EPtalk by Dr. Jayne 1/20/22

I’m getting ready for HIMSS in earnest, beginning to schedule meetings and the much-anticipated booth crawls with some of my BFFs. It’s always good to have a support team to help you spot eye-catching products, interesting giveaways, and of course the finest footwear.

Several people have asked me what I think will happen with exhibitors and whether people will drop out. At this point, I think I have as good a chance of predicting that as my old-school Magic 8-Ball. In looking at the vendor-side organizations I’ve had involvement with over the last couple of years, the breakdown is 10% not attending, 25% going stealth (will not have a booth but will attend the show and have private meetings), 15% exhibiting but might cancel or send a smaller team, and 50% forging ahead business as usual.

One of the things I’m most looking forward to is seeing people in person who I haven’t seen since HIMSS19. Although I attended virtually in 2020, that experience paled in comparison to the past. Friends humored me with lots of after-hours pictures and shenanigans, but I’ll be glad to be part of the adventure again.

Of course, that assumes that we don’t have another variant of concern pop up between now and then. It’s hard to believe we had no idea that omicron was going to be such a nightmare a couple of months ago. Here’s to hoping that given all the people who have been infected, the immunity it provides will be at least somewhat durable. It’s likely we won’t know that for quite some time, but I’m still hopeful. If it turns out that all the death and suffering and healthcare workers’ exhaustion of the last few months were for nothing, that’s going to make it all the more terrible.

I’m part of an online group that discusses alternative careers for physicians who want to leave traditional medicine. Sometimes the suggestions are decidedly non-medical, such as getting one’s real estate license or flipping houses. They may also include non-clinical careers that still require physician expertise, such as pharma, life sciences, or medical device manufacturers. Sometimes they even include staying in your specialty, but moving from a traditional practice to a locum tenens format to have more flexibility and variety.

This week, the discussion veered off into the realm of clinical informatics. I almost spit cocoa on my keyboard when one author said they were interested in clinical informatics because they wanted to get away from working with people.

I was happy to see several clinical informaticists chime in on how we work with people all the time. One noted that not only do we work with people, but often they are often tired and overworked clinicians just like the original poster. Another described the not-so-fun state of being caught between administrators who want to bloat the EHR’s configuration for business reasons and end users who want a streamlined experience that makes it easier for them to care for patients. It was clear that many of the people asking about it don’t understand the requirements needed to work at the top level in our field, such as fellowship training, board certification, or considerable experience.

I was proud of how the clinical informaticists represented our specialty – recommending an online typing tutor for the one-finger typist, AMIA 10×10 courses for the budding informaticists, and more. They encouraged the physicians interested in learning more to volunteer for technology committees at their organizations, take additional training for EHR workflows, or even pursue becoming a super-user if they are really interested in crossing to our side of the clinical trenches. We get to do and see a lot of cool things and it’s a different way of using our clinical skills to help large numbers of patients rather than just influencing those we could see in our own practices.

I was less proud of the non-informatics physicians on another thread that piled on for some complaints about EHR vendors. One chap talked all about his experiences with a particular system and how terrible it was and listed specific defects that made it unusable in his opinion. As someone who has used that system extensively, I became suspicious. Only by reading well below the scroll did you get to the part where he says that he hasn’t used the system in more than a decade. I’ve seen a lot of good EHRs and some bad ones too, but the biggest struggles I’ve seen are with decent EHRs that were ineffectively configured and implemented. I’m working with a vendor now that has extensive training resources and I wonder how many users know what’s available at their fingertips.

I wasn’t surprised that the COVIDtests.gov website had a soft go-live on Tuesday ahead of its scheduled debut. It seems to be working relatively well except for some issues processing requests from multi-family buildings. The tests are limited to four per household and won’t ship for a while, which limits their utility during the current omicron surge. Testing capacity has somewhat improved in our community, but at-home test kits are still hard to find, leading to challenges for those hoping for a quick turnaround. A good friend knew I had a stash of kits and asked to use one, which was a fair trade given his history as a maker of excellent gin and tonics. After 15 minutes in my outdoor driveway COVID clinic, he headed home with at least a small measure of reassurance.

I didn’t think much about it because I was just glad to help a friend out, until he sent me a thought-provoking text: “You know what just struck me about last night? In the richest country in the world, I, a fully insured patient, had to turn to what amounts to a black market supplier for a medical test.” Funny but not funny, and painfully true. Maybe next time I have to offer some driveway swabbing, I’ll pair my gloves with a trench coat and some kicky boots.

What’s your most challenging experience trying to obtain a COVID test? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/17/22

I’ve done several projects in the last couple of years that involve health IT interoperability. Each has been challenging in its own way. There are varying state requirements for data exchange and those have been a factor in some of the projects, with lots of extra time and effort spent trying to obtain patient consent when an opt-in strategy is in play. There are also plenty of requirements about protecting information that has been identified as sensitive, including that related to mental health, reproductive health, and the care of minors. Given all those considerations, for most of the projects my consulting efforts have probably been 80% focused on the operational and governance aspects as opposed to the technical ones.

Not that I’m a stranger to the tech piece. I started working with my first health information exchange in the early 2000s and those days certainly were an adventure. We were using it to share records within our own organization due lack of institutional support for an enterprise EHR. Since a given patient might have three or four charts on the system depending on where they sought care, we were using the HIE to try to create some semblance of a comprehensive patient record. It wasn’t elegant, but it got the job done, and we managed to reduce some duplications and identify some controlled substance reconciliation issues along the way.

Fast forward. Although the information superhighway may have been smoothed with the technology equivalent of a new coat of asphalt, there are still some steep grades and dangerous curves. There is a tremendous amount of trust that when vendors say their solutions are interoperable that they truly are. However, as with nearly everything in the healthcare information technology world, the devil is in the details. A lot of organizations have consolidated their enterprise purchases around a handful of vendors under the assumption that such decisions would bring greater interoperability and easier data sharing. There is quite a bit of variation though as organizations might not be on the same versions of a given platform.

There is also a lack of attention to the operational differences between organizations that might choose not to share certain types of data for a variety of reasons. Business goals are high on this list – reducing patient leakage, trying to consolidate all of a patient’s care at a single health system, preserving high-margin service lines, and more. Often these issues don’t become hot topics until interoperability projects are well underway and they can essentially derail even the most well-planned technical project.

A recent study published in the Journal of the American Medical Informatics Association looked at the interoperability limitations that are found even when organizations have the same EHR vendor. Although overall data exchange is somewhat easier, there are still struggles with data normalization and reconciliation. The authors looked at nearly 70 oncology sites that were using one of five EHRs and calculated interoperability scores for sharing with the same EHR as well as scores for sharing with a different EHR. They included 12 specific data elements, equally split between medications and laboratory tests, which are standardized within oncology practice.

Not surprisingly, same vendor sharing had stronger interoperability scores than sharing between different vendors. However, the results should be enlightening for anyone who hopes to do these types of projects. The authors noted that, “Reliable interoperability requires institutions to map their data to the same standards and ensure that mapping practices are consistent across institutions.” They also noted the importance of looking at potential interoperability of specific data elements. For example, there may be different levels of interoperability when looking at medications as compared to lab results or imaging studies. Even within those categories, organizations need to look at how interoperability looks for common medications and laboratories versus less common or rare examples.

Although some might think that greater standards for interoperability measures might be the answer, the researchers are concerned that this might lead to vendors and their clients focusing their attention on those elements that are being monitored rather than the overall picture. They noted, “it will be important to ensure that certification does not replace poor interoperability with poor interoperability except for a few chosen data elements.” We certainly saw this type of behavior in the Meaningful Use era when there was a tremendous degree of focus on checking the boxes even if it was at the expense of quality patient care and user satisfaction.

I’d like to see a similar study performed looking at primary care interoperability as opposed to a subspecialty such as oncology. Primary care is the core of healthcare and where the greatest exists for interoperability so that we can use existing data, avoid duplicate and wasteful studies, manage overlapping medications, and provide a comprehensive plan of care for individual patients. I’d like to see how easy it really is for my Epic-using internal medicine physician to get information from the radiologist across town who is on a different instance of Epic, as well as from the surgeon who is using Cerner in the hospital and NextGen in their office, and the telehealth vendor I used when I was out of state and the county health clinic where I might have had a COVID test. Despite what integrated delivery networks are hoping for, many of us choose the best physician for our situation regardless of whose logo is on the door.

I’d also like to see how it plays out for emergency department encounters since patients don’t always get to choose which facility they’re taken to in an acute situation. In fact, COVID is running so rampant in my city right now that one municipal ambulance district is refusing to take patients anywhere but the two closest hospitals unless the patient requires specialized pediatric care. Given the time it takes to clean the vehicles after transporting COVID-positive patients and get them back into service, they’re trying to avoid long runs and decrease their turnaround time. There’s a tremendous number of patients that seek care at our city’s other major health system, which makes the need for solid interoperability even more important.

What has your experience been with interoperability, either with the same vendor or different ones? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/13/22

Mr. H recently threw out a challenge: “Discuss: a physical line of people waiting for something indicates a failure of technology to meet a need.” I’ll certainly take the bait on this one.

I recently needed to do three transactions at my state’s motor vehicle agency. The first involved renewing my car’s annual registration, and it was very straightforward online. Typically when you do this in person, you have to show at least four paper documents. For online renewals, though, the system is hooked up with the motor vehicle inspection sites as well as the taxation agency, to make sure everything is current. For the mere price of a $3 convenience fee, I had it completed in less than five minutes. The sticker that I needed to apply to my plates arrived in the mail less than a week later, and the emotional labor to complete the entire process was zero.

Contrast that with the other two transactions, which had to be done in person. Due to the explosion of COVID in my state, the office only allows a handful of people in the building at the time. The last time I had to go there in person was in August, and at that time I waited nearly 45 minutes outside before being able to enter the building and wait in line some more. Although they had appointments during the height of the first COVID peak, they no longer offer it, despite our current peak being significantly higher than the original.

Enter the emotional labor component of the exercise. I had to look at my work schedule, figure out when I could take off during normal business hours, and marry that up with the weather forecast to try to avoid being outside in sub-zero temperatures or freezing rain. I also had to move a couple of meetings and checked three different websites to make sure I had the correct paperwork for both transactions, because having to come back would be exasperating. On the appointed day, I dug out my heavy boots and heavy coat and decided to give it a go.

Usually there are two lines, one for vehicle-related transactions and one for driver licenses and ID cards. Likely due to the online vehicle process, there was no line for those transactions. Once I made it into the building, I found the vehicle side of the office, where three agents sat waiting. Everyone who walked in was handled in real time. When the vehicle agents had nothing to do, they would start a “pre-check” process for the people waiting in the driver license line, making sure they had all their paperwork in order to try to keep the process from bogging down. Several people were turned away from the line, which was for a while the only thing that made it appear to move. The office has two workstations that can take pictures, but one was unstaffed.

Once you got to the licensing workstation, you had to present the little paper slip that you received from the pre-check station, and the worker would key in the particulars and collect payment. Then you had to do a vision test followed by multiple computer screens that you had to validate and sign before the photo was taken. Finally, the worker printed a temporary license, punched a “void” marker on your old license, and you were done. The worker then sanitized the station and called the next person over. There were multiple delays for things like people removing coats, fluffing hair, reapplying lipstick that was smeared by masks, etc. In the time that a single patron was taken care of, the pre-check worker had reviewed at least the documents of at least four people.

I got to go through the whole scenario twice since I had two different renewals and there was no sharing of data from one transaction to another. I had to write two paper checks to pay for them. (This is sounding a lot more like healthcare, isn’t it?) In one photo, I look great, and in the other, I look like I’m on a wanted poster, so it didn’t work out too well for me (although if the process was more streamlined, I might have looked like a suspect on both).

I’m a serious process improvement nerd, so I’ll offer a couple of potential solutions. These processes have the same challenges that we have in the healthcare space, including patient / client registration, managing wait times, identify verification, demographic verification, payment collections and processing, photo acquisition, history gathering, and more. What if there were people who had dedicated their careers to improving processes like these? It’s a good thing I’ve worked with a couple of people like that. When you start thinking about solutions to these problems, they’re not always novel. Some are low tech and others are high tech, but to eliminate all the defects in the process, you could use a combination of solutions.

Let’s take a shot at it, shall we? Assuming a low staffing situation, if workers were cross-trained, they could have used the second camera workstation. Since agents on the other side had capacity, if they were able to run the slow process, it could have doubled throughput. Or, they could have used the available agents to add some additional flair to the pre-check process, asking people to remove their coats, organize their belongings, pre-write their payment checks, etc. so they would be ready for the next step in the process. If they really wanted to get fancy, they could have had the trained person run both camera stations (they were literally next to each other) and used the excess staff to assist by sanitizing the stations in between rather than it becoming a bottleneck. That person could also have voided the licenses and handed out receipts after they printed. I feel like just telling people what to expect and encouraging them to get their ducks in a row before they approached the station would have helped a lot.

On the technology side, they could dust off their appointment system since it worked during the early stages of the pandemic. Second, they could have a simple texting system that would allow people to check in and wait in their cars until they received a message that they were third in line or something like that, and to come in. If they wanted to get fancy, the state could develop an online portal where registrants could pre-submit their paperwork and have it approved remotely, verify all the information they would normally verify on the screens, and receive a confirmation ticket that they could bring to the office, eliminating the majority of the process for a subset of customers willing to start the process online (except for the vision test and photo, that is). Or, they could have a separate photo kiosk where customers could do their own photo, or have it taken by a less-trained person, so that it was already in the system and the staffer would just have to marry it up with the appropriate demographics.

Alas, though, my state is one of the last in the union to adopt such cutting-edge technologies as Real ID, immunization registries, and prescription drug monitoring programs, so I have little hope. I’m definitely keeping my eye out for consulting postings on the state procurement agency website. I might be able to monetize what feels pretty obvious.

What are your thoughts on other processes where lines of people are a failure of technology to meet a need? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/10/22

I started my HIMSS22 preparations in earnest today with the booking of my flights. I had looked at them a few weeks ago and then was sidetracked by a multitude of things, and based on the dramatic jump in price, I am glad I went back and got them today. I’ll be coming from an airport that isn’t a major hub, so there are some limitations, but I was surprised to see them jump over $300 in two weeks. Capitalism is alive and well, and who doesn’t love warm weather in March? As usual, I’m flying my favorite no-change-fee airline, so if HIMSS throws us a curve ball, I’ll be covered.

Mr. H pondered this weekend whether hospitals will allow their employees to attend. I would say that’s up in the air and all depends on what happens with new coronavirus variants. My local institution banned international travel at the end of December, but said people could travel domestically if they could be back at work within 24 hours. I questioned whether that was realistic based on the number of cancellations in the airline industry. Now they’ve ratcheted it up to the “don’t plan to go anywhere in the next two weeks” level. Many of my super-subspecialty friends are pretty much isolating except for going to work because there are limited numbers of them at each hospital and they can’t afford to both be sick at the same time. Hospitals are still restricting N95s, which I think is not only ridiculous, but counterproductive.

Our area hospitals are doing daily press conferences where they try to keep people calm and confident, but those on the inside wish they would do a little more to paint a picture of what’s really going on. At one hospital where a friend is an emergency department director, they’ve run out of portable oxygen tanks twice this weekend. When that happens, it’s a mad scramble to rearrange patients and get them connected to a wall unit. It also increases the time that patients have to be boarded in the emergency department because they can’t be transported to the inpatient floors if they’re on oxygen and there are no tanks.

One of them finally came out over the weekend and said they had halted all COVID testing for individuals without symptoms. That means no back-to-school or back-to-work testing and no tests prior to travel. I get it – they have to reserve the tests for patients where the result is going to make a difference in how they are managed – but it has pushed testing to the other facilities in town, which were already drowning. Most of the commercial testing vendors now have a three-day wait for testing, and turnaround times can be three or four days on top of that, which makes things challenging.

The same system had announced that it is freezing non-critical surgical procedures. The other players in town are functionally doing the same thing, but are soft-pedaling it to the public by saying that they are managing patients “on a case-by-case basis.” Everyone is nearly out of monoclonal antibodies and no one can get their hands on the new pill-based therapies, but no one is saying that publicly.

The state has dipped below 15% available intensive care beds, yet a number of people aren’t batting an eye. They’re going about their lives like they did pre-COVID, and any talk of flattening the curve to protect healthcare workers and preserve hospital capacity is met with scorn. I ran across someone today who insisted that there’s not a shortage of nurses due to sickness or being out to care for sick family or children whose schools have closed. They said it is because “all those nurses quit rather than taking that poisonous jab.” As someone who has seen the real stats (1.25% attrition rate for failure to vaccinate), I didn’t even engage in the conversation. It’s not worth it and there will be no changing of hearts or minds with that one.

Two more physician friends resigned this week, although they still have to remain in their respective hellscapes for another 90 days for contractual reasons. Hopefully, we’ll hit the peak soon and then come down the back side of it quickly so they can get some relief. Projections are that numbers will continue to be record-breaking for the next two weeks.

Both of them reached out to me for information about telehealth practice and other ways to use their degrees without caring for patients in person. They’re both great docs and I wish I could leverage their expertise on some of my teams, but unfortunately, they don’t have much non-patient-facing experience. I have plenty of other friends who want to leave their jobs but haven’t yet due to a sense of loyalty or altruism. Some have developed healthy coping strategies, but others not so much, so I’m keeping an eye on those that are in the latter cohort.

If you’ve got friends in the clinical trenches, please be aware that generally they are not OK. Although they may seem to be coping on the surface, I don’t know of anyone who isn’t struggling to some degree. Help how you can, whether it’s having a meal delivered or just leaving a bottle of wine on the porch. Physicians are finding creative ways to pitch in. A group of local subspecialists has been reaching out on physician social media groups offering to care for patients who might normally have been seen in primary care for dermatology, ear / nose / throat, and digestive issues. They’ve also offered parking lot space for drive-through testing, which would be great if people could get supplies. Some of our local primary care practices are running seven days a week due to demand, but others have had to close entirely due to lack of staff. Things are truly all over the place.

We’re only 10 days into the new year and I don’t think it’s going as anyone hoped. Regardless of where you work in the healthcare universe, keep an eye out for those who are struggling and offer a kind word or a sympathetic ear where you can. We’re all in this together and it’s going to continue to be bad for the next several weeks.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/6/22

I spent a couple of hours tonight on the phone with a colleague who is burned out and thinking about leaving medicine. She was asking my advice, not only as someone who has worked in a variety of different care-delivery paradigms, but also as someone who might be able to help mitigate some of the hassles she’s currently encountering.

She’s part of a large Direct Primary Care practice, which manages patients more like customers as opposed to patients. Unfortunately for the physician, that comes with the expectation of 24×7 access. Apparently the organization is using something from Salesforce as a substitute for a patient portal, and when messages come in, they are in a silo, requiring the physician to also log into the EHR, load the patient, then double-document in both places. Adding to her frustration is a recent change to the Salesforce side where she can only manage messages from a laptop, which makes it hard to be 24×7 accessible if you ever want to step away from your desk or have a life.

We had a good chat about alternatives to in-person care including telehealth, which I think she’s considering. We discussed some of the pitfalls of the different telehealth companies and the challenges of being an independent contractor versus being employed, as well as the dramatically different processes that the national telehealth providers use to onboard new physicians. As someone who has historically been efficient with the EHR, I think she’ll struggle with their homegrown EHR-lite solutions, but she needs a change if she’s going to maintain her humanity.

We talked a lot about the concept of moral injury and how hard it is to deliver good care when you’re constantly operating under crisis standards of care, you don’t have adequate staff, and you’re being pushed to see more patients per hour than your comfort level allows. I’m glad she reached out and is contemplating a change. Too often, physicians wait until they’re past the point of no return or until a significant negative event forces their hands. Hopefully, telehealth will give her some breathing room while she steps away from in-person care and allows herself to recharge.

Despite my disappointment at being denied a media credential for the Consumer Electronics Show, different examples of cool technology are falling into my lap through other outlets. The first thing I ran across today was the clear-sided toaster, which not only allows you to monitor the progress of your toast, but has one-touch defrost, reheat, and bagel functions as well as seven browning levels. I haven’t shopped for any kitchen electronics in forever, but if my $9 college toaster ever gives up the ghost, one with clear sides might just be on the short list.

Withings reached out regarding its new BodyScan device, which is undergoing clinical and regulatory validation. Described as “the first at-home connected health station,” it promises to deliver weight, segmental body composition, and six-lead electrocardiogram data as well as a calculation of vascular age and an assessment of nerve activity. I’ve been happy with my Withings blood pressure cuff and have a couple of friends with Withings scales. The BodyScan certainly looks interesting, and at a $300 price point, will be attractive to people who have become accustomed to spending $800-$1600 on a smartphone.

I also ran across this smart watch sensor that helps with opioid relapse. The team at University of Massachusetts Amherst, along with colleagues at Syracuse University and SUNY Upstate Medical University, received a $1.1 million grant from the National Science Foundation’s Smart and Connected Health program to continue work on the project. The sensor feeds data to a machine learning platform to help identify if physical signs such as respiratory rate, electrocardiogram findings, etc. are at levels that indicate opioid cravings. Once a craving is identified, the device alerts the wearer to consider mindfulness techniques to try to address the situation. Ultimately, they hope to customize those interventions based on individual patient characteristics. Researchers believe they can identify with 80% accuracy when a user has taken an opioid. They hope it may evolve to help ensure proper use of prescribed opioids to prevent opioid use disorder. This is an area where we need as much assistance from technology as we can get, so I’m excited to see how it progresses.

Kohler knows I’m a sucker for the dream of a high-tech, aromatherapy-rich bath, and sent me information about its new PerfectFill technology that uses voice commands to control the temperature, filling, and draining of a bath. No more sticking your finger under the faucet while you fiddle with the knobs or worrying about scalding a little one. A former urgent care colleague who left the urgent care trenches to go to school to become a plumber let me know that the bath I swooned over last year requires special installation considerations and that he used it as an example for a class project. I know who I’m calling when I win the lottery.

I also did a bit of technology mourning this week, as I learned that all former BlackBerry phone services stopped working this week due to lack of support. BlackBerry was a tech darling in the days prior to the iPhone and at one point seemed like the number one business accessory. The last BlackBerry OS was released in 2013, but people have been limping the devices along as phones or messaging devices. I have to admit I still have a BlackBerry Torch, with its keyboard hidden beneath a sliding touch screen. It’s possibly one of my favorite phones, and fun to show off when I participate in STEM-based education programs where we talk about the history of personal electronics and communication. Most of the youth I work with can’t imagine life without a smartphone, let alone life without the internet, so it’s fun to talk with them about the pre-internet days when we used dial-up connections to bounce messages around the country.

What’s your favorite piece of extinct technology, be it healthcare or something else? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/3/22

Most of my regular readers know I’m a fan of pastry therapy, but I decided to start the year out with something a little different. My food-related knot-tying skills are apparently far less developed than those used for everyday applications (or even wilderness survival), but the taste made up for the lack of aesthetics. The warm oven made the kitchen a little more habitable with the cold snap we’re experiencing, and what better way to reflect on a new year than sitting around watching dough rise?

The last two years have made most of my friends and colleagues reflective, and I’m no different. After slogging through the worst year and a half of clinical practice I’ve ever had, I decided to hang up my stethoscope for a while. Although I’m still practicing telehealth, it’s been a transition, and I’ve spent a lot of time explaining to friends and relatives what exactly it is that I do. Unless they’ve had a telehealth visit themselves, they usually don’t quite understand how we can provide care without the ritual laying on of hands that occurs in the doctor’s office.

I’ve done some medical volunteering to keep my skills sharp, as well as some in-town locum tenens work. I’ve learned more about epidemiology and infectious diseases than I ever thought I would know, as I work to advise local schools and youth-serving organizations on how to navigate the ever-changing new normal. I’ve piloted new paradigms in specialty board certification for two different disciplines; experienced the good, the bad, and the ugly of remote continuing education; and have finally transitioned to reading all but one medical journal electronically.

I watched my consulting business ride the rollercoaster of the pandemic, alternating between not having enough work and being crushed by requests my team can’t fulfill. I picked up three clients, watched one get acquired, saw one flounder, and supported a couple more as they continue to onboard new clients and expand their offerings. I’ve become adept at canceling travel more than I book and finally let my Alaska Airlines credits that I couldn’t use in April 2020 lapse into oblivion. Victoria BC, I would have loved to have seen you, and to have embraced the floatplane adventure we had planned, but it just wasn’t meant to be.

After some medical misadventures, I started to embrace the idea of a bucket list – doing things while I’m young and healthy rather than waiting for the other shoe to drop. I’ve also vowed to take advantage of unique opportunities when they present themselves instead of overthinking them.

I spent a week in the Florida Keys, snorkeled through jellyfish, went nearly 60 miles per hour on a zip line, and did things in a climbing harness that I didn’t think I’d ever do. I’ve now officially soaked in a chandelier-lit hot tub in the French Quarter after a long day of work and shoe shopping, and am glad to have found some new travel companions for when things are a little closer to the “normal” we all remember. I had a multi-week adventure following an 80-year-old steam engine and enabled some quality teenaged school-skipping along the way. My only open bucket list item is exchanging my motorcycle permit for an actual license so I can do a road trip with my dad, but we’ll have to wait for the wind chill to disappear before I work on that one.

I’m looking forward to 2022, because frankly it can’t get any worse than what some of us have been through the last two years. Lives interrupted, loved ones lost, fires, floods, tornadoes, dreams denied, and life generally feeling upside-down are things we’ve all had to deal with as we figure out how to keep putting one foot in front of the other. I’ve met some amazing new colleagues who I’ll continue working with in the new year, and hopefully we’ll be able to deliver some cool new things that will help patients and providers alike. I’m excited to be entering my twelfth year writing for HIStalk and can’t wait to get back to the exhibit hall madness that is HIMSS and catch up in person with my healthcare IT besties.

What are you looking forward to in 2022? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/30/21

Monday’s clinical adventures were full of patients who had been exposed to COVID-19 over the Christmas holiday. A good number of them tested positive on home tests and wanted to speak to a physician to request a laboratory order for a PCR test, because they didn’t believe the home test was accurate.

There’s a bunch of epidemiology calculations that can be done to explain this using pre-test probability, sensitivity, specificity, etc. but they all roll up to this. If you have symptoms and any test is positive, whether it’s a home test or not, you need to take it as fact and isolate yourself. The healthcare system is being crushed in my state and there aren’t enough tests for people to double test.

A couple of local physician offices turned off the phones Monday because so many staff members were out that they simply could not handle the volume and opted to triage everyone to their patient portal. I’m having some guilt about not seeing patients in person while my colleagues are being pummeled, but will do what I can to help from a telehealth standpoint.

Also on the telehealth front, both Ohio and New Jersey have new telehealth bills that were recently signed into law. Common themes include expanded access, preventing insurers from denying coverage, and granting payment parity between in-person and virtual care. The Ohio bill’s expansion provisions include allowing additional provider types to deliver virtual services including optometrists, pharmacists, physician assistants, and school psychologists. It also broadens the list of entities that can bill Medicaid for telehealth services.

Proponents don’t believe that the expansion and payment provisions will raise healthcare costs, as was argued in other states such as New Jersey earlier in the year. An initial telehealth bill was rejected there due to concerns about increased costs to taxpayers, but now the bill has been signed with the condition that the state department of health will study telehealth use and patient outcomes.

Telehealth advocacy group as well as patient advocacy groups are calling for reinstitution of so-called COVID-waivers for telehealth services, which were a key part of the initial pandemic response. On an individual basis, many states allowed any licensed provider to see patients regardless of whether they had a license in those specific states.

Even health systems that normally provide telehealth urgent care services are struggling, partly due to patients who have traveled for the holidays and now can’t get remote care from their “home” health system because they’re outside their normal state of residence. This is a great example of why the telehealth laws need to evolve. I’m confident that my personal physician can care for me virtually whether my body is in my house or sitting on the beach hundreds of miles away, even if my state doesn’t think so.

Also in telehealth news, the Department of Health and Human Services announced $35 million in American Rescue Plan funding to expand telehealth infrastructure and capacity for Title X family planning providers. Many of the Title X providers are part of the so-called health care safety net that provides care for low-income populations and other groups who might not otherwise receive care. The funds will be distributed as 60 one-time grants that will be given to active Title X program participants. Applications are open on Grants.gov through February 3.

I enjoyed a recent article on terms that make hospital executives cringe. I’d like to add my personal list of language elements I wish would go away: frictionless, the use of “solution” as a verb, ecosystem, the cloud, enablement, holistic, the Internet of Things, and anything prefixed with “smart.” They’re old and tired (and in the case of “working to solution something” just plain weird) and if we have all these brilliant minds in tech, certainly we can come up with something better.

I missed this story when Jenn sent it my way earlier in the month, but was happy to see it. It details the work of the Refugee Artisan Initiative, where newcomers to the US can receive skill training and experience with micro-businesses. The organization received a community investment grant from Swedish to cover creation of medical scrubs for its staff. The Initiative is making 500 sets of scrubs which will be custom sized for employees. My new clinical gig won’t allow me to wear scrubs, so after nearly two years of wearing them exclusively, I’m having to figure out what looks good under a white coat but won’t be bulky or aggravating.

Speaking of aggravating in the context of health tech, the team at the Consumer Electronics Show has spoken and has declined to approve my request for media credentials. The email simply said that my submitted credentials were inadequate and didn’t specify which of the two were problematic. I’m baffled because I submitted items that complied with their requirements and were of the same substance as last year (just more current, in keeping with their requirements). Lots of tech companies are backing out of the in-person show and switching to the digital edition, so we’ll have to see what the engagement level is for those who still plan to attend.

I’m still on the hunt for interesting health tech that can help engage patients and enjoyed reading about the Prevention circul+ Wellness Ring. The name is quite a mouthful and is partly due to the manufacturer’s co-branding with Prevention Magazine. The ring is bulkier than I’d like, but includes technology to measure blood oxygen levels, which is intriguing to any of us who are trying to manage COVID-positive patients in their homes. The team worked with clinicians at the VA and Kaiser to trial the technology and refine the design. It can now also record blood pressure and a single-lead electrocardiogram, with data captured in its associated app. FDA approval as a diagnostic medical device is still pending, but it’s something I’ll keep my eye on.

What kind of new devices would get your attention or hold your interest? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/27/21

I’ve been working on a project with a new client for the last couple of months, and it’s been interesting to say the least. It’s been a great example for why you need to make sure that you have the right people at the table while you’re proposing the project, while you’re designing the technology, and especially while you’re executing it.

I was brought in initially to be a purely clinical resource, working with an existing clinical team to develop some evidence-based content that would feed an organization’s rules engine. It seemed straightforward until I really got into it.

The existing clinical folks were purely clinical and didn’t have an understanding of what happens when you try to put clinical information into a rules engine and how to think about documenting what needs to happen. They also had an extensive inpatient background, but minimal experience in the outpatient world, which is where the new content was to be used. They were also heavily academic and didn’t have a good understanding of how a busy ambulatory practice runs or how “just in time” the content needed to be in order to make sure the users weren’t overwhelmed. They were willing to learn, though, and once we brought them up to speed with a mini clinical informatics course, they were able to hit the ground running.

We were given some parameters around how we needed to document the content specifications, but since the front-end of the rules engine hadn’t been built yet, we were somewhat at the mercy of the designers to understand how the users would interact with our content. Wireframes were available, but don’t always tell the full story of how a workflow is going to feel or function. As we started presenting our finalized content, it became clear that we had built it to a different level of specificity than the rules engine could support. We had to do some rework to eliminate some of the granularity while maintaining the intent of the clinical rules. Although it was workable, I wasn’t entirely happy with it, but I understand that there often has to be some give and take as software is built.

After several months of development, it was time to do some user acceptance testing and we had our first look at the user interface in action. The physicians really liked the look and feel of how the rules engine connected to the workflow. It was almost seamless, until you got to the point where it was actually running. There were some definite lags in the performance as the application was trying to serve up the content we had built. At this point, the development team asked a question about how it was supposed to work and whether the users were supposed to be documenting by exception or documenting certain elements of the workflow. Since the physicians had been specifically told to build the content to support documentation by exception, this was surprising.

The mismatch in how we expected the content to perform compared to how the developers thought it was going to perform turned out to be the cause of some of the performance issues. This could have been avoided by having more cross-functional discussions earlier in the project, where everyone reviewed the specifications documents together and were able to ask questions directly. I understand the motivation in not bringing everyone together initially, since there were concerns about coordinating schedules, making sure that expensive resources were only used when needed, and that there was an understanding that the project managers were coordinating everything. Ultimately, though, it led to rework, so I’m not sure how much that decision actually supported efficiency or cost savings.

Working together, we found a few things that needed to be adjusted in the content, and they began working on changes to the rules engine. To the team’s credit, they did a quick turn-around, and at our next testing session, the workflows were performing much better. We were all very excited to get it in front of users from one of the organization’s practices and held a very small testing session where everything passed with flying colors. The next step was to release it to a single practice that had agreed to serve as our beta client.

The team had planned to hold a combined testing/training session to accomplish a couple of goals. First, making sure the rules engine performed under stress, then also making sure that the training materials and training strategy met the users’ expectations. We identified a couple of places where the materials could be tweaked for clarity, and the performance lags we had seen in the initial testing environment seemed to be gone. Everything was ready for the move to production a couple of weeks later, but unfortunately the biggest challenge was still yet to come.

The organization likes to roll out new features on a Wednesday since it’s typically calmer for an outpatient practice than a Monday. It also allows users to get used to the content for a couple of days and then have the weekend to recover if the new feature creates a stressful level of change in the workflows. They had asked the physician content creators to be available in case there were questions about the clinical aspects of the rules, so we had all blocked our schedules and were ready for the big day. It’s always exciting to see something become reality after it’s been largely theoretical for so many months.

Unfortunately, on Monday, the execution phase of the project started falling apart. Apparently, the operational leaders that the project manager had been talking to hadn’t mentioned that two of the practice’s busiest physicians had planned to take the week off to attend a conference and wouldn’t be present for the go-live. The team was happy to support whoever was available to go live, but we knew that there would likely be budgetary concerns about having the entire support team, including the physician content team, available for a secondary go-live with the remaining members of the practice. We couldn’t just push the go-live back a week because there were concerns about the physicians being busier than normal coming back from being gone for the conference.

Pushing two weeks into the future would put us in the middle of Thanksgiving week when key staff would be out of office, and then the next week would be a post-holiday week with a potential volume surge due to having been closed. Following that, the schedule was peppered with absences due to pre-holiday vacations, followed by the Christmas holiday, and more planned vacations. Having that failure of operational communications has now caused the go-live to be pushed from early November into late January, which isn’t what anyone expected, and in the mean time the lead developer announced that he had accepted a position elsewhere.

It remains to be seen how the rollout will go if we ever get to it. Failure to have the right people at the table cost us initially with the development process and then on the operational side. Looking at the root causes of the communications failures, I’m not sure the project ever had the right level of executive sponsorship to keep it on track or to ensure people were giving it the focus it deserved. As we all know, there’s no test like production, so everyone is eager to get things moving so it can be rolled to the rest of the organization. I’ve already started another engagement with a different client, but I still want to see this one through, so hopefully the January 2022 date will hold.

How does your organization handle shifting timelines? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/23/21

I haven’t been anywhere near the physician water cooler this week, but around the healthcare IT water cooler, the hot news (as expected) is the Oracle acquisition of Cerner.

I haven’t heard any optimism around it. Most of the comments are of the “lots of organizations have tried to succeed in healthcare and they all fail” variety. Many see it simply as a way for Oracle to increase its customer base as well as it being a win for Epic since customers who might have debated between it and Cerner choose the path that isn’t about to undergo changes to leadership and strategy.

I’ve been involved in a couple of EHR replacement evaluations where Cerner was a contender, but failed to win the deal despite being less costly than the alternative. Primary care physicians tend to find it underwhelming for high-volume ambulatory practices. It will be interesting to see if Oracle does any better at winning those hearts and minds with their promises of voice recognition-based workflows and automation of care delivery.

As far as the virtual hospital hallways are concerned, I’ve been in contact with several friends who are nurses, one of whom is currently infected with COVID-19. They’re irate at suggestions that infected healthcare workers should be subject to shorter isolation periods to avoid straining the US healthcare system. Especially with many healthcare organizations continuing to fail at providing adequate personal protective equipment, including N95 masks, asking those who have shouldered the burden of care to put themselves at additional risk working alongside COVID-positive colleagues is something we never imagined would be suggested at this stage of the game.

My COVID-positive friend, who happens to be an ICU nurse, commented on how beneficial it has been for her to actually sleep for as long as her body needs. She has found her isolation to be somewhat restorative even though she is having mild coronavirus-related symptoms. Asking for additional sacrifice from those workers to care for what truly has become a pandemic of the unvaccinated just rubs salt on existing wounds and will not bolster the morale of healthcare workers. I would propose that if anything, it makes them feel that people think they are expendable.

Another hot topic among healthcare policy friends is the jump in US health spending. The number topped $4.1 trillion for 2020 as we attempted to fight COVID-19 in our dysfunctional and misaligned way. Case in point: COVID testing. My county testing with no direct cost to patients through multiple drive-through clinics. Results are generally delivered same day via email. Appointments are readily available on its website, with dozens of unclaimed appointments each day. Despite this, I see dozens of posts every week in various community-focused Facebook groups and other forums where patients are looking for open slots at CVS, Walgreens, and other pharmacies because they are booked solid.

My former clinical employer is running four testing sites that do several hundred visits each day, but with a twist – they require each patient to be seen by a licensed provider (MD, DO, NP, PA), which results in a full visit billed to the insurance company. Since patients don’t incur that cost up front, they don’t understand that what could have been a relatively cost-effective testing visit has been inflated by a factor of 10. Even if they don’t pay the cost out of pocket, they’re going to pay it down the road through increased insurance premiums and shifts to cost sharing.

These processes are why spending has jumped nearly 10%, double its usual rate, with no corresponding improvement in outcomes. I don’t think people realize that $1 of every $5 in the economy is going to healthcare. Even if people did, I’m not sure it would have much meaning to them.

Other interesting tidbits in the report, since it’s hiding behind a paywall:

• Health spending works out to approximately $12,500 per person.
• The count of uninsured individuals held steady, although there was a shift in those covered from workplace-based policies to Medicaid and Affordable Care Act marketplaces.
• Medicare beneficiary counts grew more slowly due to significant numbers of deaths in those aged 65 and older.
• Individual out-of-pocket spending decreased due to deferred care, such as postponed surgeries and screening procedures.

The latter two are certainly negatives in my book. Where senior citizens accounted for roughly 15% of all COVID-19 cases, they represented 80% of the deaths. The loss of so many family members and loved ones is tragic. I’m fortunate that the elders in our family are extremely healthy and their living situations allowed them to be protected thus far, but plenty of my friends and colleagues have lost an entire generation to the virus.

I’m hearing a lot more this year about people planning to test prior to family gatherings. Hopefully that will help prevent at least a small amount of transmission and reduce the strain on our overwhelmed healthcare workers. I’ve been generally pre-quarantining just to be on the safe side, but not everyone has the luxury of working from home.

I enjoyed attending the Consumer Electronics Show last year, even though it was virtual. There were plenty of products to check out and many of the companies did a great job trying to engage the virtual audience. Obtaining a media registration last year was easy, but they made things trickier this year for me since a photo is required even for digital attendees. My credentials are still pending approval, so there’s no guarantee I’ll be on prowl in the virtual exhibit hall this year. I’ve lived a full year without the $16,000 bathtub I was eyeing last year, so I guess if I can’t attend, I will survive. One of my colleagues is attending in person and I’m a bit jealous, but I’ll be holding down the fort while he’s gone and will have to rely on him for the in-person buzz.

What conferences are you looking forward to attending this year, or do you think COVID-19 will keep us all close to home again? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/20/21

The news this week has been dominated by surges in COVID-19 cases across the country. Epidemiologists are predicting a January peak and hospitals in many parts of the country are becoming overwhelmed. Staff members at those hospitals, as well as at urgent cares, community health centers, ambulatory offices, etc. are beyond overwhelmed, as they have been fighting this pandemic for nearly two years.

Most of the colleagues who I talk to regularly are beyond stressed as their organizations try to figure out how they’re going to staff another surge. The nursing shortage continues, with some of that work being shifted to physicians, which is increasing their levels of burnout. The thing that bothers them the most is not the hours or the work, but the feeling that they community no longer supports them but instead takes them for granted, or worse, sees them as expendable.

There’s a tremendous push for people to “live their lives,” but the reality is that we would all be better served by dialing it down a notch and sticking close to home for a while. None of us want to be constrained. We’re all tired of it, but it’s a necessity for many families right now as they struggle to protect vulnerable individuals in their households.

Seeing JP Morgan Chase cancel its healthcare conference was bittersweet. Everyone is so desperate for “the old normal,” but cramming people in hotels and restaurants isn’t the right answer. There’s a shortage of home testing kits across the country at the moment and people in some cities are facing long waits for clinic-based testing, so it doesn’t seem right to burden those systems with pre-travel testing. The same goes for people planning to travel out of the country for the holidays, which can generate multiple tests per traveler on their return, depending on workplace and school policies. I’m glad people have the money to travel to the Caribbean, but I feel for the healthcare workers who will grimly trudge through the lines of tanned, happy travelers seeking testing as they wonder when they will be able to take a break. One of my urgent care clients is routinely testing more than 100 patients per day at a single location, which is an unsustainable pace.

Mr. H noted that HIMSS is reviewing its Right of Entry Protocols for HIMSS22 to see how they’ll play in Florida, which has blocked vaccine mandates for workers and won’t allow businesses to require proof of vaccination. I have to say I hadn’t thought of that before registering for the conference, but now it’s giving me pause. We’ll have to see what the case rates look like as the conference is closer. We know that vaccination doesn’t necessarily prevent transmission, but data is good as far as there being less viral shedding and a shorter duration of symptoms. As we get more data about the Omicron variant, that may change, but right now I’m definitely more comfortable being around people who are fully vaccinated as well as masked versus the unmasked people at the supermarket who are talking on the phone as they shop, aerosolizing as they go. Influenza A is starting to rip through our community as well, so if the COVID-19 doesn’t get you, there’s a chance the flu will.

From a healthcare IT standpoint, I’m starting to see hospitals and health systems put projects on hold again as they cite the need to be all hands on deck for patient care issues. Organizations that haven’t already been tuning up their telehealth strategies have probably missed the window of opportunity while utilization was relatively low. Those who have robust telehealth programs are seeing greater demand, and most of the physicians I’ve spoken with are considering retooling their schedules to create dedicated blocks for telehealth visits so that they can minimize disruption to their days. With hospitals canceling elective cases again, patients are left in the lurch, and I feel bad for those who have been waiting for procedures that are again being pushed back.

As we approach the third year of the pandemic, I’m also starting to see physicians look for part-time opportunities due to childcare issues, especially in dual-physician households. As higher wage earners, these couples have historically had greater ability to afford full-time household caregivers such as nannies, but the long hours and unpredictably lengthened days have caused some caregivers to leave their physician employers. There is also some degree of mismatch between COVID-sensitive physician families and caregivers who might not want to be vaccinated or mask at work, just like there is in any other part of the workforce. Parents of young children who were hopeful for a vaccine to be available soon for their children are crushed by the recent Pfizer announcement that they’d be amending the clinical trial for children 6 months to under 5 years of age. This could delay the vaccine by an additional six months as boosters are studied. For those families, it will be a long winter, indeed.

There are so many terrible things that have come with the COVID-19 pandemic that when you come across something good that has come from it, you just have to celebrate it. Partway through the pandemic, I was introduced to what was then called The Covid Cello Project. It started as a group of 17 professional cellists who couldn’t work due to the initial lockdowns and decided to do a virtual collaboration. Since then, it’s grown to over 500 cellists who submit individual recordings that are then compiled and mixed into a group performance. It was rebranded some time ago as The Global Cello Project to reflect its worldwide reach as well as the easing of the pandemic, but now many of us are staying close to home again, so it’s hard not to refer to it by its original name.

The founder challenged us to put our most recent piece together in only nine days (usually we have several weeks) and I spent the first three of those days in the woods, so I’ve really had to work to get my part ready. Tonight was the recording deadline, and with the support of my in-house production crew, I was able to nail it in one take. Now the team gets to work editing all the videos and mixing all the recordings and we all get to be surprised by the finished product. It’s been great to have something to think about and work on that brings people together, even though my fingers have had the most exhausting week of their lives.

What good things have you encountered as a result of the pandemic? Have you taken up a new hobby or found a new passion? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/16/21

The healthcare IT world seems to be going into hibernation for the winter. I don’t expect too many big news stories between here and HIMSS. I’ve started to see some buzz around the Consumer Electronics Show and plan to attend virtually if they ever approve my request for press credentials. I enjoyed the virtual approach last year, although some day I’d like to go in person – they say the atmosphere of the show is really something, although I’ll be interested to see what in-person attendees think of it this year compared to its pre-COVID-19 vibe.

There’s minimal buzz around HIMSS, but I’ve gotten a lot of questions about ViVE. Everyone loves an excuse to go to Miami Beach in March, but the price tag is steep and requesting media credentials would require me to reveal my true identity, so I guess I’ll have to take a pass.

Regardless of the lack of vendor or industry news, academic channels continue to put out good articles. I enjoyed this recent item in the Journal of the American Medical Informatics Association. Titled “Assessing the impact of the COVID-19 pandemic on clinician ambulatory electronic health record use,” it does just that, by looking at data from ambulatory care physicians in over 360 health systems in the US that use the Epic EHR. They looked at data from December 2019 to December 2020, capturing the full timeline of the onset of the pandemic. They used data for active use of the EHR, after-hours use, and messaging. I wasn’t surprised that they saw a decrease in EHR use at the beginning of the pandemic. However, utilization not only ramped back up to baseline but increased by July 2020. This was consistent for both in-office and after-hours use.

In-Basket messages increased, largely due to the category of patient messages, which grew to 157% of its pre-pandemic average. Most of my colleagues hate the inbox regardless of the EHR platform. It usually contains not only messages from patients but also refill requests, correspondence from other providers, requests for referrals, preauthorization paperwork, lab results, diagnostic study results, and reminders to complete documentation in a timely fashion.

Some organizations do well at allowing physicians to delegate a large amount of this work to appropriately trained staff members, which allows team-based handling of many patient messages, refill requests, and referral / authorization requests. However, others refuse to let anyone other than the physician do this work, which not only leads to burnout, but can delay care. The savviest organizations report on their inbox workload and monitor how much work is being done by which members of the staff and adjust coverage accordingly. I wish this approach would be more commonly adopted, but as long as physicians continue to do the work without pushing back, there’s not a significant incentive for those organizations to change.

I wrote recently about challenges faced by the US Food and Drug Administration’s Risk Evaluation and Mitigation Strategies (REMS) programs to help mitigate the risks of serious side effects with certain medications. I used the program for the drug Accutane as an example. Little did I know that the IPLEDGE program for Accutane and its generics would implode this week. A colleague wrote in response to a patient complaint about refill delays: “Since Monday, there has been a nationwide issue regarding IPLEDGE and the FDA’s system for controlling isotretinoin prescriptions. They decided to change several things with the system and use a new website without first ensuring the website actually works. It is *literally* a sh*tshow with the nationwide program being shut down, hold times more than six hours for their tech support, and no one able to renew their prescriptions. I would give the office a break as currently no dermatologist in the country can send isotretinoin prescriptions until the FDA fixes the website.”

Sounds like the FDA didn’t learn much from the clozapine website debacle. These are exactly the kind of technology nightmares that physician offices fear, and which can bring even a well-oiled refill process to a screeching halt. Unfortunately, there’s no mitigation for the losses and frustration caused by this type of systems failure for either the providers or the patients. There are enough experienced healthcare IT people out there who know how to plan a project and how to run a go live that this should not be happening. Sounds like there were gaps in end-user testing, help desk support, and a potential reversion plan. Now that this has happened twice, I’d be interested to hear from anyone with FDA connections on what they plan to do to keep it from happening again.

Despite the news we’ve heard in the past that chocolate is good for you, new information shows that boring old multivitamins are more likely to slow brain aging. Preliminary information from the COcoa Supplement and Multivitamin Outcomes Study for the Mind (COSMOS-Mind) showed that taking a multivitamin each day for three years was associated with a 60% slowing of cognitive aging, most notably in patients with pre-existing cardiovascular disease. The findings were presented at the 14th Clinical Trials on Alzheimer’s Disease conference. The impact of vitamin use peaked after two years then remained stable; the reported 60% slowing is equivalent to 1.8 years. I usually treat myself to some dark chocolate around the holidays, and despite the evidence, I won’t be changing that habit.

I was commiserating with a friend recently about the American Medical Association’s monopoly on Current Procedural Terminology codes. Most of the provider-side organizations I have worked with dread the AMA’s license process, which is challenging for smaller organizations that have a lot of part-time users. Some EHR vendors include AMA licensure in their own license fees, but others make you work directly with the AMA to arrange licenses. My friend must know someone with some good AMA connections, because he later sent me a picture of this AMA-branded cheese board set. I’m not sure what exactly it’s trying to convey, since it’s somewhat evocative of what you see in movies when the character who is going to torture someone opens a case with various knives and picks. From a cheese board standpoint, the recessed AMA logo looks like a great place to harbor bacteria.

The holidays always bring out some interesting corporate gifts, although lately I’ve seen more companies making donations on behalf of their workers rather than sending gifts. What’s the most unusual corporate gift you’ve seen? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/13/21

The hot gossip around the physician lounge towards the end of the week centered on CVS Health’s plans to enter the world of primary care delivery. For anyone that missed it, their plan is to use telehealth, new clinics, and teams of physicians, nurses, and pharmacists to help solve the primary care problem. CVS Health believes that because it owns resources across many of the touch points of the healthcare system, it is uniquely positioned to enter the market.

If you are not in the US or are less familiar with the company, it not only owns thousands of retail pharmacy locations (some of which offer urgent care-type services), but also a pharmacy benefit manager (Caremark). Additionally, CVS owns a health insurance company (Aetna), so I don’t disagree that it has a pretty broad portfolio.

Not too long ago, CVS Health began rebranding some of its stores as HealthHub locations. I could never figure out what that differentiator really meant. My local store was rebranded, but nothing changed – still the same products, still the same square footage, and no increase in the number of exam rooms or appointments for its retail clinic. The company plans to keep adding these HealthHub stores (including 1,000 this year) and they are supposed to host a physician-led care team that includes dieticians, mental health professionals, and social workers. At the same time, the company is planning to close several hundred other retail locations as populations shift.

Digging deeper into the company’s press releases, it sounds like the company plans to further shift store formats, stating “Three distinct models will serve as community health destinations,” including sites that are dedicated to primary care, sites that are an enhanced HealthHub “with products and services designed for everyday health and wellness needs,” and traditional CVS Pharmacy stores “that provide prescription services and health, wellness, personal care, and other convenient retail offerings.” I couldn’t find mention of any changes to the CVS relationships with Target stores or the regional grocery chains with which it has also partnered.

I don’t disagree with their goal of providing a resource to better coordinate care or manage chronic conditions. The company is well aware of what we in primary care have known for a long time – primary care services are relative cheap in the grand scheme of healthcare spending (about 10% of annual spend in the US) and can actually help prevent disease and slow the progression of chronic diseases. This can lead to overall savings in healthcare spending.

However, there simply aren’t enough primary care physicians to go around, and in our culture, the perceived value of having a primary care physician is low. People seem to prefer transactional care that happens on their schedule, and I understand that as well.

Knowing that there aren’t enough physicians, many of my physician colleagues were speculating on how CVS plans to do this. CVS apparently plans to acquire physician practices, which should be interesting. Nearly 70% of physicians in the US are employed by hospitals or corporations, which have been on a buying spree during 2019 and 2020. The hospital/health system-employed portion of that number is about 50%. The remaining corporate entities include insurers and private equity firms. When they haven’t been purchased outright, independent physicians are consolidating into larger networks.

When you stratify the data by physician specialty, it becomes more interesting. The specialties with the highest rates of being physician-owned or independent are surgical subspecialties, anesthesiology, and radiology. Among the bottom five: pediatrics, family medicine, and internal medicine – in other words, primary care. I’d be interested to learn more about the CVS Health acquisition strategy because frankly I’m not sure where they’re going to find the headcount. Just because you purchase a practice doesn’t mean a patient will stay with it. Patients may not like how the new practice runs, and I can pretty much bet that a CVS-owned location will run differently than the average private practice.

Physicians may not stay with the practice. Perhaps they are closer to retirement than advertised and decide to leave immediately following any earn-out or guarantee period. Even if you can convince a subset of physicians to join a new practice with CVS Health, they’re likely to be hampered by non-compete clauses or other negative incentives that will make recruiting their patients a challenge. Additionally, folks who have remained independent for this long, in the face of ongoing market consolidation, might not be terribly well suited for the corporate medicine life.

Being cared for by a physician affiliated with a hospital or health system is a powerful idea. Patients, especially those who are medically complex, often feel a sense of security about having all their subspecialists and consulting physicians within the same system. Even with interoperability, there’s a sense that outsiders might not have access to all the records or might not provide the same level of care. There’s also backlash against corporate entities in some communities, with concerns that profit-oriented organizations will use patient medical records for marketing or other purposes.

One of the largest challenges I see for CVS Health acquiring these primary care practices is the matter of electronic health records. Many of the independent practices that they might acquire have EHRs that support that independence, like those from Athenahealth, NextGen Healthcare,EClinicalWorks, Greenway Health, etc. Having been through countless EHR conversions, I know that getting data out of those systems is usually easier said than done. I hope CVS Health has a substantial EHR conversion budget and is right-sizing their staff to handle it because patients expect their records to move with the physician, especially if the whole practice makes a transition.

Additionally, from a human resources standpoint, the altruistic physician candidates who are causing medical school admissions to surge won’t be ready to hang out their shingles for another seven or eight years. There’s no guarantee that they will find primary care attractive unless there are major changes. On the other side, there are a lot of burned-out physicians in the world right now who might just see working for CVS Health as a good thing. Time will tell how well their recruiting efforts will pay off as well as how challenging the technical pieces will be.

What do you think of the CVS Health move into primary care? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/9/21

Many physicians are closely watching several cases that are working their way through the US court system, especially those being heard by the US Supreme Court. For anyone who has ever seen oral arguments or read the transcripts, you may have noticed that the justices tend to say what they want to say, and often there is some interesting humor involved. The transcript of Becerra v. Empire Health Foundation did not disappoint. The case questions whether the Department of Health and Human Services followed correct procedures as it created a rule that changed the way Medicare reimbursement rates for hospitals are calculated. Justice Kagan pointed out an issue with the public comment portion of the rulemaking process, asking whether it was “unclear what the commenters thought they were being asked to comment on? In other words, a commenter who said I approve of the status quo, it was unclear whether that was the real status quo or the status quo as mis-described by the agency?”

Justice Breyer tried to reframe the issue, stating “I mean, do I understand this correctly? And the changes I understand it correctly are near zero, okay?” ultimately concluding that “people are exhausted, just like me after reading this case.” Justice Thomas referred to the “indecipherable language,” differentiating the concepts of “entitled to” and “eligible for” while pushing the attorney to explain it in “ordinary language.” Justice Kavanaugh jumped on the bandwagon, explaining the perils of trying to use two different meanings of “entitled” in the same sentence as he illustrated five different problems with the rule. Kavanaugh concludes that “we’ve whacked agency rules for much less than that,” which I found pretty amusing, imagining the members of the Supreme Court as hit people. Trench coats, fedoras, and dark sunglasses, anyone?

I always keep an eye out for articles that look at how companies and individuals are faring with the new normal of working from home. Lenovo has an interesting project in the works that will allow employees to work from one of the most remote locations on Earth. The Work for Humankind Initiative will support volunteers willing to work remotely from an island that is 400 miles of the coast of Chile. Lenovo has been upgrading the technology infrastructure on Robinson Crusoe Island and has built a shared workspace that will be come a community hub once the project is over. Project organizers are looking for volunteers with diverse skill sets who can help support the local community and volunteer 20 hours per week while on the island.

Successful applicants will spend four weeks on the island, from March 1, 2022 through April 10, 2022, and the dates include a 10-day quarantine on arrival. They must be fully vaccinated and willing to undergo COVID-19 testing three times weekly if selected. Finalists will undergo health, background, and psychiatric checks. Of course, the project will feature all the latest and greatest technology from Lenovo, so dedicated Apple users might want to think twice about applying. Interested parties can apply prior to December 30. It sounds intriguing – I’ll have to see if my current consulting gig would consider letting me head south.

From Job Hunter: “Re: sex work. It’s not the kind of healthcare technology piece we usually talk about, but did you see this article about healthcare workers who are leaving the industry for online sex work?” The Medscape article talks about healthcare workers who are struggling to make ends meet and turn to sites such as OnlyFans to supplement their income, or who give up their healthcare careers entirely. One featured UK-based worker made the equivalent of his annual healthcare salary in 22 days using OnlyFans. A featured New York-based emergency medical services worker turned to the site to supplement her income during the pandemic, leading to friction when her co-workers found out. The article goes on to point out the potential of encountering medical students who engage in sex work, which reminded me of the fictional Izzy Stevens in the TV hit “Grey’s Anatomy,” who paid for school by working as a lingerie model. The idea seemed vaguely scandalous at the time, but these days nothing is shocking.

Speaking of burnout and stressed clinicians, a new KLAS report finds that electronic health records might not be the top cause of clinician burnout any more. Nearly 20% of burned-out clinicians list COVID-19 as a top reason. Physicians most commonly list chaotic work environment as a central cause, where nurses cite after-hours workloads. I’m not surprised by the latter based on conversations with my nurse friends, who never get out of work on time and almost universally are looking for new jobs. This matches the KLAS data that shows that since the pandemic started, the percentage of nurses who are likely to leave their organizations in the next 24 months has increased.

My close nurse colleagues have grown tired of having to provide float coverage to patient care units where they might not be fully trained or experienced to care for the patients they’re assigned. I’ll never forget the first night my bestie had to float from the mother/baby unit to an assignment of mostly male medical/surgical patients. There were lots of questions coming my way all night long since the nursing pool was so scarce that she barely had colleagues to ask. I’m always happy to be the phone-a-friend, but the float situation went on for months until enough nurses quit over it that the administration had to reconsider. It’s a shame they didn’t make a better decision earlier before they lost a good chunk of their staff and had to pay exorbitant rates for travel nurses to provide coverage.

COVID-19 cases are rising in my community, and I’ve decided to head back into the clinical trenches on a very part-time basis, providing some cross-coverage for a Direct Primary Care physician while she takes some much-needed time off. It’s a different model than I’ve ever practiced in, and I can’t wait to see what the charts look like when a physician gets to write their notes purely for the sake of patient care and not for billing or any other reason. She uses an EHR I hadn’t heard of before now, and I always love to see how other systems work so I’m looking forward to it.

This weekend was spent doing a lot of administrative tasks, so I figured I’d go ahead and sign up for HIMSS22. The system needs to verify your membership status and I thought the glitch that created this screenshot was pretty funny. I came back later, and the system worked correctly, but it was still worth a chuckle. Will I see you in Orlando in a couple of months? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/6/21

One of the best parts of being a HIStalk sidekick is hearing from readers. I’ve got a handful of folks who correspond regularly, sometimes with comments on recent pieces, but other times giving me a heads-up on happenings that I otherwise would have missed. I’ve been way behind on my email due to the amount of work I’ve been doing for one of my new projects and was glad to see something from one of my regular correspondents as I reached deep into the abyss that is my inbox.

Most of us in clinical informatics tend to subspecialize, depending on where we work and how many other clinical informatics professionals are on a project. When I was starting out as a relatively new CMIO, I was a generalist as far as having to work with a lot of different clinical specialties, but was relatively specialized in that 90% of my work was in the ambulatory space. I only had to know about inpatient as much as was needed to address interoperability and the flow of data from health information exchanges and clinical repositories.

From there, I moved to the health system side and had to know a lot more about hospital-based medicine, but still worked with a broad swath of specialties. I became an expert in things like Meaningful Use and clinical quality reporting more out of necessity than anything else.

As a consultant, I run into all kinds of different informatics situations and have to think on my feet. Most of the time I’m fairly well-versed in the topics that get thrown at me, but occasionally I run into something I know very little about. This particular email illustrated one of those situations and was a good lesson on how essential change control really is, along with understanding the downstream impacts of systems changes. My reader was happy to provide some background to get me up to speed.

Over the last 15 years, the US Food and Drug Administration (FDA) has been implementing Risk Evaluation and Mitigation Strategies (REMS) for various medications with serious safety concerns. The goal is to reinforce appropriate use and to help reduce the risks of those medications. One of the most well-known REMS is the program for Accutane, which can cause serious fetal anomalies. As a precursor to REMS, one antipsychotic medication, clozapine, has had FDA-imposed monitoring requirements since its approval in the late 1980s. Clozapine is an antipsychotic drug that can sometimes cause low white blood cell counts, leading to a patient being unable to fight infections. In rare instances, those cell counts can get dangerously low. These effects were seen in the initial clinical trials and frequent laboratory testing was needed before patients could pick up their prescriptions from the pharmacy.

Initially, this was managed using a paper process to submit data to the registry, but for some time, the FDA has had a website where prescribers could enter laboratory results and pharmacists could query whether patients were current. My reader states it worked pretty well, including notifications to providers when a patient was late in having a lab result entered.

However, this changed during the initial months of the COVID-19 pandemic. They note, “FDA left the monitoring up to clinical judgment as patients who were stable on the drug for years really didn’t need monthly labs. But before the pandemic and currently, the rules have been quite clear – no lab test recorded, no dispensing of drug.” This made sense in the context of an emerging healthcare crisis when there may have been barriers to patients obtaining blood work, since having people miss medication doses aren’t good for patients, particularly when missed doses could cause relapse of a serious mental health condition. Additionally, when patients are off this particular medication more than 48 hours, they have to be brought slowly back up to their steady-state dose, which creates a window of suboptimal treatment.

Fast forward to the present, where FDA had an issue with the REMS website vendor that resulted in vendor and process changes. It wasn’t clear to the reader which process changes were supposed to be beneficial as opposed to which ones were caused by limitations of the new website contractor. Regardless, the transition has been described as “an unmitigated disaster.” They note that “the new process is hard to understand, even after taking the mandatory training to register for the new website.” There are PDF forms for submission as well as an electronic process, but the new process is more cumbersome with additional fields, poor layout, and suboptimal usability. Additionally, physicians had to re-enter the results for the most recent blood draw in the new system even though they were in the old system.

To cap it off, the website locked out users even though they had pre-enrolled for the new site, and the help line was overwhelmed, leaving many clinicians, pharmacists, and patients worried that patients wouldn’t be able to get their clozapine. Ultimately, following urgent meetings with stakeholders, the FDA temporarily suspended the documentation requirements. In FDA parlance, “Tthe FDA does not intend to object if pharmacists dispense clozapine without a REMS dispense authorization (RDA).” My reader closes out with this thought — even though the FDA has been focused on pandemic-related matters, they could have handled this transition better.

Putting on my “after-action” reporter hat, it sounds like some key steps were missed, things like stakeholder alignment on business requirements, clinical usability review and sign-off on development requirements, user acceptance testing, go-live support planning, and a contingency plan for reversion or emergent intervention if things were not going well. These are all things that many of us deal with on a daily basis and it’s always baffling how these big projects miss the mark. (Case in point: the VA and Cerner, but that’s a much longer topic and I don’t have enough wine in the house to start tackling that one.)

I hope FDA is able to work swiftly with its vendors to get this sorted out so that patient care can take precedence, and that the learnings from this one will allow them to do better in the future. It’s a good reminder for all of us that work with systems that directly impact patients – we need to be vigilant and make sure that corners aren’t cut so that patient’s aren’t harmed.

What’s the most egregious example of poor change management that you’ve seen in your healthcare IT career? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/2/21

Last May, the Office of the National Coordinator for Health Information Technology (ONC) launched its Health Interoperability Outcomes 2030 initiative with a goal of engaging the public around the future of interoperability. It received over 700 submissions of “Interoperability Outcome Statements” during the comment period and has created summary statements to reflect what the future should look like. Several of the summary statements resonated with me based on current projects and recent patient experiences:

• Individuals will be able to seek and receive care (e.g., telehealth, specialty) without needing to gather and provide their health information themselves.
• Individuals will no longer fill out paper forms for any healthcare encounter or process.
• Health professionals will be able to search for and access electronic health information within their workflow and have it presented in ways that intelligently synthesize relevant data.
• Reporting for public health, quality measurement, and safety will all be completed automatically and electronically.
• Duplicate diagnostic tests and procedures will be reduced.
• Health professionals will spend less time on administrative tasks and more time caring for their patients.

If you’re interested in some bedtime reading, individual submissions are also available. Some of the more high-profile submitters have their names listed and a few have videos. Repeat themes from the bulk of the comments include the desire to stop using fax machines, the desire to have end of life or advance directives universally available without being provided by the patient, and the need for a unique patient identifier to support interoperability.

In other government health news, the Centers for Medicare & Medicaid Services (CMS) announced this week that it is ending part of the Primary Care First innovation model, specifically the Seriously Ill Population component. The initiative targeted Medicare clinicians who provided care for high-need, seriously ill Medicare beneficiaries. The patients would be attributed to a specific clinician who would receive additional payments for coordinating and delivering care. CMS determined that the outreach methods planned to identify patients would most likely not result in a sufficient number of participants, making evaluation of the model impossible. The CMS Innovation Center plans to look for other ways to best serve these patients either through new models or enhancement of existing programs.

Zoom announced this week that it is accepting beta customers for its new integration with Cerner’s EHR. The integration will allow for EHR-based provider notifications when patients are in the virtual waiting room as well as sharing of test results during the Zoom meeting. There’s been a Zoom integration with Epic since the pre-COVID days. I wonder how many development hours it took for Cerner to play catch up?

Physicians who rapidly embraced telehealth visits last year have been struggling with lack of integration over the past year often resulting in clunky workarounds as well as patient and clinician frustration. When you look at smaller EHR vendors as well as some of the larger ones, the pace of integration has been slow. I know of quite a few physicians still using completely freestanding telehealth systems or just using conferencing software because their organization claims it doesn’t have the time or resources to work on existing integrations, not to mention the number of folks using systems where they haven’t been released yet. Even when organizations have homegrown solutions to provide integration, they’re still often clunky.

It’s not every day that we see an article about a good old HIPAA violation. HHS settled with five providers who violated the law’s Right of Access Rule, which states that providers have to give patients copies of their medical records in a timely fashion at a reasonable cost. As someone who used to enjoy reading her state’s Provider Discipline Newsletter, I wonder what these organizations did to receive such disparate penalties. Where one pain management clinic received a $32,000 fine and two years of monitoring, one internal medicine physician will pay a $100,000 penalty. A medical group settled for a $10,000 fine and performance of corrective actions. There has been a total of 25 actions since this particular enforcement started in September 2019. Based on the number of health systems I see behaving badly in this regard, I’m surprised there aren’t more actions.

I’m no stranger to wandering through the woods, so I was interested in this “News & Perspectives” piece in the Journal of the American Medical Association. In response to seeing patient take toxic but ineffective drugs during the pandemic, they applied to the US Food and Drug Administration (FDA) for approval to perform clinical trials using medicinal mushrooms and traditional Chinese herbs. The double-blind, placebo-controlled study (known as MACH-19) looks at treatment of mild to moderate COVID-19 with the agents and is ongoing at UCLA and UCSD. Recruitment has been challenging due to declining pandemic cases, however. Another trial is looking at whether medicinal mushrooms can be used alongside COVID-19 vaccines for better protection. The theory is that mushrooms can alter the behavior of immune cells. Unfortunately, robust science takes time, and results might not be available until well into 2022. Hopefully, the pandemic will be greatly reduced by then, but the findings could be helpful for other viral infections. If nothing else, the effort demonstrates the need to actually test proposed therapeutics, rather than encouraging patients to take unstudied drugs or those not meant for humans.

One of my clients offered to add me to their Grammarly subscription, so I thought I’d give it a try. With the various hats I’m wearing and roles I’m juggling, I can use all the help I can get a times. I like how it works with social media and various apps, not only highlighting any potential issues as they occur, but allowing one-click corrections. Apparently, it is impressed that I have a 12-week writing streak and today announced, “You’ve surely earned some ambrosia for your efforts.” I don’t know about ambrosia, but I’d settle for some dark chocolate.

What’s your favorite celebratory treat? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/29/21

The holidays are often a time for families to catch up and share recent happenings. Especially in the ongoing COVID-19 era, there is often a lot of catching up to do if people haven’t been seeing each other as recently as they did in the past, and if they haven’t been keeping up by other means. Although most of my older relatives are on social media (including one who has a Facebook account for each device she owns, because our attempts to explain how accounts work have not been well received), others spent the time catching up on their grandkids’ exploits. I always find it interesting to see how people in the same age bracket embrace technology differently.

In the early days of Facebook, I had avoided joining because I was super busy with a multi-hospital EHR conversion project and didn’t need one more thing to suck up excess time. I remember the night I finally signed up, sitting in a hotel room in the middle of nowhere during a hospital site visit. When it searched my contacts to try to find “friends,” the first person that came up was my then 88-year-old grandmother. It turns out that was the best way for her to see pictures of my cousin’s children, since they lived across the country. Even though she used a computer for little else, she saw the value in trying something new. She was also the kind of lady who spent part of her retirement auditing classes at the community college so she could learn new things, so I think that had a lot to do with it.

Fast forward to this year, and one of our relatives is struggling with a new iPhone that her son bought for her, seemingly without talking to her about it. She had been an Android user for years but her base model phone was low on memory and speed. Since she was on her son’s plan, he volunteered to help her pick out a new device, but it turned into him buying her what she thought she needed versus what she actually needed. Now she’s stuck with an expensive phone she doesn’t like, and the family dynamics make her not want to speak up about getting something else. The grandkids worked with her to do basic things such as connecting her phone to her house’s wi-fi network and doing some minor adjustments to voice-to-text settings, but I suspect she’s still going to struggle with it.

Most of my relatives don’t really understand what I do since I “gave up being a doctor,” so of course there were some conversations about that. I’ve given up on explaining how you can still be a doctor and not necessarily see patients. In the interests of simplifying the explanation, I’ve tried to explain that what I do is kind of like being a medical school professor who helps a resident learn a new surgical technique or a better way to treat a patient, and that sometimes I also work to help create the tools that doctors use to do their jobs. They still don’t get it, but that’s OK. I’m still the one they come to with all their medical questions, even in disciplines I know absolutely nothing about, so I guess I’m still a doctor after all.

There were of course the usual conversations about everyone’s chronic health conditions and the woes of choosing the wrong Medicare secondary policy. Since I’m working on a project that involves heavy use of a health system’s patient portal, I tried to get some information about whether and how my relatives might be using the ones they have access to. Use was all over the map, partly due to limitations in what their providers allow patients to access and partly due to lack of knowledge. It seemed like using it to send messages to the doctor was the most common, followed by prescription requests. No one was using it to read their visit notes, and none of them were aware of the ability to grant proxy access to a family member or caregiver.

The latter would be great for the other members of the family that are doing a lot of caretaking, so I hope they’re able to set this up in the near future. I’m not sure I would push them to read their visit notes since they would probably become aggravated by any inaccuracies or jargon. I recently had a visit at a large academic health system and there were at least five small errors in my note. I’m not going to get excited about it because it doesn’t change the treatment plan but I’m sure they would be less sympathetic if they saw something like that in their notes.

As with any technology, it takes time for adoption to occur, and I see wide variation in how different health systems are encouraging people to use their patient portals as well as in the support that they provide to users. Those that understand how much a well-configured patient portal can help office efficiency promote it more and are willing to spend more resources on development and configuration. Those that instead view it as something they have to provide and don’t want to cultivate likely have a lower return on investment as well as a less-fulfilling patient experience. This phenomenon shouldn’t be a surprise to anyone who has worked in healthcare IT, but I think sometimes people forget it as they’re planning projects.

Since I’m working on a project that assumes heavy use on the part of both patient and provider, I’m trying to learn everything I can about what works and what doesn’t work so I can help create the best solution for my client. In addition to talking to other CMIOs who have maximally leveraged their solutions, I’m taking some classes to really learn the details about what the system I’m working with can and can’t do. I’m working with some great analysts, but there’s always a chance they missed something or didn’t think about it in a way that a physician would, and my client is supportive of the approach.

In talking with a friend who does some clinical informatics work for his university, his institution restricts him from attending vendor classes. I think that’s absurd, especially if he planned to use his own continuing education funds to cover the cost of training. I get that they don’t want random people going to classes and demanding that they make changes that are problematic, but there’s a thing called “discussion” when people have ideas, and preventing staff from learning isn’t a good look for those in higher education. It’s also not a great recipe for stakeholder engagement, but I’ve known that his employer hasn’t cared about that for a very long time, so I’m not surprised.

I hope readers were able to at least get some down time this weekend, and that all the games of “refrigerator Tetris” were successful. What was the best thing you did over the holiday? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/22/21

As health systems continue to refine strategic planning for a potential upcoming influenza season or yet another wave of COVID-19 infections, telehealth is undoubtedly part of nearly everyone’s strategy. As a consultant, it’s interesting to see how different organizations have decided to use it.

For some, it’s strictly for acute visits and urgent-care type services that they can’t accommodate due to packed office schedules. For others, it’s an adjunct to their offerings for chronic care visits, which depending on the condition may be less likely to require a physical exam. Others are using it to grow their business by reaching out to previously untapped patient populations. A small number are using it as an option for physicians and other providers who may not be able to work in-person due to a personal health issue that precludes face-to-face contact with patients, or potentially having a family member at home who is at risk for infection.

I know a number of physicians who are going through cancer treatments or who are otherwise immune compromised and being able to practice virtually has kept them from going on disability or leaving medicine altogether. It’s an option that few physicians had previously and might be one of only a handful of good things that have come out of enduring a global pandemic. Not only is the option good for those individuals, but it’s good for care delivery organizations who would have otherwise lost capacity. When those physicians can keep their own panels it’s ideal since there can still be continuity, but I know that’s not always the situation, such as in the case of physicians who are in procedure-based subspecialties.

Still, there are growing concerns about how telehealth fits into the care landscape. Concerns with the cost of telehealth compared to in-person visits have been fairly straightforward, but questions about the clinical care provided have been less well defined. A recent report from Quest Diagnostics reviewed one of the concerns in more detail. The report, titled “Drug Misuse in America 2021: Physician Perspectives and Diagnostic Insights on the Drug Crisis and COVID-19,” found that almost 70% of physicians worried that signs of drug misuse were missed during pandemic-related care disruptions. The drugs in question include both prescribed substances as well as those obtained illegally.

Researchers looked at some 5 million test results performed by Quest Diagnostics, including 475,000 from the year 2020. They combined that data with survey results from the Harris Poll, which queried more than 500 primary care physicians. The report concluded that physicians are concerned about their ability to manage patients given the risks of drug misuse. In addition to worrying that they missed warning signs of drug misuse during the pandemic, 94% of primary care physicians state they are seeing an increased number of patients with mental health issues during the pandemic and “fear a correlation between rising mental health issues and prescription drug misuse.” Additionally, 98% of physicians are concerned about issues with controlled substances as a whole, compared to 75% who are concerned about opioid medications.

Specific to telehealth, 75% of physicians are concerned that telehealth visits limit their ability to identify whether patients are at risk for or already having issues with prescription drug misuse. Where 91% of physicians feel they can recognize warning signs during in-person visits, only 50% feel they can recognize issues during a telehealth visit. In my experience as a physician, most of the warning signs I’ve identified come from the patient’s history and discussion of their current situation rather than from the physical exam, so I find this phenomenon interesting. Beyond the information gathered from the patient’s story, I’ve used data such as refill patterns or information from prescription drug monitoring program records to identify potential misuse. Although I don’t question how some physicians feel, I’d be interested to understand more deeply why they feel this way and what they find lacking in a telehealth visit.

Another angle that was brought up was the idea that physicians are less willing to prescribe opioids during the pandemic, as well as the lack of alternatives for treatment for chronic pain. Nearly 80% of them are concerned that patients will turn to illicit fentanyl if they can’t get prescription medications, with 86% of them being concerned that illicit fentanyl will lead to higher death rates than prescription opioids. I totally understand not wanting to prescribe controlled substances during a non-face-to-face visit, especially since I was fairly strict in traditional practice as far as random drug testing during visits, and agree that we need better options for treating chronic non-cancer pain. The illegal drug crisis is real and it’s important for physicians to have strategies to identify such drug use, but I don’t think that a telehealth visit rules out that ability.

The report went on to look at drug testing as a component of treatment, with 81% of physicians seeing it as critical to prevent overdose deaths. However, more than half of physicians aren’t following up when presumptive drug tests are positive, and it’s not clear why. Given the capabilities of EHRs to include flowsheets for medication management as well as trackers and prompts for drug surveillance testing, I wish more of my peers would take advantage of those features so that they could more confidently care for patients. Additionally, only a third of physicians felt confident in prescribing naloxone to treat potential opioid overdose. It’s pretty easy to configure order sets that include both opioid pain medications and naloxone, so failing to do so is another missed opportunity to leverage technology. Existing clinical guidelines can be built into the EHR to help with clinical decision making and screening for changes in prescribing patterns.

I think it’s important to not overlook telehealth as a potential adjunct to pharmaceutical pain management. There are many providers out there who offer psychotherapy via telehealth, which could help as part of team-based care to identify patients who might not have their needs met with current pain management regimens. With the potential of using lower-cost resources such telehealth therapy versus in-person physician visits, patients could have more frequent check-ins about their needs as well as the ability to learn additional techniques to better manage their pain. Other options like telehealth-enabled physical therapy could be added for patients who might not be able to participate in traditional physical therapy appointments due to time or logistical limitations.

I polled a few primary care colleagues about the report, and their consensus opinion was that identifying drug misuse was more about having a relationship with the patient and ongoing contacts than it was about being in-person versus virtual. They were significantly more concerned about fragmented care as a risk factor for drug misuse as opposed to telehealth. I’d be interested to hear if any reader institutions are looking further at this issue, and whether they’re reaching different conclusions.

Have any thoughts on the connection between telehealth and prescription pain medication abuse? Leave a comment or email me.

Email Dr. Jayne.