Curbside Consult with Dr. Jayne 7/25/22

This weekend marked the first time in a decade that I took a trip without my laptop. It was weird at first because my backpack felt surprisingly light, but it was good to know that I couldn’t slip into the trap of doing work even if I tried.

Now that the workplace is more mobile, and especially when some companies offer unlimited time off, it’s tempting to blur the lines between the work day and the rest of your life. It was a great opportunity to connect with old friends and focus on spending time together as we crammed as much adventure into 48 hours in the Big Apple as possible.

Of course, since we were a group of healthcare IT people, there were plenty of opportunities to discuss where the industry has gone since we all worked together at a big health system. Several in the group have moved into the non-profit space and payer space, which was interesting to learn about compared to others’ experiences in the vendor and consulting spaces. One person’s resume reads like he’s a job hopper, but in reality, he has been in the same job, but his company has just been merged and acquired multiple times. I’m not sure everyone would pick up on that just looking at his employment history.

There was a lot of chatter about the Amazon acquisition of One Medical for nearly $4 billion. Nearly everyone in the conversation was concerned about Amazon having access to patients’ protected health information, even though the company issued a statement that they don’t plan to share health information to advertise or market other Amazon products without clear permission from patients.

Several of us brought up the point that most consumers don’t read terms and conditions, even when there are limited updates to an agreement, so it’s likely that Amazon could obtain such a consent without patients full understanding what they’ve accepted. Most of us are a bit skeptical about how this is going to play out, so we’re going to have to watch it as the deal moves towards the regulatory approval it needs for closure.

Digital health startups were a hot topic throughout the weekend, and one of my traveling companions sent me an article that caught his attention. It’s from the Journal of Medical Internet Research and looks at the “clinical robustness” of companies in that sector. The background for the article notes that “health care technology stakeholders lack a comprehensive understanding of clinical robustness and claims across the industry.” That phrase caught my eye as well, since I’m constantly seeing companies that make me wonder what exactly it is that they do and why people, including investors, are so excited about them. Certainly there’s a hype factor for a lot of digital health startups, as well as a great deal of marketing, but the meaty information tends to get pretty thin when you start to dig into some of them. The article looked to assess clinical robustness along with the claims made by companies.

The authors used data from the Rock Health Digital Health Venture Funding Database, the US Food and Drug Administration, and the US National Library of Medicine. (It should be noted that three of the authors are employees of Rock Health, although the article states that no individuals involved in investments were part of the analysis.) The authors defined clinical robustness using the sum of the number of regulatory filings and clinical trials completed by each company with each having equal weight. For the companies’ claims, the authors looked at company websites. They looked at 220 digital health companies with an average tenure of 7.7 years.

The average clinical robustness score was 2.5, with a median score of 1. Companies specializing in diagnostics had the highest scores, followed by those focusing on treatment and those specializing in prevention. The authors found that 44% of the companies they looked at had a clinical robustness score of zero. There was no correlation between clinical robustness and the number of publicly made clinical claims or between clinical robustness and total funding.

There were some other interesting statistics in the article:

• More than 1,900 digital health startups have raised more than $2 million in venture capital funding in the US.
• In total, digital health startups have raised more than $77 billion in venture capital funding.
• Multiple studies have shown the need for greater clinical validation.
• Many solutions are not supported by robust clinical evidence.
• Solutions have mixed results on cost savings and cost-effectiveness.

Additionally, the authors noted that there have been examples of misleading claims in the industry, as well as actions by the Federal Trade Commission and state attorneys general. They note the limitations of using publications as a proxy for clinical impact, especially given that there is often a lag in publications. There were also limitations in that they only looked at venture-backed startups in the US that had raised at least $2 million in funding, which may have excluded early-stage companies as well as larger technology companies. They also note the need for deeper research into the effectiveness of solutions.

I found it amusing that the article noted that “all data were stored in Microsoft Excel,” where the calculations were performed. Excel isn’t always the most sophisticated tool, but it’s gotten the job done for me more often than not.

It would be interesting to do a follow-up study to see how many of the startups that the authors looked at are even here in two, five, or 10 years and what their clinical robustness might look like over time. I suspect we may see some significance between funding and clinical strength or between time in the market and clinical outcomes. In the short term, though, it’s often difficult to demonstrate value beyond individual case studies and client profiles. It’s certainly challenging to wade through some of the content on company websites and to truly know how broadly a solution has been deployed or whether clients are happy with it.

What do you think about the idea of measuring clinical robustness for digital health tools? What markers might you use beyond those selected by the authors? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/21/22

As I put together my travel schedule for the next year, I’m looking at various conferences. One that caught my attention in email was Becker’s 8th Annual Health IT + Digital Health + RCM Annual Meeting. The attention-getter was its list of keynote speakers including former President George W. Bush, former professional boxer Sugar Ray Leonard, and professional golfer Michelle Wie. It’s certainly an eclectic mix of speakers and I’m not sure how much they individually have to bring to the digital health discussion, but hopefully someone who is willing to pay the $950 admission fee will clue us in.

The costs for conferences keep rising, and it’s not always clear whether attendees receive the value offered. For comparison, the American Academy of Family Physicians charges between $695 and $895 for its Family Medicine Experience (FMX) conference. The National Association of Community Health Centers charges $1,290 for member organizations to attend its annual Community Health Institute & Expo and $2545 for non-member organization attendees. HLTH is pricing registration for in-person admission at $2,295. Typically, an employed physician might have one conference covered by their employer per year, so there are certainly some choices to be made.

I’ve been working with EHRs and consulting with vendors for more than a decade, so it’s been gratifying to see the improved focus on patient safety and greater movement towards standardization. A Viewpoint article published in the Journal of the American Medical Association last week discussed ways that we can continue to improve EHR safety and usability. The authors note that computer-based records have failed to live up to their promise particularly as related to the support of health care providers’ thought processes and that in fact the EHR creates distractions for caregivers.

They state that “…the term electronic health record” is a misnomer… It is not designed primarily to capture and present a patient’s record as efficiently and effectively as practical.” They go on to recognize what we all know – that “…the EHR has many stakeholders, including physicians, health system executives, educators, regulators, and patients whose needs influence EHR capabilities. In the US, requirements for reimbursement, regulatory compliance, and administrative workflow automation often take precedence over clinical efficiency and effectiveness.”

I don’t think anyone who has been working in the healthcare IT space for any length of time would disagree. We’ve all been stymied by EHRs that won’t let us document things the way we need for the patient in front of us. For example, one EHR I worked with didn’t have the capability for the physician to set a default follow up instruction of “within 24 to 48 hours.” The system’s designers insisted that a date be used, which doesn’t necessarily support what the urgent care physician is trying to say when they want a patient to see a specialist quickly but not necessarily on a certain date. As a result, the physician ends up free-texting what they want on every single patient rather than taking advantage of labor-saving features – which costs much more time and money in the long term. There are also organizational impediments to efficiency, such as when EHR decision makers refuse to let clinicians personalize their workflows because of a fear of increased maintenance or support costs.

The Centers for Medicare & Medicaid Services published a final rule stating that hospitals should review their systems using the Safety Assurance Factors for EHR resilience (SAFER) Guides so that they can evaluate usability and safety of clinician systems. The authors call for greater focus on minimizing the cognitive load created by EHR workflows. When there is too much mental effort needed to complete a given task, user performance suffers. The authors propose a SMARTER Guide to improve EHR cognitive support:

• Synthesizing information and supporting goal-oriented search.
• Monitoring care decisions, taking patient data and care setting into account, and suggesting better alternatives.
• Automating routine tasks.
• Recognizing trends toward or away from idealized patient models.
• Translating important user actions into documentation.
• Exposing contextually relevant data; and
• Reliably and consistently performing these functions.

It will be interesting to see how some of these elements are incorporated into technology over the next few years, and whether technology begins to better serve clinicians or whether it continues to be a distraction.

As an avid outdoor adventurer, sustainability and environmental protection are high on my priority list. I enjoyed this article in the Journal of the American Medical Association that looked at the use of informatics to assess healthcare systems with regard to climate impact and environmental footprint. The authors note that healthcare delivery  — including facilities, pharmaceuticals, and more — accounts for approximately 5% of global carbon emissions and propose informatics efforts to monitor healthcare’s carbon footprint. Other contributors include supply chain (production and transportation of supplies) along with staff travel and waste disposal. The authors propose synthesizing economic activity data alongside life cycle assessment models for products and processes.

Most of the organizations cited in the article are located in the UK or Australia. I would be interested to see how US organizations are looking at the problem. One of the aspects that was mentioned was one that I’ll admit I hadn’t thought very much about in the context of sustainability – wasteful clinical practices. This includes unnecessary imaging, duplicate tests, medication overprescribing, and unneeded surgeries. Many patients in the US feel that greater technology use leads to better outcomes and that medications are a much better solution than more environmentally friendly treatments such as lifestyle modification. Often the decisions made for hospital purchasing are focused strictly on cost without consideration of environmental impact, so there will need to be significant changes in priorities in order to see downstream impacts on climate or the environment.

One of my favorite readers clued me in to this publication on health worker burnout from US Surgeon General Vivek Murthy. He cites Hawaii Pacific Health’s “Getting Rid of Stupid Stuff” initiative as an example of identifying and mitigating workflows that staff felt were unnecessary or poorly designed. The effort led to a savings of 1,700 nursing hours per month across the organization.

A specific example of burnout-generating work is the prior authorization process. Although I understand the need to reduce ordering of unneeded treatments and tests, I’ve long proposed some kind of golden ticket for those of us who order judiciously. In my time as a traditional family physician, I never had an order that failed to be authorized, which meant I was following guidelines. With years of that kind of track record under their belts, why should physicians be subjected to unneeded scrutiny? To be certain, all those unwarranted prior authorization process cost the payers more money than they saved.

Should providers who follow guidelines and control costs be rewarded by reduction in administrative burdens? Would such a move serve as an incentive for clinician behavior? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/18/22

I spent part of the weekend hanging out with some longstanding healthcare IT friends. There was plenty of catching up to do. It was great to hear about everyone’s newest projects and what they think will be hot in healthcare over the coming years. We all used to work together, but now everyone is scattered to the winds at various health systems, consulting firms, payers, and vendors. A couple of have even retired and I enjoyed hearing about their many adventures and how much they’re enjoying not being part of the madness anymore.

Several of us have had experiences helping or parents or other relatives navigate the healthcare system in recent years, so there were plenty of conversations about the usefulness of various patient portals and how our loved ones are or are not using the information available to them. One hot topic was patients having access to their notes from medical visits. Although most of the folks I was speaking with were eager to see their own documents, probably due to the fact that we’ve spent so much of our careers dealing with EHRs and other clinical IT systems, very few of their parents show an interest in reading their medical notes.

The clinicians in the conversation voiced concerns about patients being able to see their notes and “how bad they really are” due to EHR-related note bloat. There were few concerns about patients reading things they would find worrisome or being offended by discussion of hot button issues such as obesity, smoking, alcohol use, or drug use. Nearly all felt that the benefits of transparence outweighed concerns, although one clinical informatics nurse lamented the fact that many of the clinicians that she supports write notes that can be described as “terrible,” including typos, sentence fragments, and disordered thought processes. I certainly feel for that physician’s patients if they try to access their information.

With that conversation fresh on my mind, I was happy to see a link in my email to a recent article in the Journal of the American Medical Informatics Association that looked at the impact of patient access to notes on clinical documentation. The authors set out to examine whether recent rules that require patient access to clinical notes have had unintended consequences, such as increasing physician documentation burden. They used what they describe as “a national, longitudinal data set consisting of all ambulatory care physicians and advance practice providers using an Epic Systems EHR” to specifically evaluate the length of clinical notes and the time spent documenting in the EHR.

As background, the 21st Century Cures Act language that required that healthcare organizations provide access to notes was implanted on April 5, 2021. The authors used “de-identified clinician-week level EHR audit log metadata extracted by Epic’s Signal software” to look at aggregate data from January 3 to May 29, 2021. This data covered over 340,000 unique clinicians for 21 weeks and excluded inpatient data. Analysis models controlled for the number of visits that clinicians were performing each week as well as other factors that might impact individual productivity. The authors also checked their data by looking at only primary care physicians and also by stratifying to compare physicians against midlevel providers. During the initial post-rule period, there was no statistically significant change in note length or documentation time.

Interestingly, providers spent more than 12 minutes creating each note, which is significant given the fact that a large number of visits delivered in the US are scheduled for approximately 15-minute appointment times. In the discussion, the authors acknowledge that they were looking at the potential for short term impacts and that more work is needed to evaluate whether there are long term impacts on having patients access their notes. Although I like how the authors approached the problem as well as their use of a large and available dataset, I wonder how many of the organizations in that dataset were actually releasing their notes at the time of the study. My own health system didn’t start releasing notes to patients for at least six months after the rule went into effect, although they did release content retroactively, which was a surprise to me as a patient.

Now that I have access to my notes, I look at them often. I have found their content to be largely fictional. My last preventive health visit contained two full pages of screening questions that were never asked during the visit as well as exam elements that weren’t performed. There were also inaccuracies in my responses to questions, along with what I find to be a very annoying disclaimer that the documentation “was created with voice recognition software and may contain errors or omissions.” Seriously? I can’t imagine having a patient see that information in one of my notes, and it definitely makes me think less favorably about the clinician I saw, especially since I wasn’t happy with the visit in real time.

I wonder how many patients are actually looking at notes that are available and whether they’re communicating with clinicians when they find problems. I know I don’t have time to deal with trying to get a correction, so I’m going to just let it be even though those inaccuracies will likely propagate themselves across other entries in the future. Even thinking about trying to correct it is tiresome.

I would love to see research looking at how many health systems are actually releasing their notes, how many have communicated to patients that the notes are available, and how many are encouraging patients to use the information to better their health. I suspect that the results of those kinds of efforts would be rather interesting.

The authors note that they are also unable to quantify non-note work that may have increased due to the availability of patient facing notes, such as increased patient phone calls or portal messages. I know that when I put on my CMIO hat to approve patient-facing documentation, I always try to make any default language as clear as possible to avoid creating confusion. However, I’ve seen plenty of notes where clinicians go crazy with free text and create plenty of confusion that I will never be able to influence.

Who’s ready to look at this data again, and see what it looks like 12 to 18 months into the process? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/14/22

I spent some time on Wednesday attending a deep dive on “The Platform Revolution Comes to Healthcare” as part 2022 MIT Platform Strategy Summit, which is taking place in the Boston area this week. The initial speakers, Vince Kuraitis and Randy Williams, spoke to what they described as four healthcare platform megatrends:

• Synergy. Platforms advance (and are advanced by) four key healthcare trends – value-based care, consumerism, interoperability/data sharing, and home/virtual care.
• Investment in digital health is fueling platform growth.
• Platforms are shaping new operational ecosystems.
• Platforms are transforming the competitive landscape in healthcare.

One of the highlights was the keynote fireside chat with Jonathan Bush, who described his experiences in building healthcare platforms. He had an interesting analogy about Dudley Dursley in the Harry Potter books, likening healthcare to Dudley. Healthcare isn’t evil, but it still kills people every year, so “we jack the safety net up so far” that “there’s no ability to move about the cabin” and trying to figure out how to innovate without violating the social safety net.

He refers to his former clients at Athenahealth as “kooks” with great affection. He notes that in healthcare, the demand curve doesn’t function the way that it does in conventional businesses, because there really isn’t a choice to not buy the service and keep the money. He notes two things that have shifted the demand curve – the COVID pandemic, which has shifted acceptance of virtual-first approaches, and the ability to assemble robust tech stacks.

I chuckled when he described in-person care as “lumbering in and taking your pants off and sitting on waxed paper every three months.” Jonathan has certainly mellowed over time, and I always enjoy hearing his thoughts. It will be interesting to see how Zus Health plays a role moving forward.

Speaking of healthcare transformation, we’re approaching the point at which health plans and insurers have to provide pricing information to the public. As of July 1, CMS required those organizations to provide machine-readable files for in-network rates and allowed amounts respective to various medical charges. Starting in 2023, they must also provide online price comparison tools to allow patients to estimate their individual payment portion for a list of over 500 items and services. In 2024, they will have to provide price comparison tools covering all services. Organizations that fail to comply face a fine of as much as $100 per day for each violation for each affected enrollee.

I’m all for empowering patients to understand the costs and options for various services, but publishing this data doesn’t take into account the differences between the same services performed at different facilities. These nuances often inform how physicians order their tests. For example, I am extremely high risk for breast cancer, to the point where I could easily qualify for preventive surgery. Prior to undergoing consultation with an expert, I used to have my mammograms at an independent general imaging facility because it was convenient, the costs were low, and a preliminary reading was provided before I left the building.

However, after having multiple consultations with nationally known experts in the field, coupled with genetic testing, I switched to having my mammograms (and now MRIs) performed at a more costly facility that has subspecialty radiologists interpreting all the studies. The average patient doesn’t understand that subtlety, and with the devaluing of comprehensive primary care in the US, I doubt those kinds of conversations are going to be happening in the exam room.

Speaking of genetic testing, I was excited to see the announcement that Myriad Genetics has partnered with Epic to make genetic testing more nearly seamless for patients and providers. My own Myriad testing several years ago was ordered with a daunting-looking triplicate paper form, where the medical assistant had to transcribe dozens of data points that already existed in the EHR. Results came back on paper, which the office had to scan into the chart. They were supposed to mail me a paper copy, but somehow couldn’t get it out the door, so after weeks of delay and begging on my part, I finally received a PDF version of the scan, minus the pretty color that I’m sure was in the original paper result. Less than ideal, but I’m excited that future patients will have better options for receiving their results and that physicians will be able to fully explore the value that discrete data brings.

Once upon a time during one of my work trips, I became a patient at Mercy. They recently sent an email to patients with “MyMercy” MyChart accounts asking them to take a survey about a new feature. Apparently  they are evaluating the possibility of implementing Epic’s MyChart Bedside capabilities and wanted patient input.

Having been on the health system side of healthcare IT, it’s often difficult to prioritize initiatives unless they are regulatory or otherwise mandated. Understanding how patients would use or not use a potential new feature seems prudent given the limited resources available to most IT teams. Survey participants were asked to rank a list of features based on how useful the participants thought they would be during an inpatient stay. I’m not a regular consumer of care through Mercy, but I did appreciate the outreach. I’ve got some contacts from residency that work there so will be interested to see if I can find out how the results are being used to make decisions.

Former telehealth darling (and now telehealth pariah) Cerebral tried unsuccessfully to recruit me before its fall, but I’ve ended up on one of their mailing lists. The company is conducting an all-out messaging campaign to explain its new focus on clinical quality and its vision for comprehensive mental health care. Putting on my primary care hat, I’m unimpressed by their messaging. It’s going to take a long time for them to overcome the perception that they have been prescribing controlled substances like someone giving out candy at Halloween.

Since I care for children, another physician recently asked me for my thoughts regarding the “right” age for her personal child to get a cellphone. This is often a hot topic around the neighborhood as well, with every child seemingly stating that “everyone else has one but me.” There’s a growing body of data demonstrating that mobile devices are harmful to mental health. One physician I refer to stated that smartphones are little more than “dopamine dispensing slot machines.” Discussions  at the recent Endocrine Society meeting highlighted issues with smartphone-associated behavioral issues, sleep disruption, and obesity.

Most adults I know don’t have the ability to separate from their phones, so it’s not realistic to think that the relatively underdeveloped brains of children would make it any easier for them. The article links to a number of publications in the medical literature regarding cell phone and screen use. If you’re a parent of children or adolescents, or if you are concerned about your own dependence on mobile devices, it’s worth a read.

Do you think that constant smartphone access and the prevalence of social media is making the world a better place or consigning us to a dreary future? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/11/22

I missed the initial announcement last month, but the US Department of Health and Human Services has issued guidance on “How the HIPAA Rules Permit Health Plans and Covered Health Care Providers to Use Remote Communication Technologies for Audio-Only Telehealth,” which will apply even after the Office of Civil Rights “Notification of Enforcement Discretion for Telehealth” no longer applies. Audio-only telehealth is important for populations that don’t have adequate broadband access or who can’t access video visits due to disability, cell coverage, or other factors.

Seeing telehealth patients over the last four years, I found that nearly half of the patients I treated preferred audio-only visits, for a variety of reasons. There are some interesting details in the document on the use of traditional landline phone services as compared to electronic communication technologies such as internet-based phone services, cellular service, and Wi-Fi. The HIPAA Security Rule applies to the latter technologies, but not the POTS lines, although I’m not sure how many covered entities still use copper wire for their communications.

Most large healthcare organizations are trying to forecast what their use of telehealth services will look like in a post-pandemic world. In speaking with CMIO colleagues, it seems like their ideas on the topic run across a pretty wide spectrum. There are quite a few who feel that telehealth has provided substantial benefit for patients and providers and therefore plan to continue it. Those organizations are increasing telehealth budgets, working on staffing strategies, and more.

One health system that I follow is doubling down on virtual primary care, standing up virtual clinics and virtual patient panels. From a technology perspective, it feels like they’re just replicating their in-person workflows in the virtual world, complete with staff performing intakes and then referring patients to go visit the hospital lab and pharmacy at the end of the visit. They’re not yet approaching things like home phlebotomy or medication delivery. Other than not having to leave the house, the visits are pretty much business as usual, so they should seem familiar to the patients.

Another system I’ve consulted for in the past is retreating from telehealth somewhat. They’re adding additional capacity for nurse practitioners and physician assistants to offer same-day acute visits and are reducing the options for telehealth visits with primary care physicians so that the physicians can focus on patients who need to be seen in the office. That approach likely provides less convenience for patients who have grown accustomed to telehealth, and also potentially requires more real estate square footage since they’re going to have more providers and increased foot traffic in the offices. They feel that telehealth is impersonal and that their patients want a level of care that can only be given in person. As a patient, I’d argue that in-person care also brings a level of annoyance that many of us are trying to avoid.

We’ll have to see how it plays out and whether their capacity forecasts are accurate or whether they see patients defect to the health system across town since it’s still offering plenty of telehealth availability.

A recent survey from the Associated Press-NORC Center for Public Affairs Research and the SCAN foundation asked 1,000 US adults for their thoughts about what their lives will be like after the pandemic. While 48% said that telehealth was a “good thing” that should continue to be available, 52% responded that they’re not likely to use virtual care in a post-pandemic world. The breakdown of responses by age was interesting. For adults over 50, a mere 16% said they would continue telehealth visits. Looking at a younger crowd, 22% of adults under 50 said they would opt for virtual care. Not surprisingly, respondents with concerns about being infected with COVID-19 had a higher likelihood of wanting to continue with virtual healthcare. Most of the patients I see are in the under-50 age bracket, so I think it’s fairly likely they’ll want to continue with current telehealth options.

Looking more generally at the responses, only 12% of adults felt that their lives are the same today as they were before the pandemic, where 54% feel that life is somewhat the same and 34% feel their lives are not yet the same. Still, many adults in the US have resumed their pre-pandemic activities, including socializing with friends, dining out, visiting older relatives in person, travel, and worship. Only about half plan to use public transportation, which I find surprising given the rising cost of fuel (survey responses were gathered May 12-16, 2022).

Despite increasing COVID in my community (at least according to sewer shed data, since testing numbers are no longer reliable), the majority of people seem to be going about their business without masks, even though they’re recommended. I’ve had a combination of allergies and a cold for the last week, complete with eight negative COVID tests, and am convinced that since I haven’t had a cold in the past two years that I’ve forgotten how miserable it can be. Of course, it might just be undetectable COVID, but based on the negative tests and narrow symptom profile, I’d be surprised. No one I’ve been around has reported being sick either, so it’s a bit of a mystery if it’s something beyond just some wicked allergies. I engage in most of my pre-COVID activities, although most of them tended to be outside or with small groups of people and are fairly low risk.

I’ll be increasing my risk tolerance in coming weeks, as I have a couple of leisure trips coming up. I’ll be masking on the plane and in the airport and anywhere that seems like it doesn’t have great ventilation. One of the events I’m attending promises to be a reunion of sorts with lots of healthcare IT people I’ve worked with in the last decade, so I’m excited about that, as well as the ability to spend some quality time with one of my favorite healthcare personalities. I did some checking on the places I’m headed, and it looks like some of the entertainment venues still have mandatory masking. It will be interesting to be somewhere that’s a little stricter than home as far as preventive measures. I’ll be traveling with a stash of COVID test kits just in case, although I’ll be keeping my fingers crossed that I won’t need them. Hopefully during my travels, I won’t need any telehealth services, although I know where to find them if I need them.

Have you had to use telehealth while on vacation, and what was your experience? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/7/22

I’m back in the swing of things post-camp and am grateful that all was quiet at my day job. Now I’m wearing my blogger hat and wading through several hundred emails trying to figure out what happened in the healthcare IT world while I was gone.

There were the usual press releases, government updates, emails from my professional organizations, and what seems like more than my share of messages that should have been flagged as spam yet were sitting in my inbox. I had links to a handful of interesting journal articles, some clinical updates, and of course the latest and greatest about monkeypox (which is apparently still awaiting a new name courtesy of the World Health Organization).

The first article that caught my eye looked at using data from Twitter to better understand how the public thinks of FDA-approved versus off-label use of medications to treat COVID-19. The authors used natural language processing to evaluate 600,000 tweets that originated in the US between January 2020 and November 2021. They examined content mentioning four drugs that received a lot of attention during the pandemic. Both molnupiravir and remdesivir were FDA-approved treatments for COVID, where hydroxychloroquine and ivermectin had only anecdotal evidence for their use.

Not surprisingly, the authors found that the unapproved agents were mentioned more often, especially during pandemic surges. They also found that Republicans were more likely to support the unapproved agents than Democrats. Individuals with healthcare backgrounds opposed the unapproved agents more than the general population. The authors concluded that “social media users have different perceptions and stances on off-label versus FDA-authorized drug use across different stages of COVID-19, indicating that health systems, regulatory agencies, and policymakers should design ‘targeted’ strategies to monitor and reduce misinformation for promoting safe drug use.” This certainly becomes more difficult in states where governmental agencies and the courts took steps to promote or protect the use of unauthorized drugs. It will be interesting to see how this continues to play out now that we’re no longer in the most explosive phases of the pandemic.

The next article that caught my attention was about decision fatigue. The term refers to “a state of mental overload that can impede a person’s ability to continue making decisions.” Whether they’re small decisions or more significant ones, decision fatigue can leave individuals feeling “overwhelmed, anxious, or stressed” and can interfere with ongoing decision-making ability. According to the psychiatrist featured in the article, individuals make over 35,000 decisions during the course of a day, consciously or not. The COVID-19 pandemic has added stress for physicians as we navigate decisions in an increasingly complex healthcare environment. She notes that physicians have “had to make decisions we never had to make before, and we’ve had to manage the anxiety of our patients.”

Many of us have also had to manage the anxiety of family members as well as their healthcare needs, from helping them schedule vaccine appointments to making sure they can navigate through the web of in-person versus virtual visits over the past two years. One member of my family postponed a joint replacement during the pandemic and was just able to have surgery last month, which was a great relief. Decision fatigue can leave people feeling tired, drained, or with foggy thoughts. People are also likely to engage in unproductive processes as a result, via procrastination, avoidance, indecision, or impulsivity. We’ve all seen enough pandemic buying to explain the latter, and I’ve definitely seen the first three among my friends and colleagues as well.

Strategies for overcoming decision fatigue include creating daily routines, making lists to help avoid random decisions, simplifying repetitive processes through services such as automatic bill pay, and reducing tasks and activities that don’t provide value. The psychiatrist notes that “research shows that the best time to make decisions is in the morning” which is a time “when we make the most accurate and thoughtful decisions, and we tend to be more cautious and meticulous.” It makes sense to me – I know that by the end of the workday, my brain is pretty much fried.

The third item that caught my eye was an ONC blog that talked about health equity by design. It summarized some of the findings of ONC’s Health Information Technology Advisory Committee (HITAC) as it looked at creating equity in data collection, interoperability, artificial intelligence, bias, and crossing the digital divide. Since data collection is important to understanding outcomes and measuring change, it will be important to capture information on race, ethnicity, sex, language, disability, sexual orientation, gender identity, and social determinants of health. Although many organizations are doing a good job capturing these elements, I often see charts where many of the fields are blank.

Bias is important especially where artificial intelligence is concerned. There have been numerous articles in the last several years looking at how particular models perform when factors are different from the data set on which the model was trained, such as when a particular demographic isn’t adequately represented in the data set. There have been significant changes in how we manage certain laboratory values based on evidence versus old ideas that race is more of a factor than it should have been.

One example of this is kidney function. In the past, race was used to set different reference ranges for certain lab values. Scientists have realized that using race can be problematic since it doesn’t necessarily represent a specific genetic makeup or group of underlying biological characteristics. I’m excited about efforts to deliver healthcare in a more equitable manner, and especially initiatives that use technology to ensure quality care for all. I’ll definitely be watching to see where some of these efforts go.

Speaking of excitement, it’s July, which means the beginning of Internship year for many newly minted physicians as well as residency promotions for other trainees. My medical school recently reached out to me asking for help inspiring the incoming MD class, who will be receiving their white coats in a ceremony later this month. I trained at a time when there wasn’t any ceremony and we just felt lucky to get a coat that fit (and many in the class didn’t, which resulted in a lot of swapping after the fact) as we raced into our third year of medical school.

New students receive theirs in the first year after several orientation weeks, and they’re not only sized properly, but are embroidered with their names and the school crest. I’m sure it instills a sense of pride and accomplishment, although based on the state of healthcare today, I’m not sure I have any inspiring thoughts for those entering a system that seems more dysfunctional than it did even a few short years ago.

What do you wish you had known when you started your journey in healthcare or healthcare information technology? What would you tell today’s entering medical students? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/30/22

I’m still in the woods. We have had good weather, so I’m grateful. I ended up sharing some of the first aid duties with one of my favorite nurses. The camp has a new policy about how we document medications that are given the participants and there’s a bit of redundancy to it. One of the volunteers was complaining, but the nurse mentioned the EHR that she uses in her hospital and the fact that she’s used to documenting the same thing in multiple places. I literally laughed out loud. I’m sure the other volunteers thought I was suffering from the campsite psychosis that typically develops late in the week, but it made my morning.

I hopped on a work call to help with some testing in the production environment. In the software world, companies sometimes refer to “eating their own dog food,” while one of the other volunteers who is a software engineer said that his company refers to it is “drinking their own champagne.” I hadn’t heard that one before, but I like it, although it’s pretty presumptuous to assume that what you’re releasing is top shelf. I’ve used plenty of software that’s closer to Three Buck Chuck than it is to Dom Perignon.

My organization is bringing up some new features and has a solid plan for the go-live, so while we were troubleshooting a small issue, we were talking about past go-live experiences. We collectively decided that intensive care unit go-lives are the most nerve wracking, although those on the labor and delivery unit are a close second. One of the major challenges with changes to the system for L&D is that you have to be able to immediately document on a patient who didn’t exist just moments before, and for whom you have no information. It’s similar to managing a John Doe patient in the emergency department, although the odds of having a John Doe during a go-live are significant smaller than having new babies arrive.

After more than two years dealing with the COVID-19 pandemic, hopefully EHR developers and those who support ambulatory clinics will be able to swiftly make the changes they need to combat the growing monkeypox outbreak. More than 50,000 doses are being shipped to states with the highest case rates, which means that systems need to be updated to document their administration. I’ve worked with a couple of niche EHRs where the vaccines are hard coded or difficult to configure, so I hope the clinics that receive the doses have systems that make it easy to capture such important patient care information. Plans are in place to distribute more than 1.25 million doses in coming months. I hope we can get ahead of the problem rather than be in reactive mode like we were for COVID.

This article caught my eye, noting that half of public databases in the US misuse gender and sex terminology. This is one of my pet peeves. I’ve worked with vendors who do a good job understanding the difference between the two and those that don’t. The authors looked at 75 databases used in biomedical research and also looked at journals to see if they had author guidelines that addressed these factors. Understanding sex and gender is important to better quantify the ways in which sex and gender drive clinical outcomes.

For those who need a quick review, “sex” refers to biological attributes such as anatomy, chromosomes, hormone levels, and gene expression. “Gender” refers to expressions, identities, social roles, and behaviors. I hope that the software vendors who continue to use these values interchangeably will eventually get it in gear.

I’m keeping it short this week since I need to get back to my camp duties. It’s been great to see how the participants are already growing and learning new things. The group I ate breakfast with this morning made my day. Since they knew that I was their assigned adult, they cooked my pancakes in the shape of a J. When you have the chance to work with people who have that level of commitment to caring for others, it gives you hope for the next generation.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/27/22

It’s that time of year, when I typically take a week off to volunteer at one of the nation’s premier summer camps. It’s always an adventure. I’m hoping that despite COVID surges in the area that we have what we previously would have considered a “normal” summer camp experience. Of course, there will be masks indoors when we are in close quarters, but there will be plenty of time to run around in the great outdoors and for the campers to have fun with their friends.

It’s been a scorcher across large parts of the US over the last couple of weeks. I’m hoping for at least a little break so that I don’t have to spend the week treating heat exhaustion, headaches, and dehydration. I’d much rather be teaching fire building, knots, lashings, and wilderness survival skills.

Although the camp offers most of the traditional activities like fishing, swimming, canoeing, kayaking, archery, and various other shooting sports, it also offers some great STEM (science, technology, engineering, and math) options. Welding is available, as are programs in movie making, game design, electronics, and geocaching. There is something for everyone. Usually the best part of the day is dinner, where an adult sits with each table of campers and gets to ask questions about their day and what they liked best.

I always get some interesting questions about what I do in my real life. The staff knows I’m a physician, but they also know I do something with computers on the side. Almost every adult has used a patient portal by this point, so I use that as a way of explaining the kind of work I do and how we help physicians make better use of information and that we help patients have a better experience. There are usually a lot of questions about what kinds of things we can do as telehealth physicians.

Although this camp is old school as far as facilities, I’ve worked with camps in the past that have remote examination setups that really deliver as far as telehealth infrastructure. Given the fact that this particular property is about 30 minutes from a very capable rural hospital, I’m not surprised that they opt to send campers into town if they need more than what we can offer on site.

Since I’m in the middle of a major project, I’ve got my wi-fi hotspot at the ready in case I need to join any calls (courtesy of my public library, which lets you check them out for a couple of weeks at a time). However, for the first time in a long time, I’m working with an extremely capable team, and I would be surprised if I hear from them. There might be something that they need that requires a physician credential to accomplish, but it’s nice to know that they’ve got my back and I can actually take time off without worrying that I’ll walk into a disaster when I return.

I’m sure that some of the people on the team think I’m a little loopy to do this kind of thing for fun, but at least one of my co-workers has made me promise to take pictures of a couple of things I’ve talked about, so I hope I can deliver. I’m just hoping this year is better than the experience I had a couple of years ago, when I ended up with a squirrel leaping from a tree to my head when I least expected it. Honestly, not having a squirrel in your hair seems a low bar when you think about it.

As a consultant, some of my major areas of work included change leadership and teambuilding. I have to say, although I have had plenty of formal training in those disciplines, some of the best training I have had has been in outdoor programs like this one. A very wise man once said, “A week of camp life is worth six months of theoretical teaching in the meeting room.” Having done this for many years, I have to agree. It’s extremely gratifying to see young people learn new skills and discover that they are more capable than they ever thought. This generation of campers has had a couple of summers of COVID-related modifications, and many of these experiences will be new to them. They will be challenged to try things outside of their comfort zones and will be allowed to fail in a safe and supportive environment. They will also probably get sunburned and get lots of mosquito bites because they’re pre-teens and teens and they won’t heed our warnings, but those too will be growth experiences.

For some of the oldest campers who come back year after year, I’ve worked with them since 5th grade and they’re now high school seniors. They’ve had phenomenal growth emotionally and mentally (and also physically, since most of the eldest tower above me). It’s been a pleasure seeing them take leadership roles and I enjoy seeing how the youngest campers look up to them and start to envision what they might look like in a few years. Many of last year’s graduating class headed into tech fields, and one of my older campers from many years ago is now applying to medical school. I hope that as they head to college and into the real world that they take the problem-solving skills that they learned at summer camp with them and figure out how to apply them, not only to the challenges of today, but to what we might run into tomorrow.

If there’s anything we’ve learned since 2020, it’s that life can always throw you a curve ball and we have to figure out how to rise to the occasion. Although I’m looking forward to a week relatively off the grid, I know I’ll come back energized and ready to get back to work (even though my body will be tired). Being around young people with so much potential and so much eagerness to learn always delivers a spark.

Who’s ready for some basketry, rock climbing, and whittling? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/23/22

I wrote recently about hospital shootings and the other unsafe situations that healthcare workers are encountering with greater frequency. We can add another hazard to the list. Earlier in the week, batteries exploded in a Milwaukee hospital parking garage, injuring two people. The incident, which occurred at Aurora St. Luke’s Medical Center, is attributed to an acid spill in a container that was holding recycled batteries. Unanticipated combustion is a thing, and it just goes to show that regardless of how well you think you’ve planned or prepared, there’s always something that has the potential to surprise you.

I’ve read a lot of articles about how physicians should manage their social media profiles, but I haven’t seen too much on how they should manage their non-work-related TV appearances. Amar Shere MD, a cardiology fellow at Saint Louis University School of Medicine, was selected to complete on the NBC show “Dancing With Myself.” Shere appeared in his white coat, but was cut after the fourth round. He has used TikTok to share his dance skills along with patient education and eating tips. He’s also a fitness instructor with an interested in promoting heart health in the community. Kudos to Dr. Shere for putting himself out there, and I hope his patients enjoy his care as much as it sounds like he enjoys delivering it.

Many physicians are watching carefully to see what happens to telehealth provider Cerebral as it has come under fire for deceptive business practices and poor patient care. I’ve seen a number of patients in the brick-and-mortar urgent care world who were trying to get refills on their prescriptions after being denied ongoing treatment due to billing disputes. Cerebral is accused of pushing patients to take controlled substances in an effort to increase patient loyalty. The company used flexibility in telehealth rules to prescribe highly regulated medications without any in-person care. Pharmacies were seeing so many prescriptions they stopped filling orders from the company and flagged its business practices for scrutiny.

Cerebral is no longer starting new courses of therapy with controlled substances and patients who are already under treatment have to transition to other drugs or different providers by mid- October. Given the severe shortage of physicians willing to take over these prescriptions, my clinical employers included, it’s going to be rough for patients who are trying to figure out how to continue treatment. The company has been removed from insurance networks and patients are left holding the bag while they go on waitlists for psychiatrists and call from urgent care to urgent care looking for anyone willing to give a 30-day prescription.

Speaking of brick-and-mortar urgent care practices, I’ve been receiving harassing emails and phone calls from a particular insurance company as they try to recredential me to deliver care at an organization where I haven’t practiced for more than a year. Apparently, their calls and emails to my former employers weren’t managed in a timely fashion (not surprising given the overall turnover in the organization), so they decided to contact me personally. They tracked down personal email addresses that I never would have used on a credentialing application and also used several emails associated with the LLC that I use for my consulting business (but never for clinical care). I finally convinced someone to understand that I don’t want to be recredentialed so they can stop trying, but it took several phone calls and quite a bit of frustration. Supposedly they’ve been trying to reach me for months to see if I wanted to remain on the plan. You’d think they’d be able to look at their own claims data and see that I haven’t submitted anything in a year, but that would require coordination within the organization. I’m less than thrilled that they spent patients’ premium dollars exploring my personal websites, but I guess they consider it trying to be engaged with their providers.

Monkeypox has arrived in my state and medical misinformation is running rampant. I’ve seen comments on local news articles suggesting that transmission is limited to certain sexual behaviors, complete with links to bogus articles blaming this “scourge” on immorality. News flash from infectious disease specialists – monkeypox is spread through contact with body fluids, monkeypox sores, contaminated clothing or bedding items, and through respiratory droplets. It’s been a long two and a half years dealing with patients who have decided that social media is more believable than their own physicians, and I sure wish we could mandate public health and hygiene classes in schools. The World Health Organization plans to rename the disease to reduce stigma and racism, but unfortunately people’s attitudes aren’t going to be easy to adjust.

I just finished reading the novel “Hamnet” by Maggie O’Farrell. It’s a fictionalized account of the life of William Shakespeare’s son, who died at age 11 at 1596. The book’s subtitle clearly says it’s “A Novel of the Plague” and there’s an underlying story about the child’s mother being a healer and her encounters with the medical establishment of the times as the bubonic plague reaches her family. My book club has a way of selecting less-than-cheery readings at times, but I enjoyed the book and found it to be a relatively quick read. Within a day or two of finishing it, I came across an article that summarizes findings about the origin of the Black Death, which ravaged Europe for hundreds of years. Researchers propose that the Black Death began in the late 1330s in North Kyrgyzstan, based on analysis of DNA extracted from skeletons found in the region.

I wonder what historians in the future will say about our current pandemic when they’re looking back at us. They’ll probably think we were similar to what modern medicine thinks about medieval “plague doctors” who wore bird-beaked masks stuffed with herbs as a way to ward off disease. Hopefully, our next book club selection is a little lighter read, but I’m always looking for summer reading suggestions whether I have the ability to make them truly a beach read or not.

What’s on your summer reading list? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/20/22

I get my news from HIStalk just like everyone else, so I was very interested to read about US hospitals sending patient information to Facebook. Involved websites include a third of those listed as Newsweek’s “Top 100 US Hospitals.” Using the Meta Pixel tracker, Facebook is receiving the IP address of patients who scheduled appointments online, as well as the physician’s name and the search-term used to locate them. Investigative reporters also found that multiple high-profile hospitals have installed the tracker on their respective patient portals.

Of course, the major concern is that these organizations may have violated HIPAA by sharing patient health information with a third party without obtaining appropriate consent. During the investigation, one of the scenarios used was as follows. On the website of University Hospitals Cleveland Medical Center, for example, clicking the “Schedule Online” button on a doctor’s page prompted the Meta Pixel to send Facebook the text of the button, the doctor’s name, and the search term used to find her: “pregnancy termination.”

The data being sent from within hospital patient portals is even more concerning. The Pixel Hunt project is a crowd-sourced effort to locate places where the Meta Pixel tracker is installed. Five real patient participants in the project had sensitive data sent, including names of medications, allergic reactions, and details about pending medical visits. The hospitals in question denied having contracts in place that would have permitted the release of this data, and investigators found no evidence that the hospitals were appropriately obtaining patient consent. Multiple organizations have since removed the tracker from their websites and patient portals, but the fact that it was there in the first place is highly concerning.

It’s unclear what Facebook has been doing with the data, and whether it’s using it for marketing or other for-profit purposes. As a patient, I find it horrifying that a health system would willingly put this kind of tracker on a patient-facing site and would want to understand why they would do that. The short answer is that those who do install it have access to analytics about ads they may have placed on Facebook and Instagram as well as access to additional marketing tools. In my opinion, neither of those reasons is enough to justify why my personal information should be sent outside of the healthcare organization. Even worse, the article notes that “if a patient is logged into Facebook when they visit a hospital’s website where a Meta Pixel is installed, some browsers will attach third-party cookies – another tracking mechanism – that allow Meta to link pixel data to specific Facebook accounts.”

As a physician who was previously employed by a health system, we know how much health systems profit from the labors of the clinicians that work under their banner. Data from 2016, which is the most recent year I could find, shows that primary care physicians generate $1.4 million in revenue each year. Some specialists, such as cardiologists and orthopedic surgeons, can generate $2.4 to $2.7 million annually. We’ve come to terms with our participation in that equation, but I doubt that physicians think favorably about health systems profiting from confidential patient information that we have worked hard to protect.

Putting on my clinical informaticist hat, the IP address is one of 18 HIPAA Identifiers that are considered personally identifiable information. I remember memorizing these for my last clinical informatics board exam because there were several questions on the topic on practice tests. When you take a piece of personally identifiable information and combine it with clinical data, it is considered Protected Health Information. When investigators were on the Scripps Memorial Hospital physician website, clicking the “Finish Booking” button sent Facebook the physician’s name and specialty as well as the patient’s full name, email address, telephone number, city, and ZIP code. The hospital removed the Meta Pixel from the final stages of the appointment scheduling flow after they were made aware of the investigators’ findings. The article contains a host of other examples of other private information elements that were shared, including patient comments about their medications and information on sexual orientation.

For every patient who has been told they can’t have a copy of their own records, or who has difficult sending records to a consulting physician due to an organization’s misapplication of HIPAA, this is particularly offensive. Glenn Cohen, faculty director of Harvard Law School’s Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics notes, “Almost any patient would be shocked to find out that Facebook is being provided an easy way to associate their prescriptions with their name… Even if perhaps there’s something in the legal architecture that permits this to be lawful, it’s totally outside the expectations of what patients think the health privacy laws are doing for them.” I’ve been privy to dozens of complex legal agreements over the years as well as numerous health systems’ Terms of Use documents for their websites and Conditions of Care documents that they make patients sign. I could see someone nesting language in those documents that might permit a number of things that if spelled out would make patients cringe.

Of course, that assumes that the health system knows what they’re doing and deliberately includes that provision. Maybe we need a law that requires language around data sharing to be in 14-point font at a sixth-grade reading level so that patients can understand, or that requires organizations to present this information in line-item veto format for patients to better identify their wishes. I don’t think the majority of patients would answer “Do you want us to share your medical information with Facebook?” in the affirmative, but then again, you never know. However, from the health system responses cited in the article, it seems that perhaps some of them didn’t fully understand the ramifications of installing the Meta Pixel tracker or what it was actually doing. Others indicated that they have confidence in Facebook’s ability to filter out patient information, and I think the majority of us would suggest that confidence is misplaced.

Since healthcare is going to an increasingly online, patient self-service model, this issue isn’t going to go away. However, I don’t see legislators or regulators dealing with it proactively since they can’t deal with other high-profile issues that dramatically impact our population. I’d love to see a flurry of complaints filed for HIPAA violations and watch Facebook burn money trying to defend itself. Needless to say, it will be a while before we see how this plays out.

If there’s anything that shows how slow the wheels of justice grind, it’s the marking of the Juneteenth holiday, which commemorates the day in 1865 when Major General Gordon Granger delivered the Emancipation Proclamation to enslaved people in Texas – more than two years after it was issued. This is the first year I’m working for an organization that observes the day and it’s a good opportunity to reflect on ways that we can do better as we work to care for all people.

What do you think about the Meta Pixel tracker and its use by healthcare organizations? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/16/22

The American Medical Association Annual Meeting is happening in Chicago this week, with the group gathering in person for the first time since the beginning of the COVID-19 pandemic. Many physicians feel the AMA has lost relevance and doesn’t speak for the majority of physicians. Regardless, I found the list of issues that the House of Delegates plans to address to be an interesting commentary on the times:

• Addressing public health disinformation by health professionals.
• Regulating ghost guns.
• Declaring climate change a public health crisis.
• Banning cannabidiol ads in places that children frequent.
• Preventing loss of insurance coverage after the COVID-19 public health emergency ends.
• Urging the Food and Drug Administration to swiftly review and approve over-the-counter status for oral contraceptives.
• Decreasing bias in evaluations of medical student performance.
• Ensuring accessibility of quality childcare for physicians in training.

Additional special sessions will include talks on the need for ethical guidelines around private equity acquisition of physician practices; Hattiesburg Clinic’s results when it looked at the impact of nurse practitioners and physician assistants; having physicians work at the top level of their licensure and not performing non-physician work; and reducing burnout.

I’m not sure how you miss this on a background check, but Bay Area Hospital in Oregon recently fired its chief operating officer after only four days on the job. It was discovered that in 2015, he had been sentenced to serve half a decade in federal prison for committing wire fraud and false representation of a Social Security number. Additionally, he used company credit cards for personal purchases. The hospital claims that it conducts criminal background checks across multiple jurisdictions, so I’d be interested to understand how this one slipped through the cracks.

In other legal news, a New Hampshire hospital has lost more than seven gallons of the drug fentanyl, which is a synthetic opioid that is 50 times more potent than heroin. Multiple hospital employees have been suspended. Drugs continued to disappear despite precautions that were added after initial losses were identified. A single nurse admitted taking more than half of the missing drugs, but the fate of the rest of the missing drugs continues to be unknown. Board of Pharmacy documents state that the nurse in question stated she took the fentanyl “for her own use as a way of coping with the stress of working during the pandemic” and also gave some to a friend. The nurse died unexpectedly in March. Nursing and pharmacy leaders at the hospital have also been suspended, with decisions on whether the hospital will lose its pharmacy approval expected later this month.

CMS has started levying fines against hospitals for noncompliance with federal price transparency laws. Atlanta-based Northside Hospital was fined more than $1 million due to problems at two facilities. One didn’t have the required consumer-friendly list of standard charges and the other didn’t have the searchable list posted in a prominent manner. CMS has issued a number of warning notices to noncompliant hospitals, but these are the first fines. Of note, neither hospital submitted a plan for corrective action which might have helped them avoid the penalties. One health policy expert cited in the article describes the hospital’s behavior as “contemptuous” in its lack of response or remediation.

A recent report from the Center for Connected Medicine (which is a partnership of Nokia and UPMC) looks at the reasons why patient self-scheduling isn’t advancing. Not surprisingly, lack of physician buy-in is a major factor. The report notes that 88% of respondents plan to prioritize investments in self-scheduling technologies in the coming year.

My primary care physician is part of a large medical group affiliated with a major integrated delivery network, and their efforts towards self-scheduling have been haphazard at best. Each office within the group is allowed to do their own thing, and then within the office, providers can opt in or out. Although I can’t even request an appointment with my physician online (other than sending a message, which I know is annoying to the staff) I can directly book with the nurse practitioners in the office. I’m overdue for calling to schedule my visit since he’s got a six-month wait, but I never seem to find time to make the call. At least I could self-schedule in those precious minutes between Zoom calls while I’m waiting for attendees to arrive at a meeting or while I’m waiting for the next patient to pop into my virtual waiting room. I definitely can’t make a phone call at either of those times.

Being a patient seems to be getting more and more difficult. I waited more than two weeks for some recent results, only to find that the ordering clinician failed to include the clinical history with the order, which might have made a difference in the results. It took four days from when the results posted in the EHR to when my clinician finally messaged me with note that “all is well, have a great summer,” which is a somewhat useless comment when you’re a patient who wants to know what the follow-up plan should be given the clinical history. Additionally, my physician eye detected a comment in the actual result report that called into question the adequacy of the specimen and that doesn’t feel like “all is well” to me.

I was forced to see this clinician because my own physician was out on a medical leave and the wait for new patient visits for other physicians in this specialty can be several months long. The visit itself was less than satisfactory, and after seeing how the results were handled, I’ll be looking to transfer. I’m fortunate to be a physician with plenty of resources, who not only knows how to research clinical guidelines but who could also reach out to friends in this specialty for advice. Both of my favorite “phone-a-friend” docs agreed with my self-created care plan so that’s something, but overall, the situation is just disheartening.

I feel bad for my physician colleague who is out on leave, because I know the backstory and that she not only feels terrible that her sudden illness left the practice in the lurch, but that there’s a good chance that she may not be able to practice medicine again. She’s an employed physician, though, so it falls on the group’s leadership to ensure that patients receive appropriate care in the face of the unexpected. I wonder how many other patients received less than outstanding care in the last few weeks and whether there will be any long-term consequences.

How have physician or other medical staff shortages impacted your own health or your patients’ care? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/13/22

I was sorry to read of Mr. H’s COVID-like symptoms, which as of his last post hadn’t yet resulted in a positive test. Especially in vaccinated patients, we’re seeing a pattern where antigen testing doesn’t become positive until five days or more after symptoms have started. Although vaccinations are still very good for preventing hospitalizations and death, I’m seeing a fair number of people with some pretty debilitating symptoms as well as a large number of patients with long-COVID symptoms. Best wishes for a speedy recovery for Mr. H.

As a physician who has spent thousands of hours staffing emergency departments and urgent care facilities, I fully support the idea of having interoperable systems to better understand patients’ medication histories. My first informatics employer stood up a private health information exchange (HIE) to help its employed physicians better share data with community physicians who also used the same EHR. It was an exciting time to learn how the connectivity needed to work and to navigate through decisions such as whether we would be an opt-in or opt-out platform in the face of changing privacy laws and state requirements that weren’t keeping up with the times. As the first HIE in the state, if was something to be proud of, but we knew it could be done better and were ready to support broader statewide efforts when they came along.

One of the major benefits of even our limited regional system was being able to see prescription histories and to identify patients who were visiting multiple physicians for controlled substances, or who were trying to refill their medications sooner than they should. Having the data made it easier to have those uncomfortable conversations with patients so that we could try to arrange appropriate follow up. From those experiences, it was natural to be a champion for Physician Drug Monitoring Programs (PDMPs) when they were first proposed. Some states were faster in creating these programs than others, and at least one state still doesn’t have a true statewide platform. As soon as one became available to me, I signed up, and before long I was using it nearly every day.

My last urgent care employer had a large number of midlevel providers seeing patients – nurse practitioners and physician assistants outnumbered the physicians nearly three to one. In my location, those providers weren’t allowed to sign up for the PDMP on their own, but required a sponsoring physician to allow them to be a delegate on their account. I thought that was unusual since those providers can prescribe controlled substances in my state as long as they have the name of their collaborating physician on the prescription, but I’m not the one who makes the rules. Several of the nurse practitioners asked me to sponsor them even though I wasn’t their collaborating physician. Apparently, the physician owners (who were the collaborating physicians for many of the midlevels) refused to sponsor them for the PDMP because they didn’t want it to create inefficiency in the workflow.

I found that approach to be short-sighted as well as non-collegial, so I agreed to sponsor a few of them who I had worked with for years and knew very well. They continued to use the system under my sponsorship until I left the practice and terminated the linkage between our accounts. It looks like their collaborating physicians still won’t sponsor them, because every two weeks I get an email from the PDMP noting that I still have open requests for sponsorship. In thinking about the fears of inefficiency, it’s likely more complex than that since the practice dispensed medications on a cash basis (including controlled substances) and was well known for making sure providers were “treating the heck out of symptoms.” Patient satisfaction was also a big push and of course it takes more time to counsel a patient about something you might find in the PDMP versus just prescribing medication. The practice also refused to install technology that would allow e-prescribing of controlled substances, so you get the picture. Attitudes like that are part of why I no longer work there, but one does still have to think about the impact of any new systems on efficiency.

An article in JAMA Health Forum addressed the topic this week, with findings that having a PDMP that’s integrated with the EHR led to increased use of prescribing recommendations by primary care clinicians. It shouldn’t be surprising to anyone that if you have a solution that makes it easy to do the right thing, people will be more likely to actually do the right thing. The researchers looked at 43 clinics and how they used the Minnesota PDMP. There were 21 clinics that had the PDMP integrated with the EHR, which reduced the need for a separate login to the outside system while also lowering the need to intentionally think about using the PDMP.

Monthly query rates for the non-integrated sites were 6.6 per clinician before the intervention versus 6.9 after. Monthly query rates for the integrated sites were 8.8 before the intervention and 14.8 after. Additionally, the findings showed a greater impact of the EHR integration on less-experienced clinicians, which they noted “may reflect a less inflexible practice style and/or faster uptake of new features in the EHR.” While the study was underway, Minnesota initiated a mandate that clinicians query the PDMP before prescribing opioid drugs, which led to an uptick in query counts in both groups, although that increase was more significant for prescribers in the intervention group.

There are several potential limitations to the study, including the fact that it didn’t directly assess opioid prescribing. The study was also limited to a single health system and its affiliated prescribers within a limited geographic range, although there was inclusion of urban, suburban, and rural areas. The study also could not identify whether queries were clinically appropriate or not or whether the PDMP queries led to providers deciding to not prescribe controlled substances when they otherwise might have. The authors do plan to look at this in a further analysis using information from the EHR.

I do hope that those who are trying to increase the adoption of EHR-integrated solutions use information like this to show that they can have a positive impact on provider workflow. They can also have a significant impact on patient outcomes when it comes to identifying patients who might benefit from an intervention with regard to controlled substances. I’m interested to see what results other organizations may have had with EHR integration and how their clinicians responded to it.

Have you integrated your state’s PDMP with your EHR? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/9/22

Since there have been so many dramatic changes to many workplaces over the last two years, many companies are re-evaluating the meaning of the workweek. I always keep my eye out for articles on this topic, as well as literature from other countries where work-life balance seems to be much higher priority than it is in the US. There have been several writeups this week about a move in the United Kingdom for large numbers of workers to adopt a four-day work week. There are 3.000 workers taking part in a six-month project to assess whether shortening the work week will alter productivity, employee turnover, company revenue, and more.

The article mentions strategies different companies have taken in trying to alter the work week, including streamlining meetings and reducing inefficiencies. Kickstarter, which is small at only 90 employees, has given them Fridays off. I know of quite a few larger companies that don’t necessarily give people Friday off, but instead offer “Focus Fridays” and other themes where employees are supposed to have uninterrupted work time without meetings or distractions. For employees who are self-motivated, this can be a solid strategy. One of the health systems I worked for pre-pandemic allowed employees to work remotely one day each week and I have to say it was some of the most productive time I had, because in the pre-Zoom era, there weren’t any meetings or calls.

Another strategy that I see some companies offering as a means to improve work-life balance is that of unlimited time off. In speaking with friends that work at a large tech company where this is the norm, it can be less of a benefit than advertised, since workers who aren’t accustomed to tracking time off may not take full advantage of the paid time off that they might have received under a more traditional system. Although when these programs were initially rolled out, there was a lot of concern about people abusing it, many companies find that workers actually spend less time away from the office. I’ve worked with plenty of people over the years who only took days off when they were “forced” to in order to get the days off the books.

Other groups are offering dedicated days where employees are supposed to focus on self-care. Advocate Aurora Health is one of those, offering “renewal days” where employees are supposed to meet together for support. I found it interesting that their original program was a three-day workshop designed to focus on finding meaning in work while building skills to combat burnout, stress, and compassion fatigue but it has since been compressed into a single-day program. That seems such a parallel to everything that has happened since January 2020, where most healthcare workers are expected to do more with less even in the face of previously unheard-of stressors. I still hear about plenty of healthcare organizations that are trying to combat serious organizational issues through the application of pizza lunches and therapy dogs so I’m not sure we’re making much progress.

The University of Missouri launches a telehealth program to train rural primary care physicians in the use of Canvas Dx with the goal of supporting autism diagnoses. The tool, from Cognoa, will be added to the platform used by the University of Missouri ECHO Autism Communities Research Team. The group will explore the time it takes from a physician’s initial concern that Autism may be a factor to a diagnostic determination via Canvas Dx. Earlier diagnoses should lead to earlier interventions and hopefully better outcomes for patients and families. The study plans to recruit up to 15 clinicians to evaluate as many as 100 children at risk for autism spectrum disorder or developmental delay. As a side note: has anyone ever noticed that the MU logo contains a mule? I don’t know how many times I’ve seen the logo but never the mule.

US Representatives Madeleine Dean (Pennsylvania) and Larry Bucshon (Indiana) introduced a bill this week that aims to protect healthcare workers from violence. It is modeled after existing protections created for airline and airport workers. The Safety from Violence for Healthcare Employees (SAVE) Act would make assault or intimidation of hospital employees a crime. Representative Bucshon is a physician, so I’m disappointed that the bill appears to focus on hospital workers and not on the tens of thousands of healthcare workers in other locations where they might be even more vulnerable, including ambulatory offices and home care. Workers in those locations don’t have anywhere near the level of security or assistance found in the average hospital. As a healthcare worker who was left out of vaccine allocations because I didn’t work for a hospital (despite delivering a high volume of COVID care) it looks like we haven’t learned and will continue to propose short-sighted policies.

One of my healthcare providers recently notified me of a data breach that may have exposed my personal health information. According to the documentation, the organization learned that an “unauthorized person” gained access to a subset of employee email accounts over a more than three-week period. Investigators were not able to determine whether emails or attachments were actually viewed, but the emails included data on both patients and research subjects including names, birth dates, addresses, medical records, insurance information, Social Security numbers, and more. It’s not clear now many patients have been impacted but they promise to reinforce training on avoiding suspicious emails and to make enhancements to email security, so it seems obvious to me how the breach occurred. Depending on what data might have been exposed, some patients will receive credit monitoring and identity protection services. Regardless, it’s going to be unnerving for many of us for a long time to come. At this point I get a breach notification every year or two, so it seems there is a lot of opportunity for improvement among the various members of my healthcare team.

Judging from my social media feeds, many people are taking advantage of what they perceive to be a “normal” travel season. I’ve seen plenty of pictures from amazing places, but my own summer will be a little low key this year. I’m juggling some big projects and a go live, so I’ll only be occasionally off the grid. It just gives me more time though to plan the next big adventure.

What are your summer travel plans, or are you going the staycation route? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/6/22

It’s been a long week, and I’ve spent a good bit of it trying to process the recent episodes of violence against healthcare workers in Tulsa and Los Angeles. The Tulsa incident had a particular impact on me since I did some EHR optimization work for Warren Clinic in the past. As the news reports unfolded, and before we knew exactly where the shooting occurred, I wondered if any of the staff that I worked closely with had been impacted. Although it turned out that I hadn’t worked with any of the victims, it was still devastating to learn of the loss of dedicated healthcare professionals who had given so much to their patients and who still had many more years of service ahead of them.

Hearing of the stabbing in Los Angeles later in the week was almost too much to bear. Those who see patients in person go to work every day knowing that it’s going to be difficult, but generally they don’t expect to be shot or stabbed on the job. I’ve worked in plenty of “tough” clinical locations. At one hospital emergency department, I had to park in a secure garage that was lined with chain link fence, essentially creating a cage. You had to have a badge to get in or out via car and accessed the hospital through a secure elevator that either took you directly into the ED or up to the ICU waiting room. I often wondered what would happen if the power went out, but fortunately it never did during the years I worked there.

Patients and visitors to that facility had to go through metal detectors. I had a security guard posted at my clinical workstation in the event things became contentious. Sometimes my patients were handcuffed to their gurneys since they were being evaluated to ensure they were “fit for confinement” after being arrested by local law enforcement.

Additionally, the emergency department exam rooms all had two doors on different sides of the room so that there was always a way for you to get out. I’ve worked in large urban trauma centers, locked psychiatric emergency units, and critical access hospitals where all kinds of unusual cases have come through the doors. I’ve had patients become agitated and aggressive before, and I was even stalked by a patient, but even in those circumstances I never actually imagined that I was at risk of being shot, stabbed, or killed while trying to help patients.

Violence against healthcare workers is at an all-time high. It’s not just physical violence or homicide, but more often includes verbal abuse and threats. The Bureau of Labor Statistics indicates that healthcare and social assistance workers have the highest rates of injuries due to workplace violence. In fact, workers in those industries are five times more likely to be injured at work than workers overall. Incidents of workplace violence have been rising nearly every year since they were tracked, beginning in 2011. Although the Occupational Safety and Health Administration has guidance for employers, there are no federal requirements for healthcare organizations to protect their employees from workplace violence.

Some states have addressed the issue. A Wisconsin law makes battery against certain healthcare workers a felony. There has been some action at the federal level, but nowhere near enough. Personally, I’d like to see healthcare organizations have to report their statistics just like college campuses do – collecting detailed information about violent incidents and reporting their numbers annually. At my last in-person physician gig, my employer had numerous episodes of workplace violence and no clear mitigation strategy. Incidents were hushed up and employees were discouraged from discussing them for fear that staff wouldn’t want to pick up shifts at certain locations. There certainly wasn’t any kind of post-event debriefing for those impacted by violent incidents. Everyone was just expected to pick up and carry on, which is exactly the opposite of what is needed.

Those incidents seemed to escalate during the initial phases of the pandemic, when everyone was scared and uncertain. They became worse as certain unapproved treatments were pushed on social media, and patients would become aggressive when told we would not prescribe ivermectin or other drugs that had been shown to not only have no benefit but to have significant risks. Patients argued with us about their diagnoses despite having positive lab results and told us directly to our faces that we didn’t know what we were talking about and that we were either lying or part of a vast conspiracy. One of the worst things I had to deal with during the pandemic was patients who refused to wear a mask in the exam room, or who would take it off as soon as I walked out the door, to fill the room with their exhaled breathing so I could walk back into a cloud of virus. To have to deal with that hour after hour, day after day, and to not be able to confront it for fear of lowering patient satisfaction scores was one of the things that contributed to my departure.

Still, I’m here, and although no one has tried to directly kill me at work, it’s certainly on my mind that what happened last week could have happened to any one of us at any time. Along with many of my colleagues, we’re feeling a certain level of survivor’s guilt after seeing so much loss in the healthcare community over the last few years. Although we’ve gotten better at protecting ourselves from disease, the steps that we need to be taking to protect ourselves from workplace violence are less than clear. Regardless, healthcare employers owe it to their teams to assess the safety and the workplace and the wellbeing of those in it. Every healthcare organization should be offering employee assistance programs to those who are struggling with the recent tragedies and increasing violence.

Readers may be asking themselves what all this has to do with healthcare IT. If you’re a frontline IT support person who works in clinical areas, the answer to that is clear. It’s also a heads-up about what the people you’re trying to support might be going through. If they seem on edge or preoccupied, there’s a good chance that they are one of both of those. I’m sure that if I were seeing patients in person, I’d be less interested in learning about new features or workflows that are about to be deployed than I would be in learning how the hospital plans to keep me safe. Even if you’re not working in a clinical area, you’re not immune to workplace violence. All of us should be standing together to demand solutions that ensure we all make it home to our families at the end of the workday.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/2/22

Surprise, surprise: research shows that patients understand their health records better when they are not full of abbreviations. The study, published in JAMA Network Open, showed improved comprehension when certain abbreviations and acronyms were spelled out. Although study subjects had previous exposure to healthcare organizations, their initial understanding of some common abbreviations was below 40%. Looking at a set of 10 common abbreviations, expanding them increased comprehension from 62% to 95%. The authors urge clinicians to consider that patients may not understand abbreviations and medical terminology. Abbreviations aside, it’s important to understand the low level of health literacy across the US and the need for most patient-facing communications to be written at or below the sixth-grade level.

I recently had another trip into the Patient Zone, and even as a healthcare provider, I found some of the things I encountered confusing. I know how to navigate the system and I still have a post-visit issue that remains unresolved three days later. The office was running significantly late, so I got to listen to quite a few inappropriately overheard conversations. One involved a staffer who kept confusing two “sound-alike” medications to the point where I wanted to step out to the clinical station and correct her. Losartan is for blood pressure, Loestrin is an oral contraceptive. I later found out that she wasn’t working in her usual clinical location because they had floated people to the office to cover shortages. Still, I hope that no one was harmed on their watch. I received some wonky directions from people in the office and it makes more sense if they were temporary staff, but the average patient might not know to question it.

I’m also trying to put myself in the shoes of patients who are receiving immediate lab results via their patient portal accounts. The clinician I saw warned me, “you’ll probably see your results before I will” and she wasn’t kidding. Barely six hours after I left the office, I started receiving a flurry of “new result available” alerts. I’m not sure how the labs were ordered, but each component of the blood work was coming back as an individual result with its own notification. It was unnerving to say the least, especially since the ones I was really waiting for weren’t among the first to return. As a physician, I know what the results mean, but as a patient I can imagine it might be very frustrating. My guess is it won’t be until sometime next week before I receive an official interpretation, once all the results have returned. I’ll be interested to see how the rest of the process goes, and if my pharmacy benefit manager will ever sort out the erroneous script that was sent. I tried to resolve it, but they were never able to find the provider’s name in their system (despite me being able to see the erroneous script from the patient-side login) so I’m betting at some point I wind up driving to the office to pick up a paper script and fax it in myself.

Needless to say, there’s a long way to go for some healthcare organizations to really embrace the idea of patient-centered design. There have been a lot of healthcare futurists over the last decade who have said that patients will vote with their feet and drive their healthcare dollars towards organizations that deliver care that is personalized and consumer friendly. Pre-pandemic I still saw the majority of patients choosing their care based on insurance coverage with very little consideration of quality metrics or anything else. Now, with all the staffing shortages and physicians leaving patient care in droves, patients seem to just be getting in wherever they can. In my area, one of the largest health systems has over 4,000 patients on its wait list for a particular specialty, which now refuses to accept any referrals from outside the health system. That doesn’t seem terribly patient-centric to me. The organization blames its inability to recruit for the shortage of clinicians. I guarantee that if they raised their salaries above 25th percentile they’d be able to recruit.

After reflecting on these recent experiences, I wasn’t sure I was in the right frame of mind to read yet another article about a “man on a mission” in healthcare. One of my shoe-loving friends has a huge crush on Glen Tullman though, so I figured I better keep up so she and I have something to chat about. The premise of Tullman’s latest venture, Transcarent, is leveling the playing field for patients as they try to meet their healthcare needs. He calls out the fact that the health insurance industry is one that doesn’t operate in the best interests of its customers. The article calls out the fact that when insurance companies profit, each dollar represents care that patients didn’t receive. Tullman proposes giving those dollars back to large, self-insured employers who are footing the bill for coverage.

It will be interesting to see if Transcarent is able to succeed where other companies have failed. Haven tried to do this a few years ago for employees of Amazon, Berkshire Hathaway, and JPMorgan Chase. So far, more than 100 companies have signed up, eager to see savings on their healthcare spending. Transcarent makes its money by taking a cut of that savings, which is achieved through pre-negotiated pricing for services as well as by directing patients to lower-cost alternatives. Corporate customers are gravitating to the approach as are health systems, some of which are financially backing the endeavor. Walmart is jumping in with a recent agreement to become a preferred provider, offering primary care, mental health, and dental services. The article was enough to hook me, so I’ll be following along as the company expands. They’ve already hired some really smart people, and I’m eager to see if they’ll be able to move the needle.

Happy 19th Birthday HIStalk! I didn’t have time to do proper pastry therapy, so this option from my neighborhood Costco will have to do. Even though white cake is my favorite, you really can’t go wrong with a cake that is filled with their signature mousse.

What’s your favorite birthday pastry? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/26/22

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/23/22

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.