local Veteran’s Affairs clinic. Similarly, many physicians “moonlight” or pick up extra shifts via urgent care or telehealth companies, so that will add to the confusion. The public comment period ends on December 6, so be sure to submit your thoughts.

The concept of patients calling physicians by their first names is always a hot topic in the virtual physician lounge so I was glad to see this research letter published this week in JAMA Network Open. In the introduction, the authors note the sentiments shared by many physicians, that using the title “doctor” helps in “acknowledging the physician-patient relationship, signifying respect for physicians, and following established social norms.” They mention the results of two previous related studies – one that found that almost three out of four physicians were called by their first name, with 61% finding it annoying, and another that found that having “DOCTOR” boldly indicated on ID badges was associated with fewer episodes of misidentification among female physicians and physicians in underrepresented groups. With that background, the authors set about determining the factors associated with use of the physician’s first name in patient portal messages.

The authors performed a retrospective review of patient messages in the Mayo Clinic EHR from October 1, 2018 to September 30, 2021. Natural language processing was used to identify the greeting and/or closing salutation and those phrases were classified according to formality. Patient demographics (age, gender) as well as physician demographics (age, gender, degree, training level, and specialty) were all identified. The authors found that female physicians were twice as likely to be called by their first names after controlling for other factors. Physicians with a DO degree were also more likely to be called by their first name, as were primary care physicians. Interestingly, female patients were less likely to use their physician’s first name. There was no difference based on patient or physician age or physician training level.

The study has a few limitations noted by the authors, including inability to control for physicians who may prefer to be addressed by their first names or for cultural/racial/ethnic nuances in greetings. The dataset was also from a single health system, so might not be applicable to other organizations. It would be interesting to see how these factors play out in different regions across the United States, since there are definitely nuances in how people are addressed regardless of whether they’re physicians or not. I’ve been called everything from “ma’am” to “y’all” to “sweetie” to “hey yo” to things that are not fit to print while practicing my physician trade, so I’m guessing there might be variation on professional titles as well. I’m currently following a thread in a CMIO group about patient portal messages and which state might best exemplify “upper Midwest nice,” so there’s definitely a physician perception of regional variability.

The authors note that “whether being informally addressed by other medical professionals or patients, untitling (not using a person’s proper title) may have a negative impact on physicians, demonstrate lack of respect, and can lead to reduction in formality of the physician-patient relationship or workplace.” They go on to state that organizations need to focus on a supportive culture and that guidelines, practice changes, or patient education may be needed. The idea of lack of respect is a common sentiment around the virtual water cooler, but times are changing and, at least in the US, social norms feel far more casual than they did a decade ago. I’ll be interested to see what kinds of comments might be added to the article since it’s so new. Responses have been mixed on several platforms that have posted articles referencing the study.

Regardless of title, role, or status, it’s always a good idea to ask people what they prefer to be called, and to discuss if you feel the need to call someone something different than what they request. I’ve worked with seasoned nurses who actively struggle with the idea of calling physicians by their first names even when asked to do so, and in those cases I’m not about to force the issue. Similarly, I wouldn’t dream of calling an adult patient by their first name without their permission, and am happy to note individual preferences on the patient chart. Half the time I refer to pediatric patients by formal titles just to make them laugh since they’ve likely never been called “young Master Johnson” or “my dear Miss Jones,” and it’s fun to watch their faces. I rotated in the UK many years ago and did enjoy the certain level of formality at my practice site where everyone referred to each other as “Nurse Thompson” and “Dr. Jones” and “Trainee Jayne,” but I don’t know if that style has remained.

Does your organization have a policy on title use, or is it anything goes? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/3/22

For those organizations participating in the Medicare Promoting Interoperability Program, Monday, October 3 marks the last day to begin your 90-day reporting period. Eligible hospitals and Critical Access Hospitals that don’t successfully attest will be hit with a “downward Medicare payment adjustment,” also known as a penalty. Participants must also use Certified EHR Technology, report on the safe use of opioid medications, complete a Security Risk Analysis, and document a self-assessment using the SAFER Guides. Hospitals spend a tremendous amount of resources trying to make sure they hit all the requirements, so for those of you immersed in this work – may the odds be ever in your favor.

A friend of mine sent over this job posting from Amazon. They asked my opinion about the posting itself and if I could read between the lines to figure out what the job is really about. It reads to me more like a business development or sales role, specifically targeting telehealth, imaging, and analytics. In the job posting, Amazon has an entire paragraph about its inclusive culture and specific focus on race, ethnicity, and gender diversity. However, they missed the mark on actual physician inclusivity, since the preferred qualification is MD – I suppose DO and internationally-trained physicians need not apply.

News of the Weird: We see writeups of healthcare fraud all the time, but it’s been a while since I’ve seen one that is tied to a sex worker scheme. The Department of Justice announced that nine defendants in California have been hit with criminal charges related to sex services that were billed to their labor union’s health insurance plan. There are more than $2.1 million in claims at stake. Seven of the defendants are dockworkers at the Port of Long Beach.

The 46-year-old ringleader was charged with one count each of conspiracy to commit healthcare fraud and aggravated identity theft. She owned three clinics that provided chiropractic treatments, acupuncture, and sexual services. Taking advantage of insurance plan policies that allowed chiropractic services without a deductible or out-of-pocket payments from patients, she hired women, including those from strip clubs, to perform sexual services. Claims were filed for chiropractic and physical therapy sessions that never occurred. Some claims were filed under the names of spouses and children, with kickbacks being paid to plan members in exchange for the false claims.

It’s not just COVID that has the attention of physicians: Norovirus causes a wicked gastroenteritis, and is feared by schools, day care providers, and cruise lines alike. Although cases declined in April 2020 due to changes in behavior due to the COVID pandemic, cases started increasing rapidly in January 2022. The number of outbreaks in the 2021-2022 surveillance year was triple the previous year. It’s simple advice – wash those hands, folks, and stay home if you have diarrhea.

I’ve written before about my sometimes love-hate relationship with wearables. Although I like my Garmin wristwatch (which also does passive activity tracking such as steps or sleep alongside active GPS activity-logging), it’s been temperamental of late. Sometimes I’ll attempt to synchronize it with my PC, and it randomly fails to import several days of step or sleep data, where other times it functions just fine. I did a lot of troubleshooting with Garmin this week and didn’t reach a satisfactory outcome, although they did offer a 20% discount on a new watch in the same line since my model is no longer made. Unfortunately, the units in the same line have more bells and whistles than I need, where other lines that are a better fit are excluded from the discount.

The experience has me looking for alternatives from other vendors, but I’m not sold on anything just yet. I was interested to see this opinion piece this week though, which talks about the potential liability issues for “prediagnostic” wearables including some smart watches. It notes that many of these technologies are not regulated as medical devices and that although patients may use them to assess their health, there are legal gray areas where liability is concerned. From the physician standpoint, it’s unclear what happens when particular product is recommended, and it turns out not to be accurate. The article goes into gory detail about the various types of liability and differing jurisdictions for claims, if readers are interested. One proposed solution would be for states to pass laws that specify that physicians receiving this “prediagnostic” data should manage it like any other patient self-reported information. This will definitely be an interesting area to watch in the coming years.

Over the last couple of years, we’ve all encountered changes to the ways we’re used to working. For me, going from having quite a bit of travel to having none at all was a major transition. I’m definitely back to traveling and have experienced two vendor conferences, a couple of company meetings, and some personal travel in the last six months. Other than HIMSS in the spring, I haven’t attended any general industry conferences, but that’s about to change since CHIME and HLTH are both on my docket for the coming months. I haven’t been to either of them previously so am looking for advice or recommendations on how to best navigate them. It looks like CHIME has added a clinical informatics pre-session, so I’ll have to figure out if I can squeeze that onto my dance card.

I didn’t make it to my specialty organization’s annual meeting due to conflicts, but several friends attended. One of them mentioned the keynote by author Malcolm Gladwell, who said of family physicians, “If there’s a problem with (trust in) healthcare, there’s no solution without you.” He went on to say, “You can’t solve it with better technology. You can’t solve it with better drugs. You can’t solve it with a fancy EMR. We solve it with communication, listening, and empathy.”

Unfortunately, that doesn’t necessarily align with what many patients want, which is cheap, transactional service-oriented encounters. It will be interesting to see how the family medicine community responds to the challenge and whether people flock to the specialty or continue to retire early. Either way, I’ve got my calendar marked for next year’s conference in Chicago so I can see where things are trending.

What are your conference plans for the coming months? Leave a comment or email me.

Email Dr. Jayne.