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Curbside Consult with Dr. Jayne 10/28/19

October 28, 2019 Dr. Jayne 3 Comments

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CMS has finally delivered its Request for Application for the Primary Care First program, which had long been promised to arrive in summer of 2019.

Everyone loves an endless summer, except for the people who have been waiting a really long time for the application for a program that was to start in January 2020. Now, applications are due by January 22, 2020 for a program that won’t begin until January 2021. CMS also promises that “in the coming week” it will release a “Statement of Interest” form for prospective payer partners who want to declare their interest in a non-binding fashion. A formal solicitation process for payer partners will then run from December 9 through March 13, 2020. CMS notes that “this timeline will allow payers to clearly assess where there is likely to be high practice participation in Primary Care First, and make an informed decision about regions in which to develop their own aligned approaches as payer partners.”

Continuing with some vague deadlines, CMS notes that the selection process for practices and payers will take place in “Winter-Spring 2020,” which gives them a fairly long runway since summer apparently stretches to October 24 in their universe.

The CMS FAQ document had some interesting tidbits, for those of you who haven’t had a chance to dive into the documentation yet:

  • If more than 3,000 practices apply and meet the eligibility criteria, CMS will use a lottery system to select final participants.
  • A second round of applications will occur for practices that are participating in the Comprehensive Primary Care Plus (CPC+) program, to begin participation in Primary Care First starting in January 2022.
  • Neither Federally Qualified Health Centers or Rural Health Centers are eligible to participate. CMS states this is because the program is designed to test payment reform for traditional fee-for-service payments, where the excluded centers bill under different but distinct rules.
  • Participants will have to comply with interoperability requirements that will be spelled out in the Participation Agreement, which is not yet available for review.
  • CMS “anticipates that Primary Care First will qualify as an Advanced APM for all give years of the model test.” I’m not sure why they can’t put their nickel down at this point and declare it. I find the “anticipates” language bothersome.
  • CMS will be using a modified CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey “to allow for increased response rate and ease of use among beneficiaries.”
  • CMS will allow practices to reduce or waive the applicable co-insurance for the flat primary care visit fee, but practices are responsible for assuming these costs. Practices can determine which patients might benefit most from this, such as patients with frequent emergency department visits or hospital admissions. Practices will have to submit an implementation plan for this at a later date.
  • Practices can offer other “beneficiary enhancements,” such as transportation to the primary care provider or other follow-up services. Patients can also receive access to remote monitoring technology or nutrition programs such as Weight Watchers. These will be detailed in the Participation Agreement, which again we haven’t seen.
  • Additional guidance regarding telehealth will be provided at a later date.

I began to dig into the 102-page Request for Applications document and immediately began to regret it. There are seven possible levels of performance for regional performance bonuses dependent on the practices’ performance relative to a regional reference group. There are also tiers for the Continuous Improvement bonus.

When I reached the part about “Quality Gateways,” which practices have to meet in Year 1 to receive a bonus in Year 2, my eyes began to cross. My vision cleared up, though, when I saw that participants must agree to participate in CMS efforts to evaluate the model, which may include everything from surveys and interviews to site visits and other unspecified activities. Everyone loves agreeing to more site visits, and the part about “unspecified activities” certainly leaves room for uncertainty.

I was glad to see that the appendix does have all of the application questions listed out, since the application itself requires a login. That at least allows practices to make sure they have all their information gathered before they try to key it all in.

At this point in the game, I doubt any of my current practice clients will want to participate, but if any do, I’ll be referring them out to some consulting colleagues who are more specialized in this area than I will ever be. The devil is definitely going to be in the details for practices that go this route, and only they will be able to truly determine whether the proverbial juice is worth the squeeze. My state isn’t one of the ones that has been selected for the program, so I won’t be hearing about it in the physician lounge, that’s for sure. I do have enough colleagues around the country, though, and I hope at least one of them bites so I can share their experience with our HIStalk readers.

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Having to wade through all the Primary Care First documents was enough to make me grateful to have back-to-back clinical shifts scheduled. Unfortunately, I saw my first vaping casualty,  a teenage patient whose lung collapsed after he decided to celebrate a recent academic event with some vaping in the high school parking lot. Luckily, he was in the car with a friend who saw him begin to go into distress and brought him for attention right away. The patient went from being reasonably conversant to beginning to turn blue over the course of a few minutes while we were waiting for EMS to arrive.

It was just another day at the office for our team of in-house paramedics, but based on the level of terror his friend experienced ,I doubt either of them will be vaping much in the near future. Due to the acute timeline of the incident, the patient’s parents didn’t arrive at our office until we had already bundled him into the ambulance and sent him on his way. That’s got to be just about one of the worst feelings a parent can have.

The rest of the weekend was largely uneventful, for which I’m grateful.

How did you spend your weekend? Leave a comment or email me.

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EPtalk by Dr. Jayne 10/24/19

October 24, 2019 Dr. Jayne 1 Comment

I enjoy mentoring students and I am always excited when one of them is admitted to medical school. There is a lot of buzz around the schools that are offering free tuition or that are subsidizing a large amount of tuition, but most people in medicine don’t realize the financial barriers that occur upstream.

My student has to pay a $1,500 deposit in the next two weeks. Although he’s working full time in our office as a clinical tech, that’s a hefty amount of money after he’s already paid for the application process, travel and lodging for interviews, the MCAT exam, test preparation, and of course an undergraduate degree.

This is a timely topic that was recently covered in the New England Journal of Medicine. The article looked beyond the shocking costs to explore how they impact the types of people that apply. Not surprisingly, few applicants come from lower-income households and minorities continue to be underrepresented in the applicant pool.

Some schools are trying to reduce application costs by having students host applicants. Other programs may reduce the cost of the MCAT and applications or offer guaranteed admissions for students at a certain level of performance at affiliated undergraduate institutions. Schools are starting to look at virtual interviews as a way of lowering costs. It’s been suggested that schools should revisit their supplemental “secondary application” processes as a way of increasing the diversity of the applicant pool while reducing the cost burden.

All of us would benefit from a more diverse physician workforce, rather than having a full quarter of applicants coming from households with greater than $250,000 in annual income as the current statistics demonstrate. Still, it illustrates the pressures that clinicians have already been under before they ever enter practice. For those of us that look closely at clinician burnout, these are contributing factors that have already raised the stress game for those who haven’t even begun to stress around government regulations or burdensome technology.

Score one for AI. A recent study by researchers in NYU School of Medicine shows that an AI tool that uses machine learning can identify breast cancer with 90% accuracy. The tool was trained on over a million images and 14 radiologists reviewing 720 images were included in the study. The tool was able to identify “pixel-level changes” in breast tissue, but radiologists were able to use logical reasoning that the AI could not. The authors conclude that AI can augment radiologists.

It remains to be seen whether this can be extrapolated to other data sets and whether it can be brought into clinical practice, but for those of us in high-risk situations, such AI augmentation is welcome. I don’t personally read mammograms, but for those of us in age brackets where eyeglasses start appearing in our pockets, it’s a nice idea to have a set of extra “digital eyes” on radiology images.

I missed this a couple of weeks ago, but apparently Senator Rand Paul has introduced a bill to overturn what he considers the “dangerous provision” of legislation allowing the US to institute a unique patient identifier. He claims his physician creds make him an expert. Clearly he’s not an informaticist and has never had to disentangle the merged records of premature twin siblings Andrea and Andre, that were combined due to a faulty matching algorithm. He cites breaches as another reason. I’m pretty sure most data breaches that would reveal a universal patient ID would also reveal name, address, DOB, phone number, and often SSN, which are the current keys to your data.

Jenn clued me in on this article answering the question of, “What’s the best shoe for the busy physician?” Physicians were surveyed with 255 responses received, including 172 men and 81 women. The idea that shoe choice is important was nearly unanimous, with 40% expressing a fondness for casual shoes or loafers, 29% choosing dress shoes or heels, 20% wearing sneakers, and 11% wearing clogs or similar.

I was initially surprised to see that more younger physicians are choosing dress shoes since that demographic is often accused of being overly casual. However, it would make sense as they have less overall mileage on their feet compared to the rest of us.

According to the article, physicians suffer from flat feet, plantar fasciitis, pain, and bunions. Physicians are sometimes self-conscious about their shoes. One of my mentees started wearing what she considers “ugly” shoes because she had too many patient comments about her “cute” shoes and felt patients weren’t taking her seriously because of her choice of footwear. My personal favorite shoe, pictured above, is the Medimex Plogs line. They’re vented for breathability, have massaging nubs on the footbed, and are also autoclavable, perfect for whatever might be on the floor of a medical environment.

Speaking of people having opinions on how people dress, I was unsurprised to see this report about women at Ernst & Young being coached on how to dress. Even if a fraction of the allegations in the piece are true, it’s a fairly horrifying read. Unfortunately, I continue to see companies who have different expectations for employees based on sex and/or gender, and also those that have no idea what to do with non-binary employees.

I have been in a position where two executives debated another’s competence while making comments about her lack of artificial hair coloring, including comments on how “all that gray makes her look old.” From that conversation, I learned that apparently men with gray hair are distinguished, but women who go natural look old.

I worked for another client that required female employees to wear at least a two-inch heel and skirts, with no slacks allowed. They didn’t last long on my roster. I’ve seen assertive women labeled as “shrill” when their male counterparts are revered as “go-getters” in the last several months, regardless of publicity around discrimination and lack of equity or parity.

I recently attended a retreat hosted at a facility owned by a traditionally male-dominated company that had a large number of female participants. The company has made many public statements about its deliberate actions to increase female participation and empowerment. Interestingly, a visit to the newly created female showers at the athletic facility revealed a urinal in one of the two stalls. At least they created some individual showers rather than the group / open showers I had heard were in the male locker room area, but it’s hard to believe that organizations still think that group showers are OK for anyone in this day and age, regardless of whether they’re separated by sex or gender.

All the restrooms were clearly marked male or female, with no availability of non-gendered, family-friendly, or separate accommodations for those who might need additional assistance even though the facility is open to families. Nothing rolls out the not-so-welcome mat like inadequate restroom facilities, so I wouldn’t be surprised if they continue to encounter challenges in recruiting women or people outside their historical demographic.

Does your company have a corporate dress policy? Is it equitable regardless of sex or gender? What do you think about the current climate? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 10/21/19

October 21, 2019 Dr. Jayne 3 Comments

The past week has been entirely too crazy, working on projects for a couple of vendor clients whose offerings are starting to overlap with each other. Everyone is chasing after certain industry buzzwords, and if you can add a feature or two that gets you into a different space where people might be more willing to spend money than your current prospective clients, apparently you go for it.

It’s been challenging for me as it’s hard to keep track of what’s a real feature that is able to be delivered vs. something that is in the works, but only parts of it are actually in the code, especially in an agile development organization. It’s particularly challenging when company leaders talk about features under development as if they are actually part of a general release.

In a startup organization, words are thrown around much more freely than they typically are in publicly traded companies, who sometimes mind their language a bit to stay on the right side of the shareholders. With that in mind, I was excited when a reader clued me in to a recent analysis looking at corporations’ earnings call transcripts in an attempt to determine whether the words used in the calls are harbingers of credit risk. Researchers at Washington University in St. Louis looked at over 132,000 earnings call transcripts and used machine learning methods to create a measure of credit risk. The resulting information informs an algorithm that assesses elements from changes in credit ratings to risk of bankruptcy.

What if you could extrapolate those findings to examine the earnings call transcripts of EHR vendors to create a model that would let you know how much of what they were saying was possibly accurate vs. what might be considered creative accounting? What if you could use proxy words to identify impending layoffs or bad decisions that were about to make your stock drop? Mr. H follows some of the earnings calls much more closely than I do, but I have definitely heard some interesting comments on calls in the past that could be interpreted in a variety of ways:

“Our cash generation capabilities continue to expand our storehouse of dry powder.” I’m not sure using gunpowder as a comparative term is a great idea in this day and age. Does the company want to seem like it’s war-like and on the offense? Or perhaps it’s a commentary on the executive team’s ability to blow up the company by continued poor decision-making?

“Scary.” I recently read an earnings call transcript that used the word three times in a variety of contexts. Could there be something predictive about the state of mind of the people on the call?

“Our team is always impatient to go faster.” That’s the kind of reassuring language end users love hearing from vendors with a track record of under-delivering or overpromising on features. Not to mention that when you’re caring for people’s loved ones, you typically don’t want your primary tools to be fueled by a spirit of impatience.

Those are immediately attention-getting, but I’d be more interested in the subtle comments that show that something is slightly off or that there might be some level of obfuscation going on. One recent call characterized what clearly looked like a cost-cutting layoff as an effort to speed compliance with new regulatory requirements. With a training database of thousands of vendor earnings call transcripts, I bet you could come up with some very interesting themes and potentially useful indicators.

In the next year or so, I have to start thinking seriously about a performance improvement project so that I can complete it and check the box for renewal of my clinical informatics board certification. Maybe I could build a tool that would better enable the HIStalk team to detect language that would be most predictive of a company that might have juicy things for us to write about, or what their odds might be of winding up on the HISsies ballot. I doubt those applications would be approved by the folks at the American Medical Informatics Association, but they would be entertaining.

If I don’t come up with a project soon, I’m going to have to seriously think about letting my certification lapse. The required projects are actually referred to as “Improvement in Medical Practice” projects, and since I don’t actually practice clinical informatics where I practice clinically, that gets a little dicey. My primary clinical employer doesn’t want the physicians to have anything to do with the EHR – there isn’t even an informatics committee. The COO (who is a practicing physician) calls all the shots on whether we’ll implement new features and how they will be shared with the masses. The likelihood of my being granted any ability to query the data or perform any kind of project is exactly zero.

They do allow a diplomate to substitute a 360-degree evaluation project instead, where they survey a half dozen of their colleagues to find an area that needs improvement, then work on it and survey again. That doesn’t exactly work in the consulting model, where I think my clients might be generally appalled if I asked them to spend resources essentially providing job coaching to someone they’re paying as their expert advisor.

Doing these projects as a way to maintain certification is frustrating regardless of your specialty. During a time when I wasn’t practicing clinically, I had to do a mock “hand hygiene” project where I had to manually enter a downloaded data set and then analyze it. The goal was to simulate the paper surveys that my peers were getting from live patients, but I learned exactly zero sitting there and keying in the data. It’s just another hoop that physicians have to jump through to try to stay certified.

That takes me back to the earnings call transcript project. Maybe if I write it as an abstract with enough sexy buzzwords I can sneak it past the evaluators. Sprinkle in some artificial intelligence, machine learning, and blockchain to get the job done.

If any of you other clinical informaticists out there have creative ideas for what a consulting clinical informaticist can do as a project, I owe you a drink at HIMSS.

For the rest of you: what’s the wackiest thing you’ve ever heard in an earnings call transcript? Leave a comment or email me.

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EPtalk by Dr. Jayne 10/17/19

October 17, 2019 Dr. Jayne 1 Comment

I had occasion recently to talk with a personal liability attorney, fortunately just socially and not professionally. He had some questions for me about the role of artificial intelligence in healthcare. Fortunately, I was able to point him towards a recent editorial in the Journal of the American Medical Association.

The article has a nice summary of the concerns that many in practice have about AI: communicating recommendations without the underlying rationale; poor training data sets used in the development process; and failure to reach an accurate result or recommendation. The JAMA article notes that case law on AI-related liability is lacking, but existing law can be extrapolated to cover these situations.

The authors’ examples support the use of AI as an adjunct to the existing decision-making process in order to prevent additional liability. However, as AI becomes engrained as part of the standard of care, this approach may necessitate more trust in AI systems at the point of care, in order to prevent the physician from making the error of underutilizing technology that could be of benefit. It’s a complicated equation, for sure.

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The VA recently announced planned steps to increase data sharing with non-VA providers using the Veterans Health Information Exchange. They’re going to shift the current opt-in protocol to one where opt-out is the norm, so patients no longer have to provide a written release for the VA to share their data electronically. A quote from the VA in one of the articles I read about it states that community providers and organizations must have partnership agreements and be part of the VA’s trusted network to receive VA health information. I hope they meant to say that you have to be part of the network to receive information electronically, unless the VA isn’t covered by HIPAA, which allows providers to share information for Treatment, Payment, and Operations without a specific release.

The HIE plans to share information including: problem list, allergies, medications, vital signs, immunizations, laboratory reports, discharge summaries, medical history, records of physicals, procedure results such as radiology reports, and progress notes. Veterans who don’t want their data shared can still opt out, but they will have to be either all in or all out – previous mechanisms which allowed some data to be shared but not others will no longer be permitted.

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Speaking of veterans, telehealth middleware provider Medici has launched “Operation 11/11” to provide no-cost virtual consults to all US veterans on Veterans Day, November 11. Proof of military service is required and participants can pre-register for services from 8 a.m. to 8 p.m. in their time zone on November 11.

Medici is welcoming four military advisors for the initiative and has also partnered with 2nd.MD to provide virtual second opinions for veterans with complex patients. Medici has an interesting model where providers pay to be on the platform and set their own rates for virtual visits. I can imagine it might be compelling for independent physicians, but struggle to see how it plays for the majority of physicians who are in employed situations.

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I was intrigued to hear about Black + Decker’s new automated medication management and home health care assistant device, Pria (first covered on HIStalk nearly a year ago). It’s the first foray into healthcare from the people who brought us the Dustbuster. The voice-activated device tracks and schedules up to 28 medication doses along with reminders and timely dispensing. It also allows patients to have access to family members or caregivers using a built-in camera for video calls. It can also enable reminders for drinking water or other key health-related activities. The product is pricey at $600 plus a $10 monthly subscription.

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I recently became aware of a club I have no desire to be a member of: telehealth providers who have licenses in all 50 states. Becoming licensed in a handful of states is enough work, so I can’t imagine wanting to have dozens of applications in process. The CNBC piece profiles a couple of telehealth providers who advocate for the approach as a way to treat patients more effectively particularly patients in underserved areas.

Data from the Federation of State Medical Boards indicates the club is pretty small, with only 14 physicians licensed everywhere as of 2018 data, up from six in 2016. The number will likely be higher for 2020 given the overall growth in telehealth. One interviewee notes the cost of procuring 50 licenses is around $90,000. In addition, there are annual fees to maintain them. If providers ever surrender a license, there’s also a process to explain that in future license renewals in other states, so if you’re going to do it, you had better be ready to maintain it. I’ve found telehealth compensation for physicians to be lower than pay rates in brick-and mortar situations. Unless you have the temperament to conduct, complete, and document visits every couple of minutes, I don’t see a lot of physicians opting for this type of practice.

An interesting potential use of artificial intelligence was detailed this week in The Wall Street Journal: prediction of marital arguments. Engineers and psychologists are using speech patterns, physiological data, and acoustic / linguistic information to detect potential conflict. One described use case is sending a text message to a highly stressed individual, warning them of an imminent conflict so they can take action.

The original 2017 study followed 19 Los Angeles couples and tracked data such as heart rate, perspiration, and activity levels. A phone app prompted them to document hourly reports on their feelings and also recorded speech content, pitch, and frequency in taking a three-minute recording every 12 minutes. Researchers were able to detect conflict with nearly 80% accuracy. The original data was gathered during a one-day period, which is a significant limitation along with the size of the sample.

A more recent investigation by the same researchers looked at 87 couples, using speed of speech and intonation to detect conflict. The research sounds promising. I hope they consider the next logical investigation, which would be parent-teenager interactions. I’m sure that would be a target-rich environment for conflict identification. Or, we could install such systems in healthcare IT conference rooms across the country – certainly there’s some conflict there!

What do you think about AI identification of conflict? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 10/14/19

October 14, 2019 Dr. Jayne 2 Comments

Most of the scribes I work with are either applying to or have been admitted to medical school and are trying to save up money as well as learn about clinical practice. It’s fun to work with them because they’re eager to learn. I enjoy teaching but haven’t been on faculty anywhere in years. Most of them know I have another job besides seeing patients, and are often interested in what I’m working on from a CMIO standpoint. We talk a lot about EHRs and what’s different about using our niche system versus what they will encounter when they go to medical school.

A recent article in the Journal of the American Medical Informatics Association looked at the existing literature to assess the current state of EHR training for medical students and residents. The authors looked specifically at “educational interventions designed to equip medical students or residents with knowledge or skills related to various uses of electronic health records” and to “compare the aims of these initiatives with the prescribed EHR-specific competencies for undergraduate and postgraduate medical education.” There wasn’t a tremendous amount of literature for them to sift through in their analysis – only 11 studies. Of those, seven covered medical students, three included residents, and one included both groups. All of the interventions they identified covered data entry, but none involved manipulating the resulting data at a panel or population level.

They concluded that the documented interventions don’t really prepare students to show mastery in the competencies required to be effective physicians. In thinking through this, I’m not sure how many current physicians have EHR skillsets beyond just data entry. Most of the organizations I work with expressly prohibit their physicians from doing anything remotely involving data analysis or population health work. All of those functions are managed at the group level or health system level rather than by physicians. Although physicians may receive various clinical scorecards, they’re not really accessing or addressing the data on their own. This certainly would be different for independent physicians, although many of my peers in those environments don’t have the knowledge or understanding of how to get at that data, either.

In digging deeper into the study and its methods, I was surprised by how much the different training interventions varied. Some were a brief (one hour) self-directed module that reviewed screenshots of different areas of the EHR; others could be as long as a multi-week simulated EHR curriculum. Most of the included workflows were based on data entry or information retrieval. Other activities included retrieving lab results, looking at medication lists, orders, and billing functions such as E&M coding. The interventions had different ways to assess competency. Some included a pre-test followed by a post-test after the intervention. Only three studies included a control group. Nine of the studies involved changing skills and only two looked at changing attitudes. Other assessment methods included quizzes, surveys, self-reported questionnaires, chart review, and structured practice with standardized patients.

The students and residents did well when they were evaluated using quizzes and surveys, and were satisfied with that approach as well as being able to demonstrate competency. Other studies didn’t show a difference between the intervention group and a control group. One study was able to show that learners receiving the intervention performed better on standardized patient examinations while they were being judged on their ability to complete a structured patient visit. Although standardized patients are an important part of learning (particularly as students and residents learn to perform sensitive examinations) they always made me nervous, since they were fully aware of what I was supposed to be doing and what kind of findings were supposed to be present, and I was being compared not only against my own classmates but the dozens of students who had examined them in previous years.

I was curious as to the specific competencies the authors were including when they identified gaps in training interventions. They expected students, prior to beginning their clinical clerkships (usually in the third year of medical school at the latest) to “be able to describe the components, benefits, and limitations of EHRs; the principles of managing and using aggregated electronic health information, including tenets of electronic documentation as well as differences between unstructured and structured data entry; and articulate standards for recording, communicating, sharing, and classifying electronic health information in the context of a medical team.” They also note students should “be able to identify how systems may generate inaccurate data, discuss how data entry affects direct patient care and healthcare policy, gather relevant data from EHRs, and assess the reliability and quality of these data.”

Again, I’m not sure many practicing physicians would be able to enumerate all of these elements. They may also not have a “working knowledge of health informatics through chart audits and research projects.” On the flip side, maybe if the physicians I work with had received better education around the role of EHRs, they’d be more interested in the idea of clinical informatics as well as what they can do with the vast amount of data they’ve been keying into the EHR over the years. The authors did note that “a significant number of trainees have had exposure to the EHR before their medical training as scribes and that inclusion of these individuals in the studies may have affected the results.”

I’d be curious to hear from those of you who are academic institutions on whether your training programs are incorporating these competencies into the curriculum. My medical school recently began undertaking a complete overhaul of the educational curriculum, so you can bet I’ll be asking about it the next time I run into the new associate dean who has been tasked with that effort. We heard a bit about it at my medical school reunion in the spring, but the main points of her address were around providing clinical exposure to students far earlier than we experienced during our training. The only EHRs available when I was a student involved one that used a green screen terminal to access lab results at the flagship hospital, and one that used a light pen to navigate at the community hospital. The academic center was just beginning to build its own clinical data viewer, whose contents were hit or miss, as I entered my fourth year. Now after a decade of best-of-breed construction, they’re all using Epic.

Do you think your current practicing physicians can demonstrate mastery of the skills the authors evaluated? Leave a comment or email me.

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EPtalk by Dr. Jayne 10/10/19

October 10, 2019 Dr. Jayne 1 Comment

The ONC blog this week featured a discussion on Electronic Prescribing of Controlled Substances (EPCS). Among physicians who prescribe controlled substances, those who use electronic systems to transmit those orders remains relatively low at 32%. Although some states have mandated the use of EPCS, others haven’t forced the issue with providers. EPCS requires multifactor authentication, and the reality for those of us who prescribe relatively few controlled substances is that the amount of work (and additional technology needed) doesn’t outweigh the potential for reducing drug diversion or other bad acts.

When I do recommend controlled substances, our practice has in-house dispensing capabilities that prevent the prescription from being diverted since we fill it right there. On the off chance that a patient wants a paper script, we print it on compliant paper. I’ve issued one paper script in the last two weeks, and it was a situation where the patient didn’t really want the medication but since they had a complicated fracture I was concerned about them going through the weekend without a backup plan for something stronger. I don’t think that script for five tablets of Tylenol with codeine has a high likelihood of contributing to the opioid epidemic. Still, mandates are coming including the SUPPORT Act, which requires that certain drugs covered under Medicare Part D must be prescribed electronically beginning in 2021. Depending on the frustrations generated by the clinician’s EHR, I wonder if some providers might just consider no longer prescribing agents that will require additional technology.

Lots of chatter in the physician lounge about the recent New York Times piece regarding wasteful spending in the US healthcare system. The comments are also a good read, especially those that note that although burdensome and wasteful, if we cleaned up these processes a lot of people would wind up unemployed. The piece actually draws on a special communication published in the Journal of the American Medical Association that estimates that 20 to 25% of US health spending is wasteful. In order to truly eliminate waste, a number of solutions would have to be employed, including following principles of evidence-based medicine, which would reduce unnecessary testing and treatments that unfortunately some patients demand. The estimated $760 billion exceeds our spending on education and the military, which is a shocking number. Evidence-based care would shave $200 billion off of that, and trimming administrative costs could reduce it another $226 billion. Better care coordination could reduce another $205 billion in wasteful spending. Another big chunk of spending is related to fraud and abuse, ringing in between $60 billion and $80 billion each year. Lots of food for thought, for sure.

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I’m not sure what to think about Devoted Health and its decision to offer coverage for Apple Watches for members of its private Medicare plans. Many Apple Watch users drive me crazy, with the constant checking of their watches as messages and information flows through to their wrists. It’s every bit as annoying as having someone in front of you checking their phone instead of paying attention – having a smaller form factor doesn’t excuse the behavior. The Devoted Health program will pay up to $150 towards the cost of the device for its members in a move to stand above other Medicare Advantage plans. The jury is still out on whether wearables truly drive improved health outcomes, so this may end up being little more than a gimmick to try to entice members to join the plan. The $150 earmarked for Apple Watches can also be used for health-related classes and other programs, some of which are actually proven to drive outcomes. Devoted Health has roughly four thousand members but hopes to scale to 100,000 members over the next four years as it expands beyond its Florida footprint.

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The workflow at my practices requires me to perform initial readings on plan radiographs while we wait for an overread. Although I’ve had a fair amount of training, some findings can be subtle and are easily missed unless you maximize the contrast and other enhancements available as you view the images on the screen. Despite my accuracy statistics, I’m always relieved when I see the overread and know that the radiologist agrees. I’m eager to see artificial intelligence applied to radiology at the point of care for rank and file physicians, not just in the intensive care units where a lot of the research is being done. Recently, several radiologist’s organizations released a joint statement warning that increased use of AI in radiology can raise the risk of system errors leading to adverse patient events. They call on regulatory boards to monitor AI systems to ensure patient safety, and also call for development of codes of conduct covering the ethics of AI use and warned against using radiology algorithms for financial gain. I can’t wait to see what diagnostic imaging looks like in a decade – it’s one of the areas with the most promise for delivering high-tech solutions to the bedside.

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As the leaves are falling and summer is way behind us, I’m going to continue to call out CMS and its Primary Care First program. Their promised Request for Application was due “summer 2019” since the first performance year starts on January 1, 2020. It’s a little difficult to gear up for a program when you don’t know if you’ve been accepted or even if you want to apply since you don’t know what the details are. CMS hasn’t even done the courtesy of updating its website, which still says it anticipates a summer release. Come on, folks, either release the app or officially delay the program. Don’t leave people hanging – and acting like a practice could realistically target a January 1 start date just makes you look out of touch.

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Since my favorite smart jewelry company Ringly went dark, I’ve been on the look out for other smart jewelry items. I’m still baffled by Amazon’s Echo Loop smart ring. It’s not fashion forward in the least but belongs to a group of devices that may or may not fill a consumer need along with Echo Frames glasses and Echo Buds earbuds. It’s a bit pricey at $130, but has potential for people who want another way to control their smart devices. Amazon refers to the group of devices as “Day 1 Editions,” which are past the beta stage but haven’t been fully proven for consumer purposes. The company describes them as “things that we’ve found delightful internally and we want to get customer feedback on it so we can continue to innovate.” It only comes in black and is only available in ring sizes nine and up, so not exactly dainty. Interested customers have to request an invitation to try the product.

What do you think of Amazon’s new wearables? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 10/7/19

October 7, 2019 Dr. Jayne 1 Comment

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Normally my issue of Health Data Management goes straight into the recycle bag, since it’s usually a regurgitation of material I’ve already seen or even written about. The fall issue’s headline caught my eye, since “Great Expectations” is one of the novels I had to suffer through several times during my high school and undergraduate years. I’m sure they didn’t intend to evoke Charles Dickens, but maybe they did considering the major characters include a naïve youngster, a convict, and an eccentric who wants everything to be just like it did at a singular time in their youth. That sounds a bit like healthcare IT, especially when you add in the themes of rich versus poor, love versus rejection, and the ongoing struggle of good versus evil.

All literary parallels aside, I’m not sure what kind of expectations I have for what is to come in healthcare IT in the next decade. I think we all have enormous wish lists, but whether those items are brought to fruition or continue to dwell in the world of pipe dreams will remain to be seen. I think about some of the things I dreamed of as a child that currently exist. What if you could have a soundtrack for your daily life, that could play whatever song you were in the mood for? If the iPod and numerous MP3 players were close but not quite, now we have Spotify to satisfy most of our music cravings. What if you could talk to your computer and get information without even typing? Siri, Alexa, and Cortana can continue to duke it out, but I’m happy to be able to see what the weather is like while I’m scrambling around in the morning doing three things at once.

On the other hand, we see an industry that continues to remain somewhat hobbled by regulatory requirements, where many vendors have had to cast aside true innovation in lieu of checking a host of boxes for functionality that their users not only don’t want but find tedious or annoying. It doesn’t matter how good they might be for patient care, if no one uses them it’s a fairly moot point. Unless there’s a carrot or stick involved, organizations and their users aren’t going to just adopt things for the sake of adopting new features. There’s too much else at stake and too many other things that demand (and deserve our attention).

With that in mind, I’m not sure what I think about the upcoming requirements to (finally) institute Medicare’s Appropriate Use Criteria Program, which has been in the wings for years. Health Data Management happened to cover it in the issue that caught my eye, and I have to admit I had kind of forgotten about it, since it’s been coming at us in fits and starts for so long.

Essentially, on January 2, physicians who order advanced imaging tests (such as MRI, CT, and PET scans) for Medicare patients have to consult qualified clinical decision support systems before ordering those tests. The software is supposed to incorporate evidence-based guidelines and Appropriate Use Criteria (AUC) to make sure people aren’t just ordering expensive tests for every little thing, or because patients demand them. Commercial payers have already tackled this issue by requiring prior authorization for these kinds of tests, which Medicare is trying to avoid by instituting the AUC requirement. There are eight conditions that are being targeted, including low back pain and headaches.

The problem with the proposal is that the penalty occurs in the wrong place. If ordering physicians don’t do the right thing, then radiology providers won’t be paid for the test. This puts them in the position of having to make sure their referral base is doing the right thing, with some even offering access to clinical decision support systems for their referring physicians, who might also have that support within their EHRs. The prior authorization requirements used by commercial insurers put the burden squarely where it belongs – on the ordering physician who needs to be ordering tests that are needed and that will provide useful diagnostic information.

The first year of the program is designed to be an educational and testing opportunity for all involved, with the nonpayment penalty being applied starting January 1, 2021. Ultimately, CMS plans to force providers who don’t follow requirements for clinical decision support to seek a prior authorization. With all the work that organizations have put in during the last several years for this requirement (during its on again, off again progression), one could wonder whether it just would have been easier to institute a prior authorization requirement in the first place. Ordering physicians already have those workflows in place in their practices and the lion’s share of work is done by non-provider staff members. Medicare could have been the leader here, standardizing the requirements and drawing commercial payers into line to create a single set of prior authorization rules across all payers. Instead, it has created an additional burden that no one in the process (other than CMS apparently) wants to deal with.

I’ve been in the clinical trenches for a long time, and frankly I can only remember one time a prior authorization was denied for one of my patients. It was a scenario I can only describe as a goat rodeo. The CT scan was ordered urgently, as the patient was in my urgent care with severe abdominal pain and a host of abnormal blood tests. Since no one is sitting at the insurance company at 7pm on a Friday night to handle a prior auth, we proceeded with the test and tried to get the auth retroactively on Monday morning. The reviewer was demanding more information, because in my note I described one of the areas of abdominal tenderness as “mild” rather than using a more serious-sounding word or even omitting a qualifier altogether. It didn’t matter that the patient had guarding and rebound tenderness in another area of the abdomen, which are ominous findings on their own; the reviewer had the word “mild” stuck in her craw.

I had to admit I became rather hot around the collar, and might have asked her if she gave a damn about the fact that the patient had a 6cm tumor in their pancreas that was causing obstruction and mayhem. She certainly hadn’t bothered to look at the test result itself, which more than showed the study was warranted. By the time we were trying to get the prior auth, the patient had already been admitted to the hospital, undergone a number of invasive tests, and was coping with a cancer diagnosis and the high likelihood that he’d never see his children graduate high school. Eventually the reviewer relented and approved the test, but it was silly that we even had to go through the exercise.

Maybe that should be my “great expectation” for the 2020s, that some day physicians who are spot-on with their test ordering won’t have to jump through hoops on behalf of their patients. I don’t have a lot of hope for it, though. What’s your great expectation for healthcare IT in the next decade? Leave a comment or email me.

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EPtalk by Dr. Jayne 10/3/19

October 3, 2019 Dr. Jayne 2 Comments

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Fall is finally here in my part of the world, although areas of the US are still near broiling. October 3 marks the start of the last 90-day EHR reporting period for those of you playing the Promoting Interoperability home game, hospital edition. Those not reporting for a continuous 90 days in the calendar year will receive a downward payment adjustment. Hospitals must also respond in the affirmative for the Prevention of Information Blocking and ONC Direct Review Attestations.

Speaking of reporting, I somehow wound up on an email list for Greenway Health customers. Apparently, there is an issue with the Greenway Patient Portal and settings that allow providers to block sending laboratory data through the portal. Originally designed to keep sensitive information from being sent, if the setting is enabled then the entire site is unable to attest to certain MIPS and Medicaid measures. Providers were advised to adjust their settings prior to October 1 so that they would have data for the 90-day collection period ending December 31. Seems like something that should have been found earlier in the year, and I’m still puzzled how I wound up on their mailing list.

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For anyone who has worked with hospitalized patients, we know how challenging it can be when patients are disoriented or at risk for falls. I was excited to read this case study about virtual sitters in the hospital environment. Mission Hospital in Asheville, NC piloted virtual sitters in its neuroscience unit. They noted a 23% reduction in falls and a 12% reduction in fall-related injuries during the 12-month pilot. Mission Health worked with Cerner to develop the virtual sitter system, using Microsoft Kinect technology to monitor patient movement. The solution included two-way audio, voice recognition, and customizable alerts. Technicians could monitor six patients at a time, and if patient movement occurred, the technician would be alerted to the specific feed. Similar to when an in-person sitter is used, the technician could use voice instructions to try to redirect the patient if needed. If the intervention isn’t successful, the technician can alert nursing staff to intervene in person. Large hospitals can spend millions of dollars on sitters, so this technology has the ability to significantly impact the bottom line.

Despite what the folks at Apple may have us believe, the iPhone isn’t the be-all, end-all of smart phones. I always cringe when a vendor launches a solution that is only available for the iPhone, as if those of us who use Android are some kind of second-class citizens despite Android having a slim majority of market share. I ran across a press release about a non-profit industry group that is working to create an open-source version of the Apple Health tool kit that can be used by Android users. Members of the CommonHealth project team include Cornell Tech, UC San Francisco, Sage Bionetworks, Open mHealth, and The Commons Project. The plans include robust governance to review partners and apps requesting to connect through the platform. UCSF is piloting along with other academic medical centers and health systems. I’d be interested to hear from anyone who is involved in the project.

From Incognito: “Dr. J – You are on to something when you note that switching back and forth between scribes and flying solo is a bit of a thing. I am convinced that EMRs bring a very different and intense kind of cognitive load than the analog world did, even without accounting for all the ‘little things’ that have been added to the physician’s thought process (because now, ‘they’ can). Adding a scribe is really just another piece of that cognitive load, even if it does reduce some bits. Switching back and forth flies in the face of ‘standard work’ in good processes. I’m sure that there are industrial design and psychology/perception experts who can tell us what we are doing to ourselves. They see it in fighter pilots and in air traffic controllers – and in Facebook ads.” Fortunately, I had a scribe all day today so things ran smoothly. Unfortunately, it’s probably the last time I’ll work with him since he’s getting ready to travel to residency interviews. Today’s scribe is a fully qualified physician, trained and licensed in another country. He’s been a delight to work with, even though his employment is a direct result of our broken health system that doesn’t always allow international medical graduates to perform the functions they might otherwise be able to. He plans to complete a residency in internal medicine so he can practice in the US, since he’s a dual national also holding US citizenship.

There was an article in my local paper about the explosive growth of urgent care facilities in the US, and not surprisingly several local physicians wrote scathing editorial letters claiming that urgent care providers are guilty of rampant overprescribing of antibiotics. The same claims are often made of telehealth providers, even though some have better data on others on how well they avoid unnecessary antibiotic prescriptions. It can be difficult to get data out of EHRs to run those types of reports, and even more difficult to try to use technology to limit prescribing, as one reader recently wrote:

“At my facility, we get fairly regular reports on antibiotic stewardship. Oddly enough the EHR is one of the roadblocks for doing what we want and need to do in this area. Tracking antibiotic use requires substantial pharmacist and infectious disease physician time where a well-designed EHR should have easy-to-use canned modules for tracking use as compared to the latest local microbiology profile. More importantly, there is no straightforward/easy way to restrict specific drugs to be ordered only by certain specialists, on certain floors or services, or with co-signatories or approvals by another service. Oddly enough, it seemed easier to implement such restrictions in the pre-EHR era. One issue is that we don’t want to block all direct prescribing of specific antibiotics since we are very mindful of not restricting initiation of a potentially life-saving antibiotic in an emergency situation such as impending sepsis. The issue of drug-specific prescribing restrictions is not just a problem with antibiotics – we have the same issues in trying to restrict rampant prescribing of other costly drugs.”

There’s no perfect system out there that can prevent all imperfect human behavior from happening. I know providers who consistently do sketchy things regardless of the education they receive, and probably the only thing that would block those folks would either be a hard stop in the EHR or a disciplinary action. Even though the organizations I’ve worked for take a dim view of such behaviors, there’s a delicate balance between admitting volumes, revenue generation, and tolerance for those who know where their bread is buttered.

Has your organization figured out how to effectively transform physician prescribing behaviors? Was it high-tech or high-touch? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 9/30/19

September 30, 2019 Dr. Jayne 5 Comments

I recently wrote about Nuance and their efforts to create the exam room of the future, where charting is performed in real time as speech occurs. Several readers reached out with some detailed questions and discussion about the technology, which spurred me to dig a little deeper.

One reader commented about the concept of meaning as it relates to voice recognition technology and the need for systems to use pattern matching to correctly identify the content of the speech. I have a tremendous time getting my phone to recognize the difference between “pictures” and “pitchers” no matter how clearly I try to articulate, and regardless of context. Getting a system to recognize words when you’re actually trying is one thing, and having them accurately identify speech in an exam room conversation that is all over the place is another.

An article in the Journal of the American Medical Informatics Association looked at the difficulty in detecting conversation topics during primary care office visits. They used transcripts of the visits to look at whether machine learning methods could be effective in automating annotation of visits. The authors recognized the complexity of the average primary care office visit, noting:

Patients present multiple issues during an office visit requiring clinicians to divide time and effort during a visit to address competing demands, such as a patient could be concerned about blood pressure, knee pain, and blurry vision in a single appointment. Moreover, visit content does not solely focus on biomedical issues, but also on psychosocial matters, personal habits, mental health, patient-physician relationship, and small talk.

When looking at the content of visits to determine what material was covered, research raters can label each so-called “talk-turn” using codes intended to capture the visit content. This process can take several hours per visit, making it difficult to scale such an analysis. Being able to automate the extraction of these topics could not only help reduce documentation burden, but could also help identify providers who may not be following up on all the clinically relevant parts of the encounter. The authors wanted to build on previous studies that looked at human-labeled interactions and showed that machine learning systems can create annotations of those conversations.

Using 279 primary care office visits, they found that different models performed better at the visit level vs. the topic level, concluding that there needs to be additional study and larger datasets available to achieve performance that would succeed in the real-world exam room. It doesn’t seem as easy to move from the realm of natural language processing generation of discrete data as people might think. I’ve often thought about what it would be like if you could just record an office visit (both audio and video) as documentation. The pain would be in reviewing it later, unless there was a way to transcribe the information or make it searchable. Various vendors have tried to solve this problem, including leveraging Google Glass to do so.

Remember Google Glass, the tech industry’s darling way back in 2013? It’s been hiding in plain sight, as an “Enterprise Edition” that’s being used in a variety of manufacturing and heavy industrial applications as well as in healthcare. A quick scan of the website shows several big-name healthcare organizations on the client roster.

I recently had a chance to catch up with Ian Shakil, founding chairman of Augmedix, whose client roster shares some of the big names listed by Glass. He confirmed that Glass is far from gone, with around 30% of Augmedix customers using it as part of tech-enabled scribing services. The remaining clients use smartphones, which might be worn or on a stand in the exam room. It sounds like patients have gotten over the concerns that many of us initially had with Glass and privacy – he cites a 98% acceptance rate by patients, which is partly accomplished by education by the front desk or clinical staff.

It was interesting to talk to someone knowledgeable about a segment of the healthcare industry that I admit I know little about. Other than some excitement around Glass half a decade ago, and some acquisitions of scribe and transcription services by other vendors in the voice recognition and EHR spaces, I hadn’t seen a lot of coverage. We spend some time talking about the way various solutions tackle the problem, from what can be described as “dictation in disguise” to human scribes to remote scribes to attempts to use voice recognition and virtual assistant technology to create a true AI-powered scribe. Some vendors like Augmedix even offer services across the continuum, depending on where their clients are, from a human virtual scribe all the way to tech-augmented scribes who use a variety of tools to enhance their abilities to document visits.

I was surprised to learn that there is variability in what is done with the recordings of patient visits created during the course of visits. Depending on the vendor and the client, some want the recordings and video destroyed and others want it preserved. It may be used for training, quality assurance activities, or even in the future as a multimedia note or for access by the patient as a reminder of the visit. Given the plaintiff’s attorney whose branch is close to mine on the family tree, I wondered about the use of the video feeds in potential litigation. I’ve pored through enough bulky, EHR-generated medical records to know that it certainly would be easier to watch the movie than to read the book in this case.

I use a human scribe in the exam room about half of the time. Our office fully agrees with industry data that shows that such support leads to better notes, timelier patient care, and reduced clinician burnout. The biggest struggle I have though is going back and forth between having a scribe with me or not having one. When I have that support, everything I say is taken down or acted upon in the exam room before we leave, and I can just close that visit in my mind and move to the next exam room. The scribes watch for lab results or radiology tests to return and make sure I don’t miss going back to take care of a patient who is still pending disposition.

When I work a shift without a scribe, I’m pretty good at the follow up piece, but I sometimes forget to put in my orders or flag patients for discharge. I’m just so used to saying, “We’re going to do a flu swab and get a chest x-ray” and having those orders placed, my brain is on autopilot right past the need to enter them myself. It’s enough of an issue that I usually tell the rest of my clinical team that “I had a scribe yesterday and don’t today, so if you see me missing orders or discharges, just grab me” and they usually laugh, because apparently I’m not the only physician who does it.

Shakil shared a great piece with me that ran in The Lancet a couple of weeks ago, one where the author discusses “Empathy in the age of the electronic medical record.” It’s worth a read for folks who might wonder what physicians who struggle with the EHR are thinking as they try to see patients. I’m interested to hear what readers think on the topic. Where are we, and where are we headed? In the meantime, I’m mentally prepping because tomorrow’s schedule does not include a scribe.

What do you think about virtual scribes, natural language processing, and the exam room of the future? Leave a comment or email me.

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EPtalk by Dr. Jayne 9/26/19

September 26, 2019 Dr. Jayne No Comments

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It’s US National Health IT Week, as promoted by HIMSS. I’m working with several organizations right now and none of them is doing anything to “celebrate” the occasion.

The reality of things is that we’re all exhausted by our health IT endeavors. Back in the early days, and before Meaningful Use gummed up the works, it was exciting to be on the cutting edge (and sometimes bleeding edge) of things. As an early adopter organization, we had some pull with our vendor and could demand improvements in the software. Now that they’re just trying to keep up with federal regulations and satisfy shareholders, there’s no initiative to make the customers happy.

If your organization is actually doing something to mark the occasion, I’d be interested to hear about it.

CMS has updated the Medicare Plan Finder website for the first time in a decade. Medicare beneficiaries can access it on Medicare.gov and use it to compare Medicare Advantage and Medicare Part D plan. The upgrade is supposed to be mobile-friendly with enhanced readability. I asked one of my favorite Medicare beneficiaries to tell me what they think of it and he couldn’t find it, probably because he was looking in Google Play rather than the website. I gave it a peek myself and it was pretty vanilla. Apparently the coverage I’d want costs a pretty penny in today’s dollars, so I better work on my skills for retirement savings. Approximately 10,000 people enroll in Medicare every day, so who knows if there will even be any money left for coverage by the time some of us get there.

Most of us are familiar with the Google influenza tracker that used to be available. Although it has been sunset, it used symptom searches to try to identify flu cases. I was excited to see this article in the Journal of the American Medical Informatics Association that looks at internet search data as a way to predict emergency department volume. The authors looked at whether Google search data can be applied to ED volume forecasting to improve accuracy compared to existing methods. The data was from Boston Children’s Hospital, local public school calendars, National Oceanic and Atmospheric Administration weather data, and Google trends. As they added data sources, the model became more accurate. I wish my facility would get on board with this kind of big data, because right now our staffing model is very, very off.

From CliqBait: “Re: hit man. Definitely a head-turner, if not also a head scratcher.” A former University of Iowa medical student goes to prison for trying to hire hit man. The Gazette details the story of a man who wanted to kill one of the university’s associate deans after he informed the student he could no longer attend. The accused pleaded guilty to a firearms charge, but the murder-for-hire plot increased his prison sentence. Pro tip: Don’t hire people to kill other people, especially when your supposed hit man is an undercover law enforcement agent. And if you do make the mistake of trying to do so, don’t offer illegal machine guns as payment for the deed.

Surprise, surprise: a recent journal article notes that data found in EHR visit notes doesn’t always match the examinations performed by physicians. Reviewers compared real-time observational data to EHR documentation and found that they could only verify the Review of Systems 40% of the time and the physical exam only 50% of the time. Most of the discordant findings were in clinical systems that were less clinically relevant to the patients’ presenting complaints. For example, patients who presented with gastrointestinal or genitourinary issues had a small number (5.4%) of findings in those systems that didn’t match. For the same patients, there were plenty of unsubstantiated ear / nose / throat exams (81.8%). One could surmise this happens because of overly-detailed defaults or copy/paste, but either cause culminates in physicians not proofreading and correcting their own notes. The authors call for additional studies to determine how extensive these findings might be since the physician subjects were residents in training and a small number (180) of patients had their encounters observed. They also encourage payers to remove financial incentives that lead to physicians over-documentation.

New England Journal of Medicine Editor-in-Chief Eric Rubin, MD, PhD is shaking things up by saying that “thought print may not be dead, it might soon need palliative care.” He plans to continue to bring the publication into the current century by making it more interactive with a greater online presence. There’s even talk about relaxing rules regarding authors who post copies of manuscripts on preprint servers, getting information into the hands of other researchers faster than the typical peer-reviewed publication pathway. Times are changing and it’s difficult for traditional media outlets to keep up. Print media continues to struggle. In a neighboring corner of the Midwest, the St. Louis Post-Dispatch just moved out of their historic building in downtown St. Louis. The new tenant: mobile payment technology company Square.

Mr. H mentioned this earlier in the week, but Amazon has moved into the telehealth space with its launch of Amazon Care. According to the public-facing website, the service offers virtual visits, in-person visits at home or office, and “prescriptions delivered to your door.” Services will include both urgent care and preventive scope of practice, including contraception and testing for sexually transmitted infections. Nurses can provide vaccinations and collect laboratory samples at the patient’s location. Eligibility is limited to Amazon employees and their families who are enrolled in an Amazon health insurance plan and who are based in the Seattle area. Employees who are enrolled in Kaiser Permanente plans are ineligible. The service is available Monday through Friday 8 a.m. to 9 p.m. and weekends from 8 a.m. to 6 p.m. Medical services are provided by Oasis Medical Group, which hopefully provides a layer of privacy for employees seeking care. Since this is a pilot program, employees have to request an invitation to participate. It will be interesting to see how this plays out in the coming months.

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Curbside Consult with Dr. Jayne 9/23/19

September 23, 2019 Dr. Jayne 7 Comments

I have a standing date every couple of months to meet up with the physician who replaced me at Big Health System. Usually we do something outdoorsy that allows us to stroll, decompress, and be somewhere other than a conference room, then follow it up with lunch or drinks depending on the time of day we manage to escape.

It’s been challenging to schedule for the last couple of months, with several last-minute cancellations on both sides due to travel and family issues. Today we finally made it happen, and it was a breath of fresh air, both literally and figuratively.

Usually we start with updates on what we’ve been doing the last several months. I tell stories of the wild and wooly world of consulting and all the things I see in the field, some of which you would think were embellished if you didn’t know the players in the industry. He in turn fills me in on the happenings at my old stomping grounds, which are usually pretty run-of-the mill.

They have been going through a major rip-and-replace system conversion that isn’t always pretty, with physicians from different hospitals jockeying for control of various committees and trying to make sure their interests are protected. We typically talk about strategies for trying to get these folks to work collaboratively and to consider the larger picture. I usually have some advice to offer since I’ve done similar work at health systems that are much larger and more complex.

Today, however, he had all the bombshells. There have been some political maneuvers leading to the loss or marginalization of two of the best folks I know in the industry. One was frankly pushed out. The circumstances are complicated, but the backstory involves making a place for the spouse of a highly-recruited subspecialty surgeon, and said spouse happened to want a particular role in the organization that was unfortunately occupied by one of my former colleagues.

Needless to say, a reorganization occurred, the position was eliminated, and the spouse was hired into a new position with a different title and reporting structure, but with the same responsibilities and direct reports. The hospital had to pay a large settlement to avoid a lawsuit. Although the downsized individual landed on their feet, the entire experience was traumatic.

The second situation wasn’t so pretty and involved some C-suite squabbles that left a second former colleague and informaticist employed, but essentially in job purgatory. He was unable to win a showdown between the informatics team and two feuding chief medical officers, and unfortunately became collateral damage. Someone had to take the fall for failing to please either of the CMOs, who were clearly out of line but politically prominent.

The first CMO had a penchant for forcing the informatics team to make every single customization his physicians wanted, going deep into the weeds where he didn’t belong. The second was just overcommitted and never showed up to meetings, then had a fit when his opinions weren’t considered.

The feud between these two was big enough that I had heard about it at a HIMSS chapter meeting, but I was surprised to hear that the clinical informatics director took the fall for their failure to get along, being “reassigned” from the flagship EHR project to another peripheral effort. It sounds like he would have preferred being let go. It’s sad to see someone with so much knowledge and potential becoming a casualty of a turf war.

Unfortunately, these are the stories that are all too common in hospitals and health systems today. Decisions are often made based on squeaky wheels or the perception of a problem without fully understand everything the underlying situation. Certain personalities are coddled based on their admitting habits or how much revenue they bring to the facility, regardless of the path of destruction they leave in their wake. Good teams’ projects languish because they’re not exciting enough or don’t generate enough revenue to get the attention they deserve. People are treated as expendable despite their long-term contributions to the organization.

These are the same reasons I left Big Health System. It saddens me to know that they are still singing the same song, just a different verse. It’s hard to drive past the billboards extolling the virtues of their care when you know what goes on behind the scenes, and what that care costs, not only in a financial sense, but in the unappreciated human efforts needed to make it happen.

Unfortunately, these two scenarios are by no means unique. I see similar situations across the country. When I try to analyze the “why” behind some of this, the only conclusion I can arrive at is that these organizations are being run from a big business perspective and not in line with the ethical and moral considerations that we expect from a not-for-profit organization. It would be one thing if this were a for-profit entity doing this, but I think we expect more charitable behavior from organizations that try to wear their caring nature on their sleeves. At least the for-profit hospital organizations are more overt about what they’re doing and why, rather than trying to hide behind some measure of community benefit.

It was good that we were “getting our zen on” in a beautiful public garden because my blood pressure tends to rise when I hear about people being treated unfairly. My friend plans to try to ride it out at this place since he isn’t terribly far from retirement.

Our conversation turned to the details of his current projects. Asynchronous e-visits are big on the list, although the primary care physicians are irritated that they are being completed by on-call nurse practitioners rather than the PCPs themselves. Patients love the turnaround time (less than an hour), which is significantly less than the time needed to leave a message at the office and get a call back. It’s cash on the barrelhead for the health system, which isn’t billing insurance for the visits and isn’t sharing the revenue with the PCPs. Since the PCPs aren’t likely to be able to turn those visits in less than an hour if they’re seeing patients in the office, and since they’re going to want the revenue if they perform them, neither of us see that paradigm changing.

Information blocking is also on the list. My friend readily admits that the health system is guilty. They won’t play nicely with the other hospitals in town and certainly won’t play nicely with independent physician organizations like my own, so they point the fingers at the EHR vendor and hope for the best.

Another hot topic is antimicrobial stewardship, although I laughed out loud when I learned his team is performing manual chart reviews to look at antibiotic use because they can’t get time allocated with the data analyst team. I was fighting that same situation before I left, but refused to perform the manual reviews because I didn’t have enough personnel to do it. Maybe it does make sense to pay nurse informaticists to painstakingly perform these reviews rather than having an analyst spend an hour a month running queries and pulling the data, at least as far as what the current leadership thinks.

It was good to get together and even better to spend an hour in a beautiful place contemplating the ornamental carp and the rock gardens. Given the time pressures we encounter during our work lives, you have to force yourself to carve out that time if you want it. We can each only do so much individually to combat the sheer madness we experience on a daily basis, but maybe if we stick together and support each other, or at least listen, we can make a difference.

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EPtalk by Dr. Jayne 9/19/19

September 19, 2019 Dr. Jayne No Comments

Patient engagement is a hot topic in US healthcare, so I’m always interested to see how it plays out in other countries. A recent effort looked at the challenges of treating tuberculosis, specifically in ensuring that patients take their medications consistently during the six months needed to eradicate the disease. Patients in Nairobi, Kenya were enrolled in a program that delivered repetitive cellphone texts to encourage patients to take their medications. Those who participated had fewer negative outcomes compared to the control group. The texts ask patients to actively confirm that they have taken their medications. Those who responded were thanked and informed of their standings compared to other patients, including whether they made it to the “winners circle” for those with 90% adherence. Non-responsive patients receive additional texts, phone calls, and potentially in-person case tracking.

Stanford Medicine has launched a digital consult service to assist in diagnosis of challenging patient cases. They parallel the offering on the “curbside consult,” where physicians ask their colleagues about a case, hoping to draw from experience and past patients. The Clinical Informatics Consult solution has been in the works for more than a decade, and is currently live as a research project that can query data from millions of patients. Clinicians submit a clinical query and receive a report with summaries of similar patients in Stanford’s clinical data warehouse, including how they were treated and what outcomes resulted. The team has responded to over 150 consult requests from Stanford physicians. Developers hope that other academic hospitals may be able to use similar technology to help their own physicians.

I was recently asked to provide a reference for a former employee. The process was conducted using an online portal called SkillSurvey. The company claims to provide a data-driven hiring approach to assist employers in identifying job-related competencies along with soft skills. According to their data, 85% of references typically complete the company’s online survey and most do so within two days. Employers receive a report that claims to be predictive of a candidate’s chances for a successful first year on the job. The data shows how a candidate ranked across multiple references which sure sounds like more fun than trying to compare screening notes from HR staffers that don’t completely hit the mark, as I frequently experienced in a past life.

They didn’t go into the detail of how a potential employee likes to do their work, which I think would also provide useful data points prior to hiring. I recently had to have a “counseling” opportunity with an employee who thinks that trying to do the majority of your work on a smart phone is a good idea. Consultants are always busy, but they need to figure out what you can get away with doing on a small-format device and what requires you to just park yourself in front of a laptop or desktop. The biggest issues I tend to see with phone-related work behaviors are these: failing to see all of the recipients on an email before replying to all (especially when the reply is inappropriate for the entire audience); failure to see email attachments; difficulty adequately managing the calendar because of limited screen real estate; increased typos; and failure to read the entire email before responding, leading to comments that waste other people’s time. I’m all about being able to be mobile, but sometimes you just need to do your work on a big screen and with a keyboard.

A colleague of mine keeps trying to recruit me to the Medici platform, which offers everything from secure physician-patient communication and referral routing to billable audio/video consultations and ePrescribe services. Their marketing is straightforward, listing three simple steps to allow you to “get paid for texting with your patients.” Many physicians might not understand the nuances of what it means to begin using a service like theirs, particularly with regards to how those patient-physician communications get documented in the patient chart (or perhaps not) and whether the auto-translation features it offers are accurate. The company also offers texting with other professionals, such as veterinarians. The Austin-based startup has raised $46 million and has used analogies to identify themselves alternately as the Uber of healthcare or the WhatsApp of healthcare. I’m not sure of the origin of their name, but of course it reminds me of the Medici family, who schemed their way through Tuscany in the 15th and 16th centuries.

Speaking of telehealth apps, Planned Parenthood has entered the telemedicine space with the launch of their new app, Planned Parenthood Direct. It offers birth control options, including contraceptive pills, patches, and rings, along with treatment for urinary tract infections. The app is live in 27 states and the District of Columbia, with plans to expand to all 50 states by next year. It also allows patients to book in-office appointments for other contraceptive services such as IUDs, implants, and injections.

I recently encountered a situation where an elderly family member was receiving unneeded screening tests on the recommendation of their physicians. Knowing the physicians in question, I had a couple of suspicions. The first physician is part of a large medical group owned by a hospital system that sees itself as a major player in value-based care, and I wondered whether it was easier for him to just order screenings rather than exclude the patient in their crazily complicated EHR. The second is an independent physician who was ordering tests that would mostly lead for profit for his practice, which was particularly disturbing because the tests in question are invasive. A recent article in the Journal of the American Medical Association adds another scenario, which is the possibility that physicians don’t want to stop ordering screening tests because it will make them seem like they’re giving up on their patients. The decision to provide less care for older patients is a difficult one, and I hope more physicians, patients, and families are up to the task given the size of our aging population.

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Sometimes companies don’t have the wherewithal to perform the difficult tasks that need to be done within an organization, so they bring in consultants. I’ve been on both sides as companies use consultants to downsize unwanted employees or deliver other reorganization strategies. It’s unsavory and has even been the stuff of movies such as “Up In the Air” with George Clooney. Having been party to horrific termination meetings in the past, I really enjoyed this piece about a New Zealand employee bringing an emotional support clown to his own firing. The clown mimed crying as the employee was fired and created balloon animals, even though they were a bit noisy. Kudos to the employee for having a sense of humor and being willing to spend $200 to give his former employer something to talk about.

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Curbside Consult with Dr. Jayne 9/16/19

September 16, 2019 Dr. Jayne 1 Comment

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This week was one of those where I question my life decisions, particularly the one where I chose to spend my clinical time in the emergency department.

Due to a perfect storm of maternity leaves, provider illness, and other factors, I ended up working entirely too many shifts in a row, which always leaves me feeling a little overwhelmed. Twelve-hour shifts are never only 12 hours, and once you get home, scare up some dinner, and deal with any urgent home issues, it’s time to hit the sack and get ready to do it again.

The mix of patients I saw this week says a lot about what is going on with our healthcare system (or lack thereof). There were too many patients who had put off care due to fear of excessive costs or high deductibles, which unfortunately led to even higher costs due to complications. Quite a few patients tried to receive care from their primary physicians, but were stymied by lack of available appointments (and sometimes by lack of someone even calling them back). There were also far too many patients who didn’t need to be there, those who hadn’t even tried a shred of self-care before deciding to come in.

As a clinical informaticist, times like these always make me think of whether there are viable technology solutions we could bring to bear on the problem. There are a host of solutions that can help, and some of them are already being employed across the country – patient portals, virtual visits, after-hours nurse coverage, remote patient monitoring, medical advice apps, and more. Sometimes these solutions do more harm than good, such as when test results are released to anxious patients before their physicians have contacted them regarding the results.

I cared for one of these patients this week. She received results through the patient portal on a Friday night and was unable to reach her physician. The results included an abnormal imaging study and some vague radiology references to “clinical correlation needed.” The patient, who already had a diagnosis of anxiety, began to have panic attacks after consulting Dr. Google, and those panic attacks manifested as chest pain. Since she had risk factors, we were obliged to work her up with an EKG and cardiac enzyme testing. Many hundreds of dollars later, she was sent home with a better explanation of her results and a recommendation to follow up on Monday with her primary physician.

Some hospital systems embargo their results until the ordering physician has contacted the patients, while others auto-release results after a predetermined delay. This particular facility releases its results on a delay, but apparently the ordering physician was much delayed in his discussion with the patient, leading to the situation.

Although technology can help the provider streamline his or her inbox and make more time for handling results such as these (as can delegation, improved office workflows, and more), there aren’t too many other tech solutions to this problem. It all boils down to capacity – whether the provider is able to care for patients in the manner in which they want to be cared for, on a timeline that is acceptable to them. The patient empowerment movement has shown us that what is acceptable to one patient isn’t always acceptable to others, and that we need to learn to meet patients where they are at if we want to deliver care that works for them. This is challenging for providers and organizations that weren’t trained this way and whose behaviors aren’t incented in this regard.

Despite all of our talking about value-based care, there are still too few organizations practicing what they preach. Patients also don’t always understand how to operate in these systems.

I had several community physicians yell at me recently because their patients were in my ED. These physicians, who are part of a notoriously controlling hospital physician group, were upset that their patients were in the “wrong” facility. I certainly didn’t go out and drag them in off the street, but I was on the receiving end of rants that were largely triggered by the fact that the whole system is broken. Now those patients are going to show up on some leakage report, and there will be many hours spent trying to build systems to try to make sure they go to the “right” facility next time.

Of course, my facility is part of the problem. Since our state has a weak HIE and there’s no easy way for me to access the patients’ records, I likely ordered unnecessary testing, which just further stresses the system. One of the docs suggested I just use the patient’s phone to parse through the patient chart, but that’s not a realistic solution either in a busy ED where it’s easier to just re-run the labs. I hate being part of the problem, but sometimes you have to choose the least of the evils in front of you.

There are so many cool tech solutions out there that I can’t keep up with them all – chatbots that help community health centers better communicate with their patients, apps to support chronic care management, telehealth platforms, virtual care, and more – but we’re still lacking in basic interoperability. We don’t even have a universal patient identifier to tie records to, even if we could tie them all together. What if each patient had a universal identifier card and we could query a master database for the patient’s record when they came in?

Some of the patients I saw during my recent experience with global healthcare described systems like that from their home countries. Our culture is different in the US, though, and it feels like patients wouldn’t be willing to accept something like that due to risks of privacy or having the government have their data. The reality is that a lot of our data is already out there anyway.

If you asked physicians and healthcare providers whether they would be willing to give up some level of privacy for the sake of better medical accuracy or a more complete record, I wonder what they would say? I certainly would, especially knowing the pitfalls of having inaccurate or missing data and knowing how much it costs to repeat studies that are already documented somewhere but just aren’t accessible at the time they are needed. Even when I can track down results, they’re almost always faxed to our front desk rather than being consumable within the electronic chart.

Since my state isn’t exactly a hotbed of data sharing, I’m curious how others operate in this environment or whether the grass is really greener on the other side of the fence.

Do you have a complete picture of your patients’ health? What would it take to make that happen? Leave a comment or email me.

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EPtalk by Dr. Jayne 9/12/19

September 12, 2019 Dr. Jayne 3 Comments

My attorney friends are always asking me about the sheer volume of information in medical records that they see for personal injury cases. It’s staggering – what used to be a manila folder full of records now might be a copy paper box when printed.

Many of the notes incorporate (or simply regurgitate) other data, which just adds to the overall length – whether it’s a copy-and-paste situation or whether it’s embedding diagnostic results such as CT scans or laboratories. Either way, it’s difficult to sift through the information.

So-called “note bloat” is a problem, and some EHRs are better than others as far as helping providers visualize key patient information. It’s not surprising that the EHR is cited in medical malpractice suits. EHR-related claims have increased from 0.35% in 2010 to 1.29% in 2018. EHR adoption has jumped from 15% to 90% across that same time period.

According to recent data from The Doctors Company, this trend continues. Issues frequently cited include system design and usability problems, which are typically cited as contributing factors to a claim rather than as a primary cause. Issues around alerts were cited in 7% of claims, while fragmented records were cited in 6%. User-related issues are an issue, from problems with copy/paste to entering incorrect information.

The Doctors Company, a medical liability insurance carrier, offers some tips for avoiding EHR-related claims: avoid copy/paste except with past medical history; contact IT if data is being inappropriately auto-populated; review entries selected from drop-down menus; and review information thoroughly before treating patients. The latter is easier said than done.

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I’m always interested in new apps, so was excited to hear about Foodvisor, which claims to use photo recognition and AI algorithms to identify the food on your plate and offer personalized coaching around your eating habits. Many of my patients who have tried to use food journals get frustrated with the tracking part, even using an app which they often find tedious. If the photos can accurately be translated to discrete data, this would be a leap forward for patients who have been unable to track their eating habits.

Patients can also use the app to track their activities, either keying them in or by syncing them from the IOS Health app. (I guess Android users are out of luck in that regard.) The company launched in 2018 in France and this month in the US after the system learned how to recognize foods that are popular here. I like their avocado mascot and am looking forward to seeing how they do in the marketplace.

Perhaps the app might be of use to medical students, whose rates of hypertension are more than twice that of the general public, according to a recent presentation at the American Heart Association’s Hypertension 2019 Scientific Sessions. The student rate of Stage 2 hypertension was 18%, compared to 8% for comparable members of the general public. The study looked at over 200 first- and second-year students at the DeBusk College of Osteopathic Medicine. Participants completed a survey on tobacco, alcohol, diet, exercise, mental health, social support, and past medical history. The real surprise was that only 36% of students had normal blood pressures – the rest were either elevated, Stage 1, or Stage 2.

They might also want to take advantage of recent data from the journal Heart was published last month and indicated that daytime naps may be linked to a lower risk of heart attack or stroke. Researchers looked at 3,500 people living in Switzerland and found that those napping once or twice a week were better off than those not napping at all. Participants ranged in age from 35 to 75 years and were healthy prior to the five-year study. The study was observational, meaning it doesn’t show cause and effect; but I’m certainly going to take those results to heart.

Each year in September, EHR/PM vendors and clients scramble to make sure they have updated CPT codes since the new codes typically go into effect on October 1. This year’s 248 new codes include six for online services, three for physicians and other qualified professionals and three for communications with non-physicians. Two additional codes cover self-reported blood pressure monitoring. Just because the codes exist is no guarantee that they’ll actually be paid for if used, so providers should check their payer contracts to see how new codes are handled before they get too excited. There are also 71 codes being retired and 75 being revised.

Providers typically look to their specialty societies for information on how they’ll be impacted by the changes. They also look to their IT teams to make sure the codes are loaded and mapped appropriately anywhere they might be embedded within technology, so good luck to those of you responsible for the changes.

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HIMSS launched registration this week for the flagship annual conference, with the coming year’s theme of “Be the change.” There’s also apparently a rebranding effort going on, with insiders being excited by their kicky new font and expanded color palette. I guess they’ll have to commission a new set of giant letters to adorn the grassy slope outside the Orange County Convention Center. The conference itself even got a rename – it’s now the HIMSS Global Health Conference & Exhibition. According to the marketing staffer who gave me the scoop, this complements their new vision and mission of being focused on the health and wellness ecosystem. The good news is that no one really used the full name of the conference anyway, so the rest of us can still call it HIMSS20 and be good. I booked my hotel a few months ago to make sure it was affordable so now I just have to book the flight.

Speaking of HIMSS, they’re hosting their annual US National Health IT Week event later this month. Its theme of “Supporting Healthy Communities” is designed to promote transformational activities to drive better health outcomes and health equity. Points of engagement include public health, population health, workforce development, expanding access to broadband and telehealth, and addressing social determinants of health. Several governors are expected to issue proclamations in recognition of the event, but it doesn’t look like there’s much going on in my neck of the woods.

How to you plan to celebrate Health IT Week? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 9/9/19

September 9, 2019 Dr. Jayne 4 Comments

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Lots of companies are talking about gamification as it relates to patient engagement and management of chronic conditions, but I never thought I would see an app designed to gamify strategies to reduce physician burnout.

The folks at the American Medical Association have released an app that tries to make a game of dealing with this serious issue. Titled “HealthBytes,” the app is designed to teach strategies to help physicians optimize their practice’s operations in an attempt to reduce physician burnout. The app can be played on a PC or smartphone. The AMA states “no matter how many times you play the game, you are bound to learn something new each time.” I’m not sure what kind of research they did to drive the creation of this game, but in my experience the last thing that burned out physicians want to do is experience anything office related if they don’t have to.

The AMA admits there is a time pressure element to the “Practice Master” game within the app. Players have four minutes to play through a physician scenario, including meeting the team, designing “my dream team,” optimizing documentation, conducting a patient visit, and creating a well-being plan for the physician and the team. Following that exercise, providers can share their score, play again, or consult AMA content designed to “offer innovative strategies to allow physicians and their staff to thrive in the new health care environment.”

After finishing my recent read of “Code Blue” by Mike Magee, which names the AMA as one of the principals behind the dysfunction of the US health care system, I find it only mildly amusing (but significantly distasteful) that they’re positioning themselves as experts ready to help solve the problem. One of my colleagues refers to the AMA (along with payer executives and federal regulators) as part of the Medical Axis of Evil.

The AMA is trying to be all over the issue of burnout, including offering the trademarked “American Conference on Physician Health” that will be held September 19-21 in Charlotte, NC. The organization is co-hosting with Stanford Medicine’s WellMD Center and the Mayo Clinic Department of Medicine Program on Physician Well-Being. The conference website lists of statement of need that “Physicians’ professional wellness is increasingly recognized as being critically important to the delivery of high quality health care.” It also notes that the meeting “is designed to inspire organizations throughout the country to seek ways to bring back the joy in medicine and achieve professional fulfillment for all our physicians.”

The sheer fact that presentations will include more than 70 wellness projects and programs illustrates the significance of the issue of burnout. I was surprised to see that the two-day conference costs $825 for AMA members ($925 for non-members), with a whopping $25 discount given to presenters who only have to pony up $800 to attend.

AMA is also offering a practice transformation boot camp immediately prior to the conference, at the bargain price of $279 for the day (although you do get a $100 discount if you register for both). Tack on an additional $214 per night for hotel accommodations plus meals and travel. Frankly, if I was going to spend that kind of money, I’d be heading to the beach since that is my proven strategy for improving my own physician well-being. I noted on the website that AMA recently extended the registration and now it closes a mere nine days before the conference, perhaps an indicator of what potential attendees think of the conference.

I frequently read articles about burnout, physician wellness, resilience, etc. and they often portray clinicians in the trenches (not just physicians – it’s all of us) as somehow being lacking, therefore we are subject to burnout. If we could just be more resilient, if we could just explore mindfulness, if we could just tweak every fiber of our practice’s operations, we would be OK. If we could just embrace the therapy dogs, take a walk in a grassy meadow at lunch time, or build the ideal care team, we’d be able to dodge the flaming arrows we encounter on a daily basis.

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In the spirit of fairness, I gave the game a try. I found it simplistic and revealing only of the information that most of us already know. I made the leaderboard on the first try even despite being penalized for answers that were situationally correct but not what the game was looking for. It suggested hiring a scribe, which it refers to as a CDA (clinical documentation assistant – always great to add more acronyms), along with getting the IT team to restructure my EHR inbox. Good luck with that latter suggestion in a large health system environment where any changes to the EHR require the approval of three committees, a resource analysis, and endorsement by the person behind the curtain.

I admit I played it at work with the sound turned off, so maybe I missed out on some kicky soundtrack that might have made it more enjoyable, but mostly it just made me more aggravated than I already was about the situation.

An increasing body of research and commentary is describing “burnout” as the wrong word for the situation. Instead, they’re labeling this phenomenon as moral injury, the damage that occurs to an individual’s moral conscience as a result to the trauma we face in practicing medicine. The original definition of moral injury as coined by professor Jonathan Shay included three components: 1) when there has been a betrayal of what is morally right; 2) by someone who holds legitimate authority; and 3) in a high-stakes situation.

Although other definitions have evolved, I think this still holds for a large number of situations that healthcare providers face daily. One more recent definition from Brett Litz and colleagues describes that “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long term, emotionally, psychologically, behaviorally, spiritually, and socially.”

Tweaking the process for the office’s morning huddle isn’t going to do much to address the more deep-seated issues at play here. It is insulting for the AMA to put this in front of its physician constituents.

People often ask me how I cope with the craziness of healthcare, especially when you add the craziness of information technology on top of it. On some days, the answer is “barely.” Fortunately, I have a support system with friends and colleagues who understand what it’s like to work in this environment. I try not to take it too seriously and have modified my clinical career to one that is healthy for me. Being in traditional primary care was not, but providing episodic care is better. Doing clinical informatics work helps me feel like I’m doing something to help my fellow clinicians, regardless of the muck in which we operate on a daily basis. I also spend quality time on my treadmill watching utterly mindless shows on Netflix and there’s a smattering of time leftover for music, as well as my arts and crafts hobby. It’s a lot of work to stay sane in this environment.

What do you think of the response of the AMA and other professional organizations to the problem of burnout in healthcare? What would be a better answer? Leave a comment or email me.

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EPtalk by Dr. Jayne 9/5/19

September 5, 2019 Dr. Jayne No Comments

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Telehealth technology in the news: Mayo Clinic has rolled out a cancer tele-rehab program, resulting in quality of life improvements for participants. The outcomes studied included pain and daily function, which were linked to reduced hospital length of stay as well as reduced need for post-acute care.

The technology used wasn’t strictly in line with what many of us consider telehealth. The 516 participating patients were assigned to either a control group that reported symptoms by phone or web-based survey, an intervention group that also received phone calls from care managers providing instruction on walking and exercise; and a second intervention group with the same interventions plus the addition of medication-based pain management. The number of hospital admissions was comparable, but the length of stay for the first intervention group was four days shorter than the control group. The second intervention group’s length of stay was about two days shorter. Researchers note that cancer pain is often undertreated and impacts the functional status of patients, so engaging with rehab services can lead to better outcomes.

More than a decade ago, I did some HIE work that we thought was pretty cutting edge, but now doesn’t even begin to scratch the surface for interoperability. Being able to access a patient’s full and complete medical information, whether provided by the patient or obtained from other sources, is the equivalent of the holy grail for some physicians. Having been in the clinical trenches for a fair amount of time, though, I wasn’t surprised by the statistics that nearly half of US patients are omitting significant pieces of their histories provided to their care teams.

Data noted in a recent survey of over 4,500 patients included issues such as domestic violence, sexual assault, depression, and suicidal thoughts. Patients are often uncomfortable addressing these issues with providers, especially during relatively brief medical encounters. They may feel they will be judged or lectured. The rate of information withholding is higher among women and younger patients. If the patient isn’t ready to share that kind of information, it’s unlikely to be available from other sources, but I hope that our efforts with patient engagement and empowerment will ultimately lead to patients who feel comfortable sharing information that will help us be better partners for health.

Flu season is nearly upon us, with recommendations to try to vaccinate all patients six months and up before the end of October. As the flu season becomes nearly year-round, the opportunities continue for patients (and staff) to contract the illness.

I once worked with a practice that did not provide employees any sick days and punished them for calling out sick. Their mantra was, “If you’re going to be sick, you might as well be paid for it.” It’s shocking to hear from a healthcare organization, so I was interested to see a recent study that looked at healthcare workers that continued to deliver care while suffering from acute respiratory illnesses. The authors looked at multiple flu seasons in nine Canadian hospitals from 2010 to 2014. At least 50% of participants reported at least one acute respiratory illness, and nearly 95% of workers reported working at least one day while they had symptoms. The relative risk of working while ill was greater for physicians and lower for nurses.

Study subjects were more likely to work with less-severe symptoms and were more likely to work on the first day of illness rather than as it progressed. Most people working while sick felt their symptoms were mild and 67% felt “well enough to work.” Not surprisingly, those without paid sick leave were more likely to state they could not afford to stay home. The authors conclude that “further data are needed to understand how best to balance the costs and risks of absenteeism versus those associated with working while ill.”

In related news, a recent study concludes that the N95 respirator is no better than a standard medical mask at preventing transmission of influenza to healthcare providers. That’s good news. Anyone who has ever had to wear the N95 knows it’s not much fun, not to mention the need for some people to shave beards to get it to fit correctly.

A related editorial notes that although the study was designed to address limitations of previous studies, the current study was somewhat underpowered and might be impacted by under-reporting of symptoms and delays in specimen collection. It also didn’t address the inpatient setting. It did, however, mimic conditions that are typically seen, including providers who may or may not wear the masks they are supposed to, or who may not wear them correctly. This makes the findings more generalizable.

Our flu vaccines are scheduled to arrive today. Personally, I can’t wait to roll up my sleeve since one of my colleagues has already been diagnosed with influenza.

I missed out on the groovy time that was the Epic User Group Meeting, but was intrigued to hear the announcement that they’re pulling together records of more than 20 million patients for medical research. As Mr. H noted, they’ve made this announcement before, so the real news is that clients are actually signed up. Cosmos is designed to gather de-identified data from Epic customers and make it available for evidence-based medicine research.

I’m sure it was a splashy announcement at the annual UGM gathering, but I question the ability for that data to be truly de-identified and how clean it is. Nine organizations have contributed more than 7 million patient records, with 30 additional customers being in discussions with the company. Participating hospitals and health systems agree to ensure data contributed is standardized enough to support research. Epic plans to dedicate resources to do terminology mapping to allow the platform to work.

The data won’t be available to researchers until there are at least 20 million patients in the data set and already people are salivating at the possibility of using it for rare diseases or difficult-to-treat conditions. Researchers will use existing Epic applications to work with the data, along with potential new applications.

There are certainly privacy concerns at play here, even with de-identified data. We’ve all seen how easy it is to re-identify that information. It’s unclear whether patients intended their data to travel far and wide and whether existing consents cover this kind of an aggregation.

I’ve seen half a dozen Epic builds over the years and frankly the lift needed to standardize some of the data might be the limiting factor. My own Epic patient charts are chock full of errors that I don’t have the time or energy to try to correct, so good luck to those who think this is going to be the answer to all kinds of research problems. There’s also the issue of data that lives in Epic that was converted from legacy EHRs, which after being converted and normalized, might not even resemble the original clinical intent.

I’d be interested to hear from anyone who has been involved in this project or who is closer to the details. What did you think of the announcement at UGM? Is it just one more shiny object for organizations to follow, or is it really a game changer? Leave a comment or email me.

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EPtalk by Dr. Jayne 8/29/19

August 29, 2019 Dr. Jayne 2 Comments

There has been quite a bit of discussion in the physician lounge about recent articles looking at health outcomes and social spending in the US compared to other comparable countries. The authors used data from the Organization for Economic Cooperation and Development spanning 1980 to 2015 and compared relative spending on social services and healthcare.

Countries in the dataset included Australia, Canada, Denmark, France, Germany, Japan, the Netherlands, Sweden, Switzerland, and the UK. They found that non-US countries spent an average of 8.8% of their gross domestic product (GDP) on healthcare, but the US spent 16.8%. In comparison, the US spent 16.1% of GDP on social services compared to 17% in other countries. When education was included in social spending, the US spent 19.7% of GDP compared to other countries’ 17.7%. The authors also found that in the US, a greater portion of spending occurs for the elderly.

The findings contradict the belief that the US spends so much more on healthcare because it doesn’t spend enough on social services. Previous analyses found that US healthcare spending is greater due to labor, pharmaceutical, and administrative costs, which shouldn’t be a surprise to anyone who works in the industry.

Several of my colleagues who are department chairs were also in a heated discussion about CMS star ratings on the Hospital Compare. CMS recently announced that updates to the methodology behind the ratings will be delayed until 2021, although CMS will continue to publish the ratings. Many hospital organizations are asking for the ratings to be removed or suspended until the updates are implemented.

Although the ratings are better than having no information at all, they’re difficult for patients to use when making decisions. For example, my local academic medical center has a lower rating than the closest community hospital, but if I needed anything more complex than removing my gallbladder or appendix, I’d be headed straight to the lower-rated facility.

CMS received 800 comments within 145 letters from various organizations, many stating that they feel the ratings are overly vague, they are too complex, and they oversimplify quality measurement. Submissions asked for greater precision in the ratings along with improved apples-to-apples comparisons. CMS will use the comments to develop the proposed rule for release in 2020, so the current methodology remains in place. A public listening session will be held on September 19 to further discuss the ratings and proposed changes.

Direct Primary Care was also a hot topic, with one physician noting he’d like to make the jump “to get out from under the corporate overlords.” The DPC movement might get a boost if The Primary Care Enhancement Act of 2019 (HR 3708) becomes law. The Act would update the US tax code to allow patients with health savings accounts (HSAs) to use those funds for DPC payments. Currently, DPC payments are treated as insurance premiums, so patients trying to use HSA funds incur a tax penalty. The number of primary care physicians considering a move to a more direct model is on the rise. A previous bill failed to pass in 2017.

Paladina Health and SSM Health are forming a direct primary care joint venture in St. Louis. There are many different DPC models, and this one is of the direct-to-employer variety. Employers will pay a flat fee to cover physician services, including office visits, some medications, and labs. I have a friend who works for Paladina Health and he enjoys seeing fewer than a dozen patients a day ,with office visits that are long enough to actually tackle patient problems and discuss non-pharmaceutical interventions like diet and exercise. He’s skeptical about the joint venture with SSM because one of the draws for him to work for Paladina Health was getting away from being employed by a hospital system. SSM Health plans to offer direct primary care to its own employees who are covered under its health plan.

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The American Medical Informatics Association announced the keynote speakers for its annual symposium in November. CMS Administrator Seema Verma will keynote on Sunday, November 17, and patient advocate Peter Kapitein will speak on Wednesday, November 20. Kapitein hails from the Netherlands, and the part of his bio that caught my attention was his role in founding a fundraising bicycle ride up the Alpe d’Huez, one of the grueling highlights of the Tour de France. His bio also notes that his employer (the Dutch central bank) “facilitates him to work three days a week for the victory over cancer.” I can’t wait to hear more in person.

The Electronic Health Record Association (EHRA) has given its support for the new NCPDP SCRIPT version 201701 standard for electronic prior authorization (ePA) of prescription drugs under Medicare Part D. However, it did note some concerns around the deadline for implementation, recommending a full 24 months for implementation once the final rule is published. The standard is designed to allow pharmacies to communicate with practices using expanded electronic transactions, reducing the number of phone calls needed to complete prior authorizations. EHR and pharmacy vendors have to create updates and their clients will need to modify their systems, so it’s not a small undertaking. The current proposal requires implementation on January 1, 2020 and the new version of the SCRIPT standard isn’t fully backwards compatible, which could cause issues. EHRA is also recommended an update to HIPAA to reference the new standards since some individual states may be pursuing their own.

Individual state standards would be just about the worst thing we could interject into anything involving healthcare IT and especially interoperability. Clinicians practicing in cities close to state borders might be caught in the crossfire like they currently are with requirements for paper prescriptions, resulting in multiple workflows which doesn’t really help efficiency.

In my past life, we had to maintain multiple different paper prescription formats along with custom code to ensure the correct version was printed based on the patient’s pharmacy of record rather than the location of the practice. Our EHR vendor only supported script generation based on the latter, and contentious pharmacists across the state line refused to honor our prescriptions. In my current practice I have to deal with different local rules regarding controlled substances (you can purchase pseudoephedrine on one side of the street without a prescription, but must have a paper script on the other) and it’s a pain. It’s also probably one of the reason we dispense a lot of the drug from our in-house pharmacy, so patients just don’t have to mess with it.

I’ve also run into the differences in state standards in my recent foray into telehealth, dealing with different standards on reportable conditions ranging from sexually transmitted infections to dog and cat bites. For the latter two, most states require physician reporting, but the mechanism varies dramatically. In my home county, I can report via email, while in a neighboring county it has to be a phone call, and across the state line it has to be a faxed form. Thank goodness for Google, which helps me track it all down as the need arises.

What do you think about individual state standards for healthcare IT? Leave a comment or email me.

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Email Dr. Jayne.

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