Curbside Consult with Dr. Jayne 9/26/22

It seems like lately I have been seeing more of the patient side of healthcare than I care to. That trend continued this week as I was again pulled into the caregiver role. A close friend experienced an accident while far from home, leading to injuries that prevented them from traveling under their original arrangements. Initially, I was engaged to help arrange travel that would get them home quickly, while also accommodating medical needs. That was an adventure in itself, involving lots of phone calls, some hypothesizing about the patient’s condition, a remote airport, dense fog, and a circling plane that ultimately had to be diverted before making another attempt the next day. That kind of experience is certainly nerve-wracking for those trying to coordinate things from afar and even worse for the patient.

Because I wasn’t able to speak with the medical team at the hospital where they were treated, I was hoping to get a greater understanding of the clinical picture by reviewing the notes available in the hospital’s patient portal once the patient made it back home. Initially, I just had the information from the discharge packet, which was lacking some important elements, namely three of the four diagnoses that I expected to see based on the patient’s description of the situation and the other data on the discharge summary. However, there was an access code for the patient portal, so I was eager for the patient to login and take a look.

Unfortunately, there was a problem with accessing the portal, because despite keying in the access code and the patient’s demographic information, it wouldn’t allow us to proceed. We tried to make an account from scratch without the access code, and that didn’t work either. For some reason the system wasn’t able to validate the patient’s information. Of course, the patient knew their own demographics, and the date of birth and name were featured correctly on the discharge paperwork, so we could only hypothesize that the Social Security Number was wrong. Upon making it home, the patient called the portal assistance number on the discharge paperwork only to be told that no one could assist because it was a weekend. I joked that I hoped there weren’t any typos in the insurance information that was entered, because dealing with a denied claim can be a months-long challenge.

On Monday, the patient called the number given with the failed portal login message, and was immediately transferred not to a patient assistance line but to the hospital’s internal IT department, who couldn’t assist. After three more transfers and 40 minutes of being on hold, they finally hung up and called the Emergency Department directly. It turns out that there wasn’t a typo in the Social Security Number, but rather that it hadn’t been entered at all when the patient was registered by the Emergency Department. The receptionist was able to add it to the account, allowing the patient to finally access their information five days after the visit. We were able to see the patient’s Emergency Department progress note as well as the Radiology reports, but unfortunately there was no access to the images that would certainly be of interest to any physician with whom they’d follow up, given the nature of the injuries. There was no information on how to get the images, so we assumed there would have to be another phone call to the hospital.

On one hand, I wished the patient had known to request copies of the images while they were still at the hospital – but most patients don’t think of that, and a patient with a head injury who was having memory issues at the time definitely shouldn’t be expected to be responsible for that. The care team knew the patient was from out of state – in the facilities where I’ve worked in recent years, we’ve always been able to create a CD with images in that type of situation. It doesn’t sound like anyone offered that as an option, at least as far as the patient can remember. On the other hand, the patient doesn’t necessarily remember giving anyone a photo ID, which would be surprising in a hospital that’s part of a large integrated delivery network. At least they remember giving someone an insurance card, but all bets are off as to how the financial part of this experience will play out.

In looking at the Emergency Department note, its contents confirmed my suspicions about missing diagnoses. The physician mentioned several different findings that should have triggered additional diagnoses for the visit, but apparently didn’t. He also failed to mention the patient’s significantly elevated blood pressure and didn’t enter any comments for the patient as far as when they should follow up with someone, and what kind of physician would be advised. As a physician who has spent the last 15 years practicing in emergency care facilities, it was appalling. In every facility where I’ve worked, we’ve been encouraged to put all pertinent diagnoses on the chart and to ensure that there is a follow-up instruction noted for each and every one.

We can talk about patient engagement, quality transparency, and cost comparisons all we like, but in reality, all of that goes out the window when you require emergency care. This patient didn’t have the opportunity to shop around, to vet the qualifications of those that might be treating them or see what the cost might be for what is clearly going to be an out-of-network visit. They were prudently taken to the nearest emergency facility, which is the right thing to do when you’ve experienced head trauma, loss of consciousness, and blunt chest trauma. Unfortunately, what we call our healthcare system let them down, and without advice from their friend who happens to be a physician, they (like many patients) might be unsure of what should be done next.

The lack of follow-up is particularly concerning, especially since the patient was far from home, had fractures requiring follow-up, and the emergency physician provided less than two days’ worth of prescription pain medication. This kind of thing often leads to patients taking massive quantities of over-the-counter medications as a result and isn’t ideal in a patient with elevated blood pressures. Even if the Emergency Department had a policy to only give a set quantity of pain medications, there was no option given for local follow-up either. The patient is lucky they didn’t have complications, but their pain was poorly managed and I can’t imagine traveling in that state.

I’ve thought a lot about this situation the last few days, and particularly about the health system involved. Although the hospital was somewhat remote, the health system isn’t, and frankly I expect a little better from an organization whose core values include compassion and accountability, and whose website talks about advocating for each patient it serves. I’m glad I can help the patient navigate this situation, but the need to embrace a BYOD strategy (Bring Your Own Doctor rather than Device in this case) is a sad commentary on how patients experience healthcare more often than we think. I hope some hospital administrator reads this and questions whether this might have gone on in their organization, because based on my experience as a consultant, this situation is far from unique.

What has been your worst experience as a patient? How did you manage it? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/22/22

Plenty of people have returned to a level of comfort with business travel and it seems like they’re flocking to conferences. Redox is promoting their Connect Customer Conference to be held in Philadelphia on October 18. The one-day conference is priced at $99, although current customers can get a discount code through their account manager. The fee includes breakfast, lunch, snacks, and admission to a reception at the Philadelphia Museum of Art. The conference itself will be held at the Philadelphia Masonic Temple, so props to Redox for scheduling what might be the most architecturally interesting conference of the year.

I had to renew my Drug Enforcement Administration registration this week, and the $888 fee always hurts. Most mainstream telehealth-only physicians aren’t allowed to prescribe controlled substances, but we’re required to maintain a DEA registration to serve as a proxy for proof that we haven’t done anything shady. The DEA, similar to multiple state-level controlled substance agencies, has yet to come to terms with the reality of telehealth. They still want you to list a physical address at which patient care occurs, which some of us don’t have. I hate having to use my home address, but it’s the only way to register. Let’s hope that agencies will evolve to recognize that some of us may never see patients in person again.

I appreciated the “Renewal Application Quality Assurance Survey” that appeared after finishing my registration. The questions included some commentary that falls into the “things we wish we could say” category. For example, the first question asked for feedback on the overall experience, noting “Please be aware that some common complaints describe aspects of the application that are operating as intended” including the fact that failed logins don’t explain why (so fraudsters can’t exploit that data point) and that the burden of information needed for login is intentional. In addition to rating the login experience, users are asked to rate the usefulness of help/error messages and overall application ease of use.

My readers know that I’m a sucker for a compelling headline, and the hint of research that would explain “Why Hard Thinking Makes You Tired” certainly grabbed me. The theory is that intense mental activity causes a buildup of substances in the brain. Specifically, the chemical glutamate builds up in the brain’s decision center, leading to alterations with thought processes and the progression of mental fatigue. The authors used magnetic resonance spectroscopy to evaluate changes in the brain during the workday. Glutamate is processed during sleep, so the bottom line is that it’s probably a good idea to avoid critical decisions while tired.

I’m a big fan of patient portals and giving patients the ability to schedule their own appointments, testing, and diagnostics if it’s something they want to do. Of course, not every patient is going to be able to do that, or wants to do that, but for those that do, it can take the load off of office staff and call centers. A recent article looked at whether self-scheduling of diagnostic imaging studies had an impact on health disparities. The authors looked at outcomes of a process using the patient portal at the University of California San Francisco and a subset of diagnostic imaging studies that were flagged as eligible for self-scheduling. The portal-based scheduling process was only available in English and allowed for scheduling of a subset of MRI and ultrasound tests as well as CTs, bone density scans, and mammograms as long as a provider had placed an order accompanied by a “ticket” that would help the patient schedule the correct test type, location, and date. The time period analyzed was January 1 to September 1, 2021.

The authors found that subsets of active patient portal users were less likely to take advantage of self-scheduling, including Latinx, black / African American, and non-English speaking patients. Additionally, those with Medicaid or Medicare coverage were less likely to schedule online versus those with commercial insurance coverage. There’s always a chance that patients won’t self-schedule, and backup processes need to be in place to ensure that no one falls through the cracks. Still, more than 18,000 tests were self-scheduled during an eight-month time period, which is nothing to sneeze at. The authors did note a couple of study limitations, including inability to determine whether the patient actually scheduled the test on their own or whether they had assistance from a family member or caregiver.

Looking at the design of this study, the patient stratification piece was likely fairly straightforward because organizations have been required to collect this specific demographic data for quite a while. As researchers look to further understand patient behavior, it will be more important to understand other data covering social determinants of health. Another article that came out this week looked specifically at clinician awareness of their EHR’s ability to capture that kind of information. The authors looked at data from the National Electronic Health Records Survey and analyzed it based on physician, practice, and EHR characteristics. They found that physicians who practice in community health centers were more likely to document these factors than those practicing in other locations. Similarly, physicians involved in payment models that included social care initiatives were more likely to document. Regardless of practice site, physicians who were more aware of advanced EHR capabilities, such as patient engagement or population management features, were more likely to document social factors.

The authors recommend that organizations develop strategies to increase provider awareness of documentation capabilities, especially in practice settings where they are less likely to be aware. I was surprised that payer-owned clinics were found to have lower awareness of documentation capabilities for social determinants, so there’s certainly room for improvement in that environment. The authors also call for policy efforts to expand the use of clinical quality measure that look at social risk screening.

I agree that promoting lesser-used features of the EHR should be part of ongoing optimization efforts, whether they are related to social determinants, provider efficiency, or something else. Unfortunately, many organizations have cut budgets for optimization efforts and ongoing EHR training.

What is your organization doing to improve documentation standards and to get the most return on its EHR investment? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/19/22

One of the more thought-provoking articles I’ve read this week was in the Journal of the American Medical Informatics Association. Of course, the title caught my eye: “Do electronic health record systems ‘dumb down’ clinicians?” The abstract was compelling as well, although I was able to read it only after entirely too many clicks were needed despite my AMIA membership.

The abstract discusses a panel that was held at the 2021 AMIA Symposium and sponsored by the American College of Medical Informatics. The panel sought to answer the title question, looking at how the incorporation of EHRs might be negatively impacting care delivery. Discussions centered on how less-than-optimal EHR workflows might impact clinician efficiency, thought processes, and knowledge both during system use and during the longer term.

In broader coverage of the topic, the journal goes beyond the panel discussion, starting with the evolution of EHRs including both homegrown and commercially developed products. It notes that although early EHRs improved safety and efficiency compared to paper-based systems, “several critical perspectives were lost.”

The authors note that data showing impacts on patient outcomes were lacking and that most studies have focused on the processes involved in delivering care. Since early systems were concentrated among a small number of academic medical centers, there wasn’t much portability across institutions. They go on to explain how the Meaningful Use program and the HITECH Act of 2009 incentivized provider organizations to not only expand EHR use in the marketplace. but also to focus on a core set of functions that would lay the groundwork for broader improvements in care.

Having been part of an organization that was already knee-deep in EHR implementation and adoption before Meaningful Use came along, I can attest that it actually slowed us down, because we had to focus on ensuring that prescribed workflows were followed versus being able to customize or configure workflows that worked best for our clinicians. It’s validating that the article notes some of the same negatives that were created in the name of progress.

A series of great quotes are included in the piece. They’re attributed to a New England Journal of Medicine article that was penned by John Halamka and Micky Tripathi in 2017. They are quoted as saying that the HITECH Act had some less-than-ideal consequences. “We lost the hearts and minds of clinicians … We tried to drive cultural change with legislation. In a sense, we gave clinicians suboptimal cars, didn’t build roads, and then blamed them for not driving.” One of my favorite family physicians and clinical informaticists, Jan Lee MD, used to refer to this as “paving the cow paths” when physicians actually needed high-speed roads with no obstacles.

The article goes on to discuss in detail how EHRs might impair clinicians in the short term. Although there are many beneficial features in modern systems, including allergy checking, order sets, and often a treasure trove of patient information, there are also interruptive alerts and distractions. Sometimes users are unwilling to question information supplied by the EHR, and alert fatigue can cause users to ignore warnings and alerts that might in fact be useful. The article gave specific examples, ranging from hundreds of thousands to millions of interruptive alerts where only a fraction (2-4%) were accepted. The way that EHR notes are organized can obscure the details of a patient’s situation. The use of copy-and-paste functionality in progress notes was specifically called out as potentially misleading and dangerous.

As far as long-term impacts of EHR use, the authors noted that standardization of EHR documentation has led to less-granular terms being used during the creation of History and Physical documents. At one institution, EHR templates reduced the possible descriptors from 1,800 to 360, meaning that some clinician documentation might be hidden from view by other clinicians. An unintended consequence of this might be the shrinking of clinical vocabularies used by medical trainees. As those trainees become faculty, and older faculty members retire, the broader vocabularies are ultimately lost, and notes become less optimal. Additionally, after using templates to order certain treatments, such as total parenteral nutrition, clinicians lost the ability to order these treatments manually. The authors note that this can be dangerous during system outages or when clinicians move to a less-automated environment.

The panel also discussed solutions, which fell into four general categories: institutional and end-user readiness and competency; EHR design and capabilities; regulatory policies and healthcare system-vendor partnerships; and decoupling clinical documentation from billing and regulatory requirements so that clinical notes contain only that information necessary to care for the patient.

I think you would be hard-pressed to find a clinician in the US that wasn’t in support of the latter suggestion. Technology could be a great booster of the latter as well. I’d much rather have a photo of a rash in a chart than a rambling description of someone’s idea of a “lace-like reticular rash with mild to moderate erythema and occasional popular features.” Unfortunately, in many situations, the words will get you paid, but a photo will not.

As far as the other categories, the panel called for improved EHR training, expanded downtime simulations, and greater incorporation of learning about EHRs during undergraduate and post-graduate medical education. Medical students and residents need to understand the “why” behind various parts of the EHR as much as they understand the data that they’re keying in. They call for greater clinician involvement in the design and validation of EHR systems and improvements to alert messages to ensure that such interruptions are clinically important and obtain enough clinically relevant information for clinicians to take action.

It will be interesting to see how EHRs evolve over the next five to seven years. More interesting will be assessing the approaches taken by health systems in how they implement and optimize EHRs. I still see far too many organizations that think that installing an EHR is some kind of “set it and forget it” process.

Physicians constantly complain about the impact of EHR upgrades, but in the last conversation I was in about that topic, not a single physician admitted to having seen any kind of upgrade documentation or educational materials that told them what to expect or what benefits might arise. It feels like those kinds of communications might be casualties of the rampant understaffing I see in many organizations. Gone are the days when we used to send a member of the EHR implementation to every office to make sure clinicians knew what to expect and that their questions were answered. I’m sure the materials are probably out there on some intranet site that physicians have long forgotten how to access.

On the whole, I don’t agree with the premise that EHRs have made us dumber, but I do think they have impacted our workflows tremendously, and not always for the better. There certainly is room for improvement and evolution of technology, but everything comes at a cost. When hospitals are trying to figure out how to keep beds staffed, they are less concerned about things like EHR adoption or end-user satisfaction.

Do you think EHRs have dumbed-down clinical practice? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/15/22

A colleague recently asked me what I thought about “quiet quitting” and the attention that the concept has been getting recently in the mainstream media. There has been quite a bit of discussion around it in physician-specific social media groups, alongside discussion of burnout and the role of self-care in a post-COVID workplace.

Many workers in healthcare are still being asked to come in to work when they are sick, despite the fact that they have designated sick days allocated for such a thing. They are pressured that if they call off sick, they’ll be burdening their teammates. Others are told that they can only call off if they find a replacement, which really shouldn’t be the employee’s job.

By most definitions, quiet quitting is the idea that a worker only does what is required of them based on their job description. This means no extra work, no volunteering for additional projects, and in the case of many clinical workers, no picking up of extra shifts. Hospitals have been short staffed for years and the COVID pandemic only exacerbated a problem that was already there. During the first year, everyone was motivated by a sense of needing to pull together, to help humankind, and to be there for their co-workers, but after two and a half years in the grind with ever decreasing support and appreciation, people are simply done with it.

Hospitals (and medical practices, and other clinical organizations) have always had the ability to create safety nets for their workers. It’s easy to come up with excuses not to. I remember trying to implement a “float pool” for our medical group’s ambulatory practices more than a decade ago, similar to what hospitals had in place at the time. Staff could volunteer to be part of the pool on their days off and they would be paid a small amount to remain on call in the event they were needed to cover a shift. If they worked, they would receive their usual rate of pay. Instead, the group’s leadership balked at paying people “for doing nothing.” They failed to understand that it wasn’t about what the float pool member was doing, it was about what they were not doing on their day off in exchange for being on call.

The administrators decided instead to ask for people to volunteer to pick up extra shifts if there were shortages, and then if they had no takers, they offered various hourly incentives. Guess what? Staff learned not to pick up extra shifts until the incentives reached a certain level, which ultimately cost more than what someone would have been paid to be on call. Once a clinical staffing pool reaches a certain size, it’s a virtual guarantee that someone will be out sick on any given day, so the economics would have favored the float pool approach. Additionally, creating a float pool would have ensured people were ready to work on a given day rather than offices having to hope and pray that someone would volunteer, and then to cope with the scrambling that inevitably ensued when someone rolled in an hour or more after the practice opened.

These types of bad decisions have only been magnified in the last two years. Just look at travel nursing during COVID surges. A major driver behind that was the unwillingness of hospitals to appropriately compensate existing staff nurses. I had friends who quit their medical / surgical nursing jobs and then worked as “travel nurses” in a hospital less than five miles away for a significant salary bump. Hospitals went way over budget paying traveling and locum staff, when they could have avoided having those nurses quit if they addressed underlying drivers of low employee satisfaction. Those nurses who stayed put are now increasingly burned out and quiet quitting is the order of the day.

The other reality in our post-COVID world is that people’s priorities simply have changed. If they’re struggling with childcare, they’re not going to volunteer to work extra hours. Families with two wage earners where one has a significantly higher earning potential have redone the math and determined that it doesn’t make sense for both partners to work when there are children requiring care. People seem to be retaining some of the hobbies that they cultivated during the early days of the pandemic and want to ensure they’re spending time on activities that make them feel good and in which they find value.

It will be interesting to see how organizations respond to the shifts in productivity that will result from quiet quitting. Some high-profile companies have already signaled that they’ll just fire people, which doesn’t seem like the way to become employer of choice.

I had some travel this week, which always makes for good people watching. For the first time since spring of 2020, I actually had difficulty getting a space at my favorite airport parking garage. The airport was hopping, although many of the stores remain closed during peak times. I’ve learned to pack a lunch if I have any hopes of eating something that is healthy and convenient. I would estimate that 80% of the people waiting in the gate areas are on either laptops or phones, so I wonder what they would think about this study that looks at the relationship between chronic blue light exposure and accelerated aging.

Researchers at Oregon State University looked at the impact of such exposure on fruit flies. Where previous studies had looked at the consequences of light-related stress on retinal cells, newer studies have examined whether exposure to blue light caused reduced lifespan and degeneration of organs such as the brain. The authors looked at flies that were genetically altered to not have eyes, in an effort to study metabolism and cellular pathways. Some flies were kept in constant darkness and others in constant blue light, for varying durations. The authors noted that those kept in blue light for longer durations had changes in metabolism including impairments in cellular energy production. There was also neurodegeneration in the blue light group, with decreased levels of certain chemical transmitters in the brain.

The study found that if the impacted flies were placed in darkness, their lifespan could be brought back to normal. Reading the paper sent me straight back to my freshman year in college, where the fruit fly lab convinced me that I no longer wanted to be a biology major even though that was what pre-meds were expected to do. Even though I never want to see another diagram of a metabolic pathway, it was interesting to see how much research has evolved over the intervening years. The next step in research of this type would be to look at the impact of blue light on cultured human cells, which have similar metabolites.

Only time will tell the fullness of consequences that we’ll experience from prolonged screen time. I’m perfectly happy to spend my free minutes in the outdoors, reading an actual paper book, or doing some retro hobbies. I’m taking a stained-glass class next weekend, so we’ll have to see how that goes.

Do you have a pandemic hobby that you’ve kept? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/12/22

I was glad that Mr. H mentioned Friday’s opinion piece by former VA Secretary David Shulkin MD. With a title like “State lines should no longer be barriers to health care,” I was hooked.

Going through medical school, I had a passing exposure to the idea that one would need a state-specific license when they went into practice. Mostly this exposure came by watching the anguish that your supervising residents went through as they tried to obtain licenses so that they could earn extra money by moonlighting at rural emergency departments or by covering nights or weekends on the medical center’s newly created hospitalist service. The medical center had a variety of services to support the application process, including access to fingerprinting courtesy of campus police and notary services from the medical school office of student affairs.

Once out in practice, that process becomes more difficult. Especially in a post-COVID world, the process may require making various appointments in person and during normal business hours, which isn’t terribly helpful if you’re a busy physician. Although some states are members of the Interstate Medical Licensure Compact which can expedite this process, a significant number of states have yet to opt in. This can mean going through the licensure process from scratch – providing various transcripts, reports of test scores, copies of certificates, and more.

One state where I applied demanded a copy of my high school transcript, which didn’t seem terribly relevant for someone with a medical degree and a couple of decades experience under her belt. I had a very interesting conversation with the registrar at my high school who eventually found it on microfilm. It looked like something that couldn’t possibly be a legitimate document, with each semester’s results being contained on an address label-like sticker that was applied to a single sheet of copier paper that had my name handwritten on the top. But it had the all-important embossed school seal, so I guess that made it official.

Still, and especially since this was a state that bordered my own, I thought it should be easier since the same standards of care that apply on one side of the line apply to the other. They are called “community standards of care,” not “state-specific standards of care.”

I had been practicing telehealth part time when COVID hit, and the relaxation in licensure requirements boosted my volumes. Almost overnight, I could see patients from 17 states, and as more states relaxed their rules, our wait times for on-demand telehealth visits decreased dramatically. As the pandemic eased, however, many states ended these programs, thereby limiting their residents to a smaller pool of clinicians.

One of the reasons that was cited by multiple states was the concern that easier access to telehealth would result in higher healthcare expenditures and the states didn’t want to be on the hook for that. States were also lobbied by their own state medical boards, in the context of the boards wanting to be able to ensure quality care and discipline physicians. Those boards also receive licensing fees from the physicians who want to practice in a given state, so I’m sure that was a factor.

We knew it would take time to see whether patients would return to in-person care or if they’d continue flocking to telehealth visits. Although many of us have witnessed changes in our volumes, the evidence was largely anecdotal. This week also brought us some research, as the journal NPJ Digital Medicine published a study looking at “The impact of expanded telehealth availability on primary care utilization.” The authors looked at 4 million primary care encounters from 939,000 unique patients from three health systems during the period between 2019 and 2021. They found little change in overall primary care utilization as telehealth services became more broadly used. They noted that “our results suggest the availability of telehealth is not resulting in additional primary care visits, rather, telehealth is serving as a substitute for certain in-person encounters resulting in no overall increase in primary care utilization. Further, it seems telehealth was mostly utilized for patients whose medical needs required multiple primary care visits during each year, suggesting that these telehealth encounters enabled follow-up for patients with chronic illness.”

They noted that additional studies are needed to determine the impact of expanded primary care access on other types of visits, such as urgent care or emergency visits. The authors also noted some limitations to the study, including the inability to determine if patients received additional primary care services from other facilities outside the study dataset. They also could not assess the quality of telehealth encounters compared to in-person visits.

I would also note that although the study looks at visit volume, it doesn’t take into account the differences in the costs of different types of visits. I’ve seen lots of institutional data that shows that telehealth urgent care visits are extremely cost effective, with one organization reporting a savings of nearly $150 for each patient encounter that was handled virtually versus at one of their brick-and-mortar urgent care clinics.

Now that states are cracking down on licensure, it makes it difficult for organizations to maintain the flexibility they need to care for patients. I can barely practice telehealth urgent care now because I’m not licensed in enough states. As an independent contractor, I’m not about to shell about big bucks, and a bigger amount of my time, to obtain additional licenses, so I’m effectively a wasted resource in the primary care / urgent care space.

David Shulkin calls for the states to adopt a model that stretches the boundaries of care, much like the Veterans Administration has done. Many organizations continue to lobby state legislatures to allow continued licensure flexibility, and some states have created lower-cost, telehealth-specific licenses that allow continued practice with more acceptable overhead. Shulkin uses motor vehicle driver licensure as an example, with operators being obligated to follow the laws of the state they’re in regardless of where their license was issued. In that kind of model, physicians would agree to abide by the laws of the patient’s state.

Such flexibility would not only help telehealth programs, but would also help in-person care. Organizations that require support from locum tenens physicians would have access to larger pools of physician candidates and would experience fewer delays in a physician arriving onsite. Ultimately patients would win, which should be the goal of 99% of what we do in healthcare. This would be administrative simplification at its finest.

Unfortunately, I know how state medical boards think, and I don’t see them running to jump on this particular bandwagon. Still, a girl can hope. Maybe some day I’ll be able to see more than two patients a day again.

What do you think about cross-state licensure? Will we see improvement in this decade? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/8/22

I’m one of the few people in my social and work circles who has yet to have COVID, so I was eager to get one of the new bivalent vaccine boosters. There’s already a lot of misinformation going around with this booster and I feel more credible as a physician being able to genuinely say that I trust it enough to get my own dose on the leading edge of the rollout. I also have quite a bit of work travel coming up and am looking forward to the extra protection.

I initially scheduled a booster through my hospital’s patient portal, only to receive a phone call that they aren’t yet offering the bivalent version and aren’t sure when they’ll get it. However, I was able to find a convenient 8 p.m. slot at my local CVS HealthHub, so I decided to check it out.

Online scheduling and registration processes were quick and easy, and I immediately received a confirmation via email and text. About an hour before the appointment, I received a text with a link to check-in when I arrived, although the check-in button was locked out until 15 minutes before the appointment.

I quickly found the vaccination area in the store, although the signage for where patients should check in for vaccines was difficult to see given all the Halloween candy displays that were stealing my attention. Since I had registered online, the check-in process only involved verifying my name and date of birth. The pharmacist mentioned that they had been giving vaccines all day, which was good to hear.

The vaccination cubicle wasn’t soundproof, but it was clean and well organized. Barcode scanning was used to capture information from the vaccine vial prior to administration. I needed a new vaccine card since mine was full and the pharmacist had to hand-write, it which I’m sure becomes tiresome during the day. They may not be at a volume of administration where it makes sense to print labels as some of the high-volume hospital vaccine clinics do. I was in and out before my actual appointment time, making it back through the gauntlet of Halloween candy without a purchase.

I felt fine the rest of the evening, doing a little work and binge-watching the first part of the new season of “Call the Midwife.” I received a patient satisfaction survey from CVS, which I completed. Upon reading the questions, I realized that they didn’t offer me a Vaccine Information Statement like they should have. An interesting part of the questionnaire is where the patient can record a video snippet instead of a typed review. Any submission becomes the property of CVS and they can use it for marketing, so I wondered how many people actually do that. I took a pass on that one.

I slept well, but woke up terribly achy and felt like the joints in my fingers didn’t want to work at all, which is rough for someone who types all day. I also had significant pain in my underarm, which made me remember the issue I had in 2021 where my COVID vaccines caused an abnormal mammogram, sending me down a diagnostic rabbit hole with ultrasounds, extra mammogram views, and more. I was so excited to get the vaccine that I completely forgot about the follow up at the high-risk breast cancer clinic that I had scheduled for later in the month, and immediately cursed my enthusiasm. I mean, how do you forget something like that?

I’d like to chalk it up to the fact that I think I’ve blocked most of 2020 and 2021 from my mind as a coping mechanism for what I experienced on the front lines. Current recommendations call for waiting several weeks after a COVID vaccine before having a mammogram, so I hit the patient portal and messaged my surgeon to find out what she recommended. I was pleasantly surprised to receive a reply within the hour giving me a specific recommended time frame, so I called the office to start the rescheduling dance.

Any time you try to reschedule an appointment with a busy surgeon, especially if it has to be linked in time with a diagnostic study, it’s stressful. The staff did their best to find me a slot within a month of my “clearance” date, so I was happy with that. While I was on hold so they could dig through the schedules and try to make something work, it got me thinking – if I’m a professional who should know better, especially from my own previous experiences, and I couldn’t remember how this works, what are the odds that the average patient isn’t going to do the same thing?

It would be useful if the breast center could send a reminder to patients educating them on the need to space their vaccines and their mammograms so that others don’t wind up in the same predicament. Especially for a high-risk individual, that reminder would be most appreciated, and it should be pretty easy to send out a message through the patient portal. Any time spent crafting and managing that outreach would more than recouped by not having to deal with numerous patients calling to reschedule.

A couple of hours later, about 14 hours after the vaccine, my immune system was apparently doing a really good job of reacting to the vaccine because I started feeling terrible. Headache, crushing fatigue, nausea, and shaking chills came first, then hot flashes, followed by dizziness. I literally had to lie down between conference calls. Then came the drenching sweats. I’m sure the people on my afternoon calls got a kick out of my wardrobe changes.

Then, as quickly as the symptoms started, they were gone – no more headache, significantly reduced achiness, and with nausea giving way to feeling hungry. It was like a switch had been flipped. I had some dinner, did a quick Zoom with one of the organizations where I volunteer, and felt back to normal enough that I went out and walked a couple of miles.

All in all, this was similar to the experience I had with the second dose of the original COVID vaccine, with symptoms right at the 12-hour mark that totally resolved within 24 hours of the vaccine. I didn’t have anything like this with the first or third doses, however.

Although I wouldn’t want to repeat the experience, I’d rather have it than some of the debilitating cases of COVID I’ve seen in the last few months. It’s certainly preferable to the ultimate “bad outcome” that is dying, and which we still see (most recently in my world in a 42-year-old, which was truly tragic). The long COVID clinic at our local children’s hospital has a one-year waiting list, so hopefully vaccines will be helpful in preventing the need for those services. Everyone’s mileage varies as far as how they experience this vaccine. I don’t share this to frighten anyone, but as a longstanding early adopter of many technologies, including this one, knowing what to expect or what might happen might allow someone to plan ahead.

Have you received the new bivalent vaccine, and what was your experience? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/1/22

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/29/22

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/25/22

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/22/22

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/18/22

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/15/22

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/11/22

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/8/22

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/4/22

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/1/22

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/28/22

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.