Curbside Consult with Dr. Jayne 4/18/22

A client I haven’t worked with in a couple of years reached out to me over the weekend, asking if I had copies of some materials that I had created for them. The project I originally worked on had been shelved because the company decided to take its solution in a different direction.

I wasn’t surprised when the work was mothballed. When you’re working on the vendor side, priorities can change drastically. Sometimes it’s a new regulatory requirement or the need to keep up with a third-party certification. Other times it’s a high-profile client with a contractual request. I’ve also seen projects get shelved when a competing solution turns out to be more work than originally scoped.

As a clinical content creator, you can’t get your feelings hurt when things change and your work winds up on the chopping block. Sure, as a physician you can be offended that your peers aren’t the priority, but it’s the nature of the beast when you’re working in the vendor space.

Fast forward and the company is trying to land a big client who needs content along the lines of what I created. There’s been a fair amount of turnover among the product and development teams, and although they remembered having content, no one could find it on any of their shared drives, SharePoint sites, email archives, or anywhere else. Despite corporate IT policies that discourage it, unless it is expressly prohibited, I keep copies of all my work product, so I was able to find it easily.

A quick glance reminded me that some clinical guidelines have changed over time and it probably needs a good going-over. I asked the representative from the vendor whether they had done any requirements gathering sessions with the prospective client or how they planned to approach the project. Although I don’t have capacity to work on it personally, I’ve got some informatics colleagues who could step in and get them moving.

I was surprised to hear that despite the fact that the client wasn’t able to find my content and therefore really didn’t have a good handle on what it contained, that they were planning to put it in front of the prospect and hope for the best. Apparently the buzzwords used by the prospect seemed in harmony with what was in the project charter (which they were able to find), so they assumed it was appropriate.

Since the product owner who reached out to me knows me pretty well, I shared a couple of thoughts on the idea of putting half-baked content in front of a high-value prospect without doing any requirements gathering. Without really understanding what the customer needs, how can you hope to hit the mark?

Unfortunately, I see this all too often in the healthcare IT industry these days. There’s a lot of tail wagging the dog between sales and product organizations, and ultimately the customer suffers when they have been promised something that doesn’t exist or that is quite a bit farther down the roadmap than they are led to believe. Having been in the CMIO trenches for longer than I sometimes care to admit, I’d much rather have honesty about what might or might not be available than to be the victim of a bait and switch. I know what my priorities are and what things I can bend on if it comes to that, but if the vendor isn’t interested in documenting my needs, I’m not sure why I’d want to be working with them in the first place.

The product owner was sympathetic to my recommendations, but mentioned that she’s under a lot of pressure from her leadership to make it look like they already had this content (even though they couldn’t even locate it). She knows she’s in a bind and is unhappy with the approach, but as we all know, the mess rolls downhill and sometimes you just have to do things you don’t want or like to do if you want to make those above you happy. Particularly if you’re in an organization that’s strongly top-down and feedback isn’t seen as something positive, you can feel pretty stuck.

I’ve spent plenty of time in organizations like that over the years, so I don’t envy her position. I sent her the files and the contact information of a couple of informaticists that used to work for me. Although I hope they’ll do the right thing (not only for the prospective client, but for the vendor’s own future success) but I’m not optimistic. I know my colleagues will let me know if they hear from the vendor, and it should be good for some stories over cocktails if they do start an engagement together.

While I was digging through my file archive, it was kind of fun to have a blast from the past and remember some of the projects I’ve worked on during my wild ride through the clinical informatics world. I think I’ve worked for clients that use just about every major EHR vendor as well as dozens of bolt-on solutions and even quite a few homegrown ones. I’ve worked with some amazing people who would bend over backwards to make sure that their projects delivered maximum benefit for patients and clinicians, and they’ve made even the most difficult projects rewarding. I’ve also worked with people who were only focused on how to make themselves look good and often did so at the expense of their teams and their colleagues. Those are the most difficult projects because even if you’re a consultant, no amount of experience or advice can make a difference unless there’s higher executive stakeholders who are willing to accept the fact that there’s ego-driven nonsense going on.

I also found some hilarious pictures of go-lives, some of which involved themes and costumes. One involved camouflage and a “M*A*S*H” theme and I think that was probably one of my favorites. I had forgotten coming up with IT-themed nicknames for everyone on the project, including General Release, General Ledger, Colonel Memory, Major Cluster, Major Milestone, Major Conversion, Major Problem, Captain Cloverleaf, Captain CCOW, Lieutenant Login, Sergeant Surescripts, Sergeant SAN, Private Practice, and of course Commodore Sixty-Four. One of the project team fired up her Cricut and made frames to go around our ID badges with our new credentials. That client produces stories that become legends, and I’m glad I got to have that experience.

What’s the most fun healthcare IT project you’ve worked on? What kind of things have you taken from it to enhance your current work? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/14/22

I wrote at the beginning of the pandemic about the increased visits my practice was seeing for sexually transmitted disease testing. A recent Washington Post piece covers the increase in syphilis and gonorrhea during 2020, partly attributable to clinic closures and delays in seeking care. Scarce public health resources were focusing on COVID-19 and availability of testing services was variable. I was distressed to see a significant rise in cases of congenital syphilis, which rose 235% since 2016 and hit a new high of 2,148 cases. Pregnant patients who are infected can experience pregnancy loss and infants who are born with syphilis can have devastating health issues.

Other diseases were also on the rise in 2020, including gonorrhea. Surprisingly, chlamydia was on the decline, although that may be due to decreased testing and delays in seeking care. Many infected patients don’t have symptoms and are only diagnosed on routine screening, so a decline in face-to-face visits might also be a driver. With the power of all the data we have in our electronic health records, organizations should be able to do a better job of identifying patients who are eligible for STD screening and can use patient engagements solutions for outreach. Depending on configuration, there may be barriers to outreach because it’s a sensitive topic; but that doesn’t mean we shouldn’t do our best to address an entirely preventable category of illness.

Many of us in healthcare IT cringe when healthcare workers incorrectly cite HIPAA as the reason that they can’t provide patients with their own health information. As a field consultant, I shuddered every time someone claimed a regulation wouldn’t let us configure the EHR in a certain way or modify a workflow so that the site would run more efficiently. The American Medical Association has created a series of articles that debunk regulatory myths. Hot topics that impact our field:

• HIPAA does not explicitly state that physicians can’t respond to online reviews from patients. However, they must maintain privacy, even if the patient has revealed personal information. Responding may however violate community guidelines for review sites, so physicians and practices should do their homework before responding.
• Clinical support staff who perform non-clinical tasks in the EHR are not required by federal or state law or regulation to log out and back in when switching back and forth between clinical and non-clinical tasks. They also don’t have to log out/in when switching back and forth from a scribe role to a clinical support role.
• The Joint Commission does not support or prohibit the use of documentation assistants such as scribes.
• Medicare doesn’t require physicians to re-document information captured by the staff, only to verify it, as long as there are no state or institutional policies to the contrary. This includes documentation completed by medical students.
• There is no federal rule that physicians are the only clinicians that can enter orders via computerized provider order entry. Other members of the care team are permitted to pend or send orders as requested by the physician, as long as state law allows.

One of the most often cited (and incorrect) myths is that The Joint Commission and/or OSHA prevent food and beverage at clinical workstations. I’ve seen dozens of nursing supervisors tell people that the hospital will fail a Joint Commission inspection if there are cups at the nursing station. In reality, The Joint Commission does not address where food or drinks can be located. Even the Occupational Safety and Health Administration doesn’t determine specific locations where workers can eat or drink. They do, however, prohibit eating and drinking in places where one could be potentially exposed to blood or infectious materials.

Hopefully, organizations aren’t allowing blood, urine, or stool specimens at the nursing station, not only because it can lead to contamination, but because it’s simply gross. Employers can make their own rules, and certainly it’s a good idea not to allow open drink containers in areas where a spill would damage electronic equipment or patient records, and people shouldn’t be eating by the computer and dropping crumbs in the keyboards. The reality of healthcare staffing these days is that often people don’t get dedicated meal breaks and sometimes scarfing a granola bar while you’re giving report on patients is the only way you’re going to power through. But when employers decide to put the hammer down, they need to not blame other organizations that have no opinion on the matter.

Speaking of regulations, I’m spending part of this week working on my bucket list. Despite being in a helmet-optional state for the week, I’m glad that my course requires reasonably adequate helmet coverage. I always feel a little squirrely when I participate in activities that have inherent risk since I know that I’m likely the highest trained medical professional available if something goes wrong. I’ll be glad to not have to manage the consequences of failing to protect against head trauma. The weather is looking rather frightful, so I’m hoping for the best.

I ran across a solution today called JustAskEvie. It offers real-time EHR support for clinicians, powered by a network of fellow clinicians who provide peer-to-peer support. Services include coaching on specialty-specific workflows either during a physician’s onboarding process or during their first days using the EHR. Their goal is to be complimentary to the training offered by organizations or as a replacement option for those who might not have been able to attend scheduled training. They also offer go-live and upgrade support as well as after-hours coverage.

The company is hiring “Evies” for a variety of EHRs. I like the idea, but I imagine there might be some challenges when working with organizations who have heavily customized their EHRs. Several physicians who were part of the conversation voiced interest in checking it out as a potential side gig, with two noting that their organization doesn’t offer compensation for those physicians who agree to be super-users or to provide peer-to-peer support. It reminds me of the staffing equation we’re seeing in nursing and elsewhere in healthcare. Rather than pay for in-house resources who know the local system and climate, organizations are willing to give money to a third party to achieve a similar outcome. I understand why it happens, but on some level, it is still baffling.

How does your organization compensate clinician super-users? Or does it expect them to do it out of the goodness of their hearts? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/11/22

I spent some time this week with people who are knee-deep in public health efforts. One of the major topics of conversation was a preprint study that looked at ongoing declines in the US life expectancy. This year’s decline is significantly smaller than what we experienced last year, with us losing about half a year on average in 2021. The overall US life expectancy is now 76.6 years, representing the lowest value in more than two decades. Although the decline is less steep, it causes some less than optimistic thoughts among public health proponents who thought that having a readily available COVID-19 vaccine would help stabilize life expectancy data. Unfortunately, I think many underestimated the resistance to vaccination that we have seen across the country.

A big part of the discussion was the disparity between life expectancy in the US compared to other countries with similar resources, including Austria, Belgium, Denmark, England and Wales, Finland, France, Germany, Israel, Italy, Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Scotland, South Korea, Spain, Sweden, and Switzerland. Researchers felt this was largely tied to lower vaccination rates in the US compared to our peers. Other wealthy nations have seen increases in life expectancy in 2021 to the point where the gap between the US and our peers differs by more than half a decade. In addition to COVID, our numbers are likely impacted by conditions like diabetes, high blood pressure, and obesity that seem to be growing every year.

Another central theme in the conversation was the sheer amount of healthcare spending in the US compared to the outcomes we see. Although there has been a lot of discussion about value-based care over the last several years, we still see plenty of organizations focusing their marketing efforts around procedural subspecialists who can bring fee-for-service cases to their hospitals. Sometimes it feels like patients would much rather spend money for a pill or a scan or a procedure than they would on healthier lifestyle choices. The reality is that public health isn’t sexy and most of the time the general public doesn’t want to hear about it, despite the fact that clean water, waste management, safe housing, and vaccines are all public health measures that have made life better for many people.

The group knows I’m a clinical informaticist and asked me what technologies I thought could be brought to bear to help the life expectancy crisis. There are a lot of solutions out there, but I think we need to focus on a couple of key themes rather than following every shiny object that passes in front of eyes. First, we need to educate our patients. Patient engagement solutions such as chatbots, patient portals, and the like can help deliver patient education so that patients understand their health situation and know what to do to move things in a positive direction. For some patients this may need to be low tech, such as simple phone calls with a health coach or navigator, and those patients shouldn’t be left behind.

Second, we need to help patients track whether the things they’re doing to try to improve their health are making a difference. I’m surprised that readily available home monitoring devices such as smart scales or connected blood pressure cuffs aren’t used more. They don’t necessarily have to have all the bells and whistles, such as sending data to their care team, but need to be able to help patients see a trend and to know if what they’re doing is helping things get better or not. Seeing immediate results can make a huge difference in patient morale as well as readiness for patients to continue an intervention.

Third, we need to make sure that everyone involved in a patient’s care is aware of their health factors. Interoperability is key here to ensure that there’s not only avoidance of duplicative or unnecessary services but to ensure that different members of the care team know all the different conditions a patient has. There are still a number of patients that see multiple subspecialists with minimal coordination, so I think it’s going to be important to continue to invest in infrastructure such as health information exchanges.

Last, we need to continue to spend some of our tech funds on health surveillance, including not only public health analytics to help identify the next pandemic or severe health threat, but also on analytics to monitor the improvement or decline in the overall health of populations and what might be contributing to those changes. With all the computing power available to us, we should be a lot better informed. If we’re going to get health spending in check, we have to measure, manage, and measure again. I do have some favorite vendors in these areas, but I’m interested to see what our readers think and how impressed (or unimpressed) you might be with the solutions your organizations are using.

I spent a good chunk of the weekend helping some young people learn wilderness survival skills in the context of a fictional “zombie apocalypse” that was made more dramatic by the presence of near-freezing temperatures. It was also a team-building exercise, and it was interesting to see how the different groups came up with completely different shelter designs even though everyone started out with two tarps and a ball of twine. Several used the landscape to their advantage for wind and rain protection, and another did some interesting things with old tires that they found dumped in the woods. One less-than-enterprising group tried to just gift wrap a picnic table with their tarps. Although it was probably effective as a survival shelter, it didn’t score well on creativity in the peer voting at the end of the day.

The winning shelter was a simple design. I spotted one of my co-leaders napping in it following the judging, so I hope it earned all the “suitability for sleep” points that it rightfully deserved. Most of the groups spent the night in their shelters with only sleeping bags and I’m sure the excitement of having made it through the night is an accomplishment they won’t soon forget. Certainly none of them were impressed by my zombie antics, so I suspect I’ll just have to go back to being the “boomer” that the youngsters seem to think I am.

Has your company ever done any “extreme” team building? If so, what did you do? If zombies were taking over the world and you had to abandon your living space, do you think you would make it? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/7/22

A bill introduced in the US House of Representatives last week would allow employers to offer separate telehealth plans to its employees, much like they offer separate dental, vision, and medical coverage now. The Telehealth Benefit Expansion for Workers Act bill is a bipartisan effort, and it would also modify HIPAA and the Affordable Care Act to allow all employers (including seasonal and part-time staff) to benefit. It would allow freestanding telehealth programs to be separate from traditional medical coverage.

I haven’t seen any commentary on this from hospitals and health systems, which are probably still digesting how it will impact them if it passes. I haven’t had time to dig into the specifics of the bill, but I suspect the devil is in the details as far as what constitutes a freestanding telehealth program. For organizations that are already offering services but want to be able to capture their piece of the standalone pie, I imagine there will be a need to customize platforms to allow for different types of billing as well as to comply with any other program-related definitions. We’ll see how this bill navigates through the committee process and other parts of the legislative journey. If you’ve got any insider scoop, do tell.

In other telehealth news, the Government Accountability Office urges Medicaid to assess how its beneficiaries are using telehealth and to ensure that they are receiving quality service. The call to action is based on data from five states that showed significant increases in the number of services delivered via telehealth as well as the number of Medicaid beneficiaries participating. There are certainly challenges in delivering high-quality telehealth visits to Medicaid patients, who often have difficulty accessing healthcare in general. Technology may pose additional barriers due to cost, particularly when video is required for telehealth services. It will be interesting to see what types of studies are designed and what the outcomes are. A well-managed telehealth program can delivery high quality care, so let’s hope the studies are completed quickly so we can build upon the findings.

Despite spending the majority of my time on clinical informatics these days, I’ll always be a family physician at heart. With that in mind, I was disheartened to see a recent report from The Commonwealth Fund that showed the US ranking last for women’s healthcare among wealthy nations. Specifically, we had the highest rate of preventable deaths for reproductive-age women, with 200 avoidable deaths per 100,000. The UK was next with 146, followed by 132 in Canada and 90 in Switzerland. The maternal mortality rate in the US was three times the rate of other countries in the report, with high death rates among black women. The US also posted high rates of chronic health conditions, mental health issues, and difficulty paying medical bills. Although many of the people in legislative roles in the US are neither women nor of reproductive age, hopefully they have some family members who might fit into those categories and will consider taking action.

Back when my state’s Board of Healing Arts used to send out a paper newsletter listing its disciplinary actions, I often marveled at the ignorance, recklessness, and sometimes downright stupidity of some of my peers. Now I have to settle for digital snippets depicting doctors behaving badly, and a recent article. The Office for Civil Rights, which is charged with enforcing HIPAA, recently announced findings in a few investigations. Two were particularly salacious: one was a dental practice who provided patients’ protected health information to those running a state senate election campaign and another was a dental practice who disclosed a patient’s information on a website while replying to a negative online review. Seems to me like specialty medical certification boards should consider dropping some of their exam questions that deal with esoteric disease processes and consider adding basics of HIPAA (and being a decent human being).

News of the weird: a man in Germany received 90 COVID-19 vaccinations so that he could sell vaccination card forgeries that included actual vaccine batch numbers. Staff at a vaccination center became suspicious when he presented for immunizations two days in a row. He was found to have blank vaccine cards, and although he was not detained, criminal proceedings are under way. Forged documentation is a hot commodity in Germany, where vaccine passports are needed to enter public venues.

Insomnia is a big problem around the world right now. I attended a couple of presentations at HIMSS that discussed solutions. One looked a prescription digital therapeutics as a potential intervention, while the other discussed a smart pillow to gather data as part of an overall sleep management program. During a recent trip, I had four straight days of poor sleep and felt the effects. I couldn’t control the heating and cooling in my room the way I needed to, and of course there were random hotel noises in the hallway and loud pipes in the bathroom. I’m sure stress was also a contributor, but sometimes there’s not a lot you can do to mitigate that compared to the other factors. With that in mind, I ran across an article discussing a recent study of sleep data that revealed 16 distinct ways that people sleep.

The data was gathered from smart wristbands used by the United Kingdom Biobank. The bands tracked patterns of sleep and wakefulness by measuring arm movements. Clusters of sleep patterns were then divided into five categories with a number of subcategories to total 16. Groups ranged from those waking up mid-sleep to those sleeping well without naps, and everything in between. The researchers also identified disruption that was likely due to shift work as well as those with fragmented sleep. I don’t know where I fall on the continuum other than knowing that my recent sleep has been “a cluster,” but I hope I can get things to reset soon. I’ll be spending several nights in the upcoming weeks sleeping in a tent, which usually does the trick since I crash hard after being active in the outdoors.

Have you found your sleep suffering in the third year of the pandemic? What strategies have you taken to improve things? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/4/22

I spent some time this weekend at a non-healthcare, non-technology conference. It was nice to get away for a few days and spend time learning ways to improve my skills for one of my hobbies.

I’ve been attending this particular conference since 2018, and many of the attendees know about my past life in the emergency department. There were quite a few questions about COVID and whether I think it’s really over. I typically respond that I don’t think it will ever be over, but we’re learning how to cope with it in the US. Because our lives are back to normal, at least in part, many people have forgotten that there are other nations where people still haven’t had adequate opportunities to receive vaccines.

The Our World in Data website is one of my favorites. It shows that a high percentage of people in Africa have yet to receive even one dose of vaccine. It makes you think twice about living in a country where a large number of people still believe that COVID isn’t real and vaccines aren’t safe, despite there having been more than 11 billion doses administered worldwide.

I had some time to kill at the airport, so I participated in an online research study from Harvard University. The study was designed to evaluate strategies to influence vaccine-hesitant individuals to become up to date with the COVID vaccine schedule. Participants were educated on several strategies to try to persuade people to receive vaccines and then were asked to create narrative statements that they felt might work. Messages were to be in response to a patient who was concerned that the vaccine was rushed, that mRNA technology is too new, that fetal cells were used in vaccine development, and that vaccines cause death. The researchers plan to use a natural language processing algorithm to evaluate the messages, and which are best at demonstrating receptiveness. They also gathered data on the respondents’ perception of the concerned patient and whether they would be willing to interact with that person again, which I thought was interesting. I’ll have to keep my eye out for the results of the research in the future.

I also had time to read a study that was recently published and has been regarded as somewhat controversial. The Journal of the Mississippi State Medical Association published the study, “Targeting Value-Based Care with Physician-Led Care Teams” in its January issue. It details findings from Hattiesburg Clinic’s value-based care journey with its Accountable Care Organization. When cost of care was examined, the study revealed that care delivered by non-physician providers who were practicing independently was more expensive than care delivered by physicians. The findings led the Clinic to redesign its care model as well as to publish its findings. Multiple news outlets and physician organizations picked up on the article, leading to headlines about how midlevel practitioners just might not be the answer to the primary care physician shortage at all.

Looking at the organization’s journey, in 2005 it employed a combined total of 26 APPs (advanced practice providers), including nurse practitioners and physician assistants. Today it employs 118. Over the last 15 years, Hattiesburg Clinic had made decisions to expand care teams by allowing these providers to manage primary care patient panels on a largely independent basis. The Clinic has more than 33,000 Medicare beneficiaries and an associated Accountable Care Organization, so it was monitoring its outcomes carefully. The study found that by allowing APPs to operate independently, the organization “failed to meet our goals in the primary care setting of providing patients with an equivalent value-based experience.”

The authors looked at 2017-2019 CMS cost data on Medicare patients who did not have end-stage renal disease and who were not in a nursing home. The data showed that per member, per month spending was $43 higher for patients who had a non-physician in charge of their primary care needs. When applying risk adjustment factors for patient complexity, the difference was $119 per member, per month. Originally, the analysis was to help the organization identify high-cost providers so they could intervene. They didn’t expect the results they identified, including increased testing utilization, more specialist referrals, and more emergency department utilization for patients who were under non-physician care.

They also found that physicians performed better on nine of 10 quality measures, with notable differences in vaccination rates for influenza and pneumococcal disease. Physicians also had higher patient satisfaction scores across multiple domains measured via Press Ganey. Although they concluded that non-physician providers are valuable members of the care team, the organization determined that independent practice was not in the organization’s best interest. They then embarked on a year-long transition that would allow APPs to inform their patients that they would start seeing the supervising physician as well, and that the physician would become the primary care provider of record. Additionally, APPs in specialty areas were restricted from seeing new patient consultation visits except in emergencies or when approved by the referring physician.

There are some interesting factors to note with regard to the findings. First, the Hattiesburg Clinic is focused on value-based care. Their experiences may not translate to organizations that are still operating under a predominantly fee-for-service model. Under the value-based care model, excess testing and referrals cut into the organization’s bottom line, so there’s an inherent level of buy-in for operational changes. In a fee-for-service model, the organization can benefit from certain kinds of overutilization, which doesn’t encourage restricting services. Also interesting is the finding that the patients who had the best quality were those who had alternating visits with both the physician and the APP.

There are also some weaknesses in the study itself, including controlling for years of experience of the APPs compared to years of experience of the physicians, and any variation in the organization’s onboarding and training of different types of providers. Having worked with new and experienced nurse practitioners, physician assistants, and physicians, I’ve seen across the board that inexperience is directly related to the propensity to order increased testing and referrals. When you’ve seen a given clinical presentation hundreds or thousands of times, you’re likely to be more confident in your ability to manage the patient on your own and are also experienced enough to refine testing to the minimum necessary. The published writeup also doesn’t include enough information on the analysis to determine whether some of the differences were statistically significant.

It will be interesting to see if the authors submit their work for the additional scrutiny of one of the national journals and what the findings look like when they are subjected to additional statistical analysis. Although the findings seem dramatic, they underscore the need for critical reading and to determine whether findings are likely to be similar to other situations. There are hundreds of organizations across the country who have the same types of data as Hattiesburg Clinic, and it would be interesting to see whether they reach the same conclusions. We’ve entered an era where there is more healthcare quality and cost data at our fingertips than we’ve ever had, and it’s time to really start using it.

What does your organization think about Hattiesburg Clinic’s findings? Have you looked at this issue yourselves? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/31/22

A recent survey conducted by the American Medical Association found that 85% of responding physicians are using telehealth in their practices. Approximately 60% of physicians agreed or strongly agreed that telehealth enables the provision of high-quality care. I wasn’t surprised by the breakdown of visit types – 93% of them are offering video visits and 69% of them are offering audio-only visits. More than half of respondents say they are motivated to increase the use of telehealth in their practices. Uptake of other telehealth services, such as remote monitoring, seemed low at only 8%. As far as other interesting statistics, more than half of physicians indicated that telehealth had improved job satisfaction. The online survey was conducted anonymously, with 2,000 physicians responding.

A lot of people think that true telehealth services have to include both audio and video, but in my experience as a telehealth physician, it seems that the majority of patients are happy with audio-only services. Physicians have mixed feelings about doing audio-only visits. It’s definitely easier to assess whether people have an increased rate of breathing when you can see them, and you can quickly gauge their overall level of distress. Especially when caring for sick children, I like to see if they are clingy and how consolable they are as part of the evaluation.

For many adults seeking telehealth services, however, observation and other elements of physical examination don’t add much to the clinical picture. Ultimately it should be a balance, taking into account the patient’s preferences and the clinician’s comfort level with different telehealth modalities. There are plenty of studies that indicate that inclusion of audio-only services results in greater telehealth access among underserved populations, older patients, those who seek care in safety net facilities, and some demographic subsets.

Although there’s a lot of enthusiasm about telehealth, other sources look at telehealth from a different lens. One survey commissioned by UnitedHealth Group found that 55% of physicians are frustrated by managing unrealistic patient expectations for virtual visits. About half are also frustrated by issues with audio and video technology. Providers who responded to the UnitedHealth survey were less optimistic about telehealth’s impact on job satisfaction, with only 25% saying it was improved. There was also division on the role telehealth plays with regard to physician burnout – 30% said it increased burnout, while 30% said it reduced it. I’m sure the perceptions are valid at both ends of the continuum since I’ve seen some outstanding telehealth implementations and some that are marginal at best. I do hope that those organizations that plan to continue making it a large part of their patient care strategies spend the time and money to optimize their offerings for both patient benefit and clinician satisfaction.

Henry Ford Health unveils a new brand, dropping the word “system” from its name. According to its press release, removing “system” places more emphasis on the word “health” and broadens the vision. The new logo drops the iconic Henry Ford signature and oval and adds three shades of blue as well as a swath of purple. The purple is certainly eye-catching, but I’m not sure what to think about the different blues. The organization plans to roll out the new branding to its largest facilities first, with others phasing in the new branding over the next few years. Along with the visual branding, Henry Ford Health is launching an omnichannel ad campaign titled “I Am Henry.” It includes stories from the organization’s patients, employees, and from the communities it serves.

The organization’s press release notes that the “new logo clearly transitions the identity from one steeped in the visual history of founder Henry Ford, to a brand expression focused on humanity, backed by a powerful heritage of innovation and drive.” I’m not sure I fully feel that, but I’m willing to play along. On one of my recent projects, I learned an incredible amount about marketing, branding, and how different visuals can evoke specific responses from viewers. Looking critically at the new logo, I find the font rather intriguing. The majority of the letters are strong and uncomplicated, but the leg of the R adds a bit of whimsy. The swooping crossbar of the leading H pulls you into the name, and the trailing H feels downright playful. The purple feels a little too bright compared to the blues, but that’s just me. I’d be interested to hear what the marketing gurus out there think of it compared to my decidedly amateur opinion.

I learned last night that a physician who I worked closely with during my residency took his own life on Monday. He was a few years ahead of me in training . The loss of a young and talented physician (as well as a father and spouse) is tragic. Each year, 300 to 400 physicians die by suicide. Even if we personally are not at risk, the odds are that someone we work with might be struggling. The grief was particularly heavy since Wednesday was Doctors’ Day in the US, which was created to honor physicians for their dedication and their service to humanity. Knowing that some physicians feel there is no way to get through the challenges is heartbreaking, especially since I’ve lost two colleagues this way in under two years.

Judging by the reports in some of my social media feeds, the day was subdued for many, with occasional “snacks in the breakroom” celebrations. One physician reported that their organization gave everyone a book on wellness, which for many frontline physicians has become synonymous with pizza parties and therapy dogs. Another received a heart-healthy cookbook that appeared to be left over from a recent cardiology department open house based on the sticker gracing the back cover. I doubt hospital executives think about the idea that their selections might be posted on nationwide Facebook groups as a humorous counterpoint to those “best places to work” lists. Sadly, some physicians reported receiving no recognition in the clinic at all. With all the work physicians have put in over the last couple of years, I’m hoping that for them Doctors’ Day 2023 will be a better one.

Did your organization do anything to mark Doctors’ Day? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/28/22

The only thing being discussed in the virtual physician lounge this weekend was the trial of Tennessee nurse RaDonda Vaught, who was found guilty of criminally negligent homicide following a medication error. Criminally negligent homicide is a lesser charge than reckless homicide, of which she was found not guilty.

For anyone who hasn’t been following the story, the short version is as follows. Vaught, who was a nurse at Vanderbilt University Medical Center, was managing a patient order for the drug Versed. The patient had been admitted to the hospital’s neurological intensive care unit following a brain bleed. The drug was ordered to help manage anxiety and claustrophobia prior to a PET scan. Vaught couldn’t find Versed in the automated medication dispensing cabinet and used an override to unlock a broader menu of drugs, leading her to obtain the drug vecuronium instead. Versed is the brand name for the sedative midazolam. Vecuronium is the generic name for the drug Norcuron, which is used to aid in “surgical relaxation” for general anesthesia or to create paralysis for patients who are on ventilators in the intensive care unit.

Vaught failed to validate the name of the drug, didn’t notice a warning on the medication vial itself, and didn’t stay with the patient after administration.

Vaught’s attorneys argued that although she admitted making errors with the medication, those errors were part of normal operations at Vanderbilt and reflect systemic dysfunction. Prosecutors alleged that she ignored multiple warning popups, including one that would have said the drug was a “paralyzing agent” and that would have required a reason for the override. Other nurses working on the same unit testified that overriding the medication dispenser was a common occurrence and that a recent EHR upgrade had created delays in obtaining medications from the cabinets. They cited organizational emails instructing nurses to override warnings to reduce delays. Additionally, there was no barcode scanner in the imaging department, where the medication was administered. A scan of the patient’s hospital ID bracelet against the medication might have prevented the fatal drug administration.

As a clinical informaticist and process improvement specialist, I think about these kinds of errors all the time. Our system of having both generic and brand names for drugs causes a lot of confusion. I trained in a residency program where we were only allowed to refer to drugs by their generic names, which probably prevented some errors by newly minted physicians. However, when I entered private practice, there was a lot to learn, as many of my patients referred to their drugs by brand name. I ran across a couple of situations where the patient was on two drugs from the same class that would have been caught had the generic names been used. Fortunately, none of the patients were harmed before we could modify their regimens.

This error also brings up the issue with “look alike” or “sound alike” drugs. In the EHR realm we’ve taken steps to manage the former with interventions such as Tall Man Lettering for drug names ,which help to differentiate names that are close. One could argue that Versed and vecuronium aren’t close other than that they both start with the letter V, but it’s important to understand the level of baseline confusion that might exist when hundreds of drugs are used within a patient care unit on any given day. The practice of medicine has become significantly more complicated over the last two decades with hospitalized patients often being “sicker” than they were in the past. Due to medical advances, patients who previously might have died are living longer, often with a dozen or more drugs to address their health conditions as well as to mitigate issues caused by the drugs themselves.

There are also issues with the setup of the automated drug dispensing cabinet. At the time, the Vanderbilt system only required two letters to be entered to access a drug menu. One organization I worked with had their cabinets set to require five letters to locate a drug. They also had all paralytic agents in a specially colored locked container to make it clear that nurses were accessing something that required additional diligence. Additionally, Vaught was administering medications outside her usual department and didn’t document the administration of the drug. Its lack of inclusion in the medical record led to a death certificate that noted a natural death following a brain bleed rather than being related to the medication administration.

Vanderbilt didn’t report the medication error to the state. Only a year later when an anonymous tip was sent to state agencies did an investigation begin.

Anyone who has practiced in a complex care environment, such as an intensive care unit, understands how even a small distraction can have significant consequences. As a sleep-deprived resident physician, zoning out even for a second could mean missing a critical part of a patient’s information. In past times, ICU nurses may have cared for one or maybe two patients. Today I see them caring for three or more patients, which certainly isn’t helping with attention issues or distraction.

In a hearing before the Tennessee Board of Nursing, Vaught stated that she was distracted while precepting a trainee, but admitted responsibility for the incident. Although this incident occurred long before the COVID-19 pandemic, I can only imagine the level of distraction that nurses faced over the last two years.

In response to this case, I hope all facilities are reevaluating their processes for overrides on automated drug dispensing cabinets and how they store critical drugs such as vecuronium. In speaking with a pharmacist friend about this case, she noted that not all hospitals have increased their search requirements to five characters as my client did. If you’re at one of those institutions, I’d encourage you to quickly prioritize an evaluation of your processes.

This case is a perfect example of the Swiss cheese model of process safety. The more holes that are present, the easier it is for a mistake to happen. When the holes are particularly large, such as when medication overrides have to happen on a daily basis, people become desensitized to the safeguards that are designed to protect patients.

Certainly there were individual actions that led to this tragedy. Policies weren’t followed and literal bright red warnings were ignored. But without the combination of circumstances, the patient would not have received the wrong medication.

Those of us on the clinical front lines have all made mistakes. Some of those mistakes become near misses because of systems that protect patients (and also us as caregivers). But some of those mistakes become true medical errors that have devastating consequences. Comments from my peers run the spectrum from “it’s all Vanderbilt’s fault” to “she deserves the death penalty.” The reality though is that we could all benefit from a closer look, as well as a slower and more thoughtful one, at how a situation like this might unfold in our worlds.

Have you ever been responsible for a medical error? What advice would you give for those who design and maintain the systems upon which you rely? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/24/22

I’m still recovering from HIMSS22. Between the Daylight Saving Time change and a couple of weeks of hopping across time zones, my sleep has been disrupted for days. After experiencing the new normal of conferences, I wonder what healthcare IT marketing budgets will look like in 2023 and beyond.

A recent Medical Marketing and Media article notes that medical marketing budgets increased by 15% in 2021, although they were still below pre-COVID levels. The data was drawn from pharma, biotech, and medical device companies. It looks like money is being funneled to digital channels as opposed to personal promotion. Those strategies include paid digital advertising, content marketing, social media, websites, and microsites. Physicians should be happy that paid traditional TV advertisements have dipped to around 5% of marketing budgets overall and more than half of respondents aren’t using any paid traditional media, such as TV, print, or radio.

Roughly half of the companies’ marketing budgets were being directed to engage healthcare professionals. While 46% of marketers trying to reach professionals used meetings or events in 2020, this dropped to 40% in 2021. Nearly 37% of respondents said they decreased their meetings and events budgets, and fully a third said they spent nothing on that channel. Those surveyed were positive on using social media to reach healthcare professionals, with 39% increasing their paid social media budgets. Consumer-focused marketing represented 31% of expenditures, with more than half of companies relying on social media.

Speaking of marketing: Anthem plans to change its name and rebrand to Elevance Health. The company says the new name will represent the non-insurance services it offers, including digital health, pharmacy, complex care, behavioral health, and more. It also notes that the new name highlights its “commitment to elevating whole health and advancing health beyond healthcare.”

I’m not a big fan of smashing words together to try to come up with something new, especially since using either word – elevate or advance – doesn’t really say anything about what the company stands for. Fortunately for consumers who are often confused by these rebranding efforts, the names of the Blue Cross Blue Shield health plans it owns will not be changing. Shareholders have to approve the name change at their May meeting, and if I had to vote, I’d want to know how much the rebranding effort will cost and what the company believes the return on the investment will be. Even if the ROI isn’t good, it will still stimulate the economy through countless print orders, website design efforts, and creation of promotional items. As a healthcare consumer, I’d rather see payers spend money on reducing administrative burden and compensating care providers fairly versus buying a bunch of new travel mugs and business cards.

I do a lot of consulting around patient engagement and getting patients to do many pre-visit tasks electronically prior to appointments. There’s always pushback from individuals who feel that patient questionnaires are too long and that they’re not worthwhile. A recent study in JAMA Network Open shows that patients prefer sharing sensitive information electronically rather than in face-to-face encounters. Disclosure of domestic violence, depression, and other conditions was twice as likely when inquiry happened in a tablet-based app compared to questions from a person. The app used in the study was integrated with the EHR, allowing clinicians to better follow up on positive responses to screening questions.

Hopefully this will help solution designers understand that pre-visit gathering can be useful rather than an annoyance to patients. I think more patients would be apt to participate with pre-visit questions if two things happened. First, patients deserve a better explanation of why the provider needs the information and how it can improve quality of care. Second, providers have to actually use the information the patient already provided and make it clear that they’ve reviewed it and might have a couple of follow up questions, rather than just proceeding on autopilot like they may have done for years.

I was interested to read about Amwell making its telehealth platform available through LG’s healthcare platform. It made me instantly think of a Jetsons-like interaction where one could be standing in front of their smart refrigerator having a healthcare visit. On the flip side, integration with smart appliances might be invasive, especially if my healthcare provider can get information on how often I restock the vodka in my refrigerator or how many vegetables are in the crisper drawer. No release date was available, which means either it’s still early in development or they’re just playing coy. If it’s the former and they’re looking for provider and patient opinions, I might know someone who’s interested.

I ran across this article while flying last week. Payers are apparently shelling out $979 million in excess healthcare expenditure due to turnover in the primary care physician ranks. The underlying study estimates that for each primary care physician who leaves practice, there is $86,336 in additional spending the following year. This may be due to patients going to the emergency department because their primary physician left or choosing more expensive specialists to manage problems that could be handled by primary physicians. More than a quarter of the spending was linked to burnout-related turnover.

From Jimmy the Greek: “Re: buzzword bingo. Check out this word salad masterpiece found in a Gartner report.” Gartner says:

Hyperautomation initiatives focus on ensuring that businesses and IT process workflows are as frictionless as possible. This task-level digitization is the foundation for process-level and cross-functional enablement of decision making for business agility and resiliency. Well-architected hyperautomation initiatives demand standardization of processes, which enables improved quality and cycle time. Additionally, digitalization enables accessibility and transparency, which catalyze both human and digital workers.

I’m still trying to wrap my brain around the idea of how one catalyzes a nonhuman worker. For those of us who were educated at a time when the art of diagramming sentence structures was still taught, this paragraph is a masterpiece. Thanks for sharing and for a bit of distraction during a busy day full of conference calls.

What’s the most obtuse thing you’ve read this week? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/10/22

Healthcare workers are still at risk for COVID infections. Even though vaccines have been proven to reduce hospitalization and death, there’s still risk of infection and the potential for subsequent disability. A growing body of evidence shows long-term cardiovascular and neurological complications from even mild cases of the disease, and an estimate of over 1.5 million adults in the US who are seeking permanent disability determination following infection.

During my recent visit to the hospital as a patient, I don’t recall seeing hospital employees wearing anything other than surgical masks. Some patients were wearing KN95 masks, but it made me wonder whether wearing surgical masks was an employee choice or whether there is still a supply shortage for respirators or other types of masks.

With that in mind, I wasn’t surprised to learn that OSHA plans to increase healthcare facility inspections to assess preparedness for the next COVID-19 variant that might emerge. The initial focus will be on facilities that were previously cited or had complaints filed against them. OSHA is supposed to be finalizing an infectious disease standard for worker protection, and for the healthcare workers who have been permanently impacted by the pandemic, it can’t come soon enough.

I’m a history buff, so was quite excited to see the announcement that Ernest Shackleton’s ship Endurance has been located nearly two miles below the surface of Antarctica’s Weddell Sea. It’s remarkably well preserved due to the extremely cold waters and the lack of wood-damaging organisms. The technology needed to locate the wreck is pretty remarkable, but so is the determination of those who worked in difficult conditions to make it happen. The ship’s resting place is protected as an historic monument under the 1959 Antarctic Treaty, so nothing was disturbed in the exploration of the wreckage. Kudos to the anonymous donor who financed the $10 million mission.

Healthcare news and announcements are at a minimum this week, other than Epic’s announcement regarding Garden Plot. My inbox is full of poorly worded but jargon-rich emails practically begging me to visit various HIMSS booths. Having more than three buzzwords in the first sentence dramatically lowers my chances of actually showing up.

I’ve also received some tips on pretty cool things that will be revealed next week but am sworn to secrecy, so you’ll have to follow along for the news as well as our on-the-ground reporting. Mr. H is doing the short version of the conference, but I’ll be there Sunday through Thursday, so we’re leaving a gap in reporting Friday’s keynotes. Both of them looked interesting, but I know from experience that by Friday I would be too exhausted to care and prefer to sleep in my own bed rather than dropping another $200 on a hotel room.

I’m experiencing a last-minute flurry of work prior to the conference, however. It seems my clients must have some kind of fear that I’m going to run away to Florida never to return, because a couple of them have decided they want to accelerate projects that haven’t been on their priority lists for weeks. I was able to accommodate some because they were close to completion and just waiting on a few details from the client, but others are just going to have to wait. I may address some of them on the plane, depending on my mood and the surroundings, but no promises were made.

The farther I get in my career, the more I’m likely to engage the rule that “no is a complete sentence.” I don’t mind going the extra mile when someone has an unexpected need or something out of the ordinary happens, but I don’t make a habit of running around crazy when it could have been avoided.

I’m also doing some last-minute shoe shopping, having decided that in 2022 footwear comfort is much more important than style. HIMSS was already becoming more casual the last time I attended in person, and based on the numbers of us who are used to working at home in hiking pants and pullovers, I’m sure the casual ethos will extend to the exhibit hall. I’ll still be looking for good shoe photos, though, so if your feet are young and you’re feeling sassy, I’ll keep an eye out for you.

As far as packing, it’s also a good 50 degrees warmer in Orlando than it is for me at home. Although I’m looking forward to breaking out the spring and summer clothes, I hope it’s not completely sweat-inducing next week in Orlando since I’ll be doing a lot of walking from my hotel out in the cheaper part of town. Maybe some day I’ll hit the big time and be able to stay right across the street, but that wasn’t in this year’s budget.

The biggest challenge of the week has been an issue with my Outlook calendar, which Microsoft assures me will be fixed once the time change actually occurs on Sunday. This week looks normal, as does the week following HIMSS, But starting Sunday, the system has gone wonky when converting between good old Chicago time and the East Coast. Fortunately, my administrative assistant is reconfirming all my meetings and creating a backup document in case things don’t go as well as we hope on Sunday morning.

I have a new friend joining me on the party scene this year and am looking forward to connecting with old friends as well. It’s been a long depressing winter for me, so if you see the blond-haired person in sunglasses sprawled out on the lawn in front of the convention center, it just might be me. I have to enjoy it while I can, since HIMSS23 in Chicago won’t likely lend itself to lounging on the grass.

Are you packed and ready for HIMSS, or still knee-deep in ViVE? Or are you just glad to be staying home in your yoga pants and quarter-zip while the rest of us head to the boat show? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/7/22

As a CMIO, I spend a great deal of my time thinking about patient experience. Telehealth is a major focus for my organization, and in the name of patient experience, we worry about dozens of details:

• Are the colors on the website pleasing?
• Can patients easily figure out that we offer telehealth, and what hours?
• How patient-friendly is the registration process for the patient portal?
• Have we optimized the pre-visit check-in process?
• Are we asking enough questions to gather the information the physicians want, but not so much information that patients are frustrated by the questions?
• Is the connection to the telehealth platform seamless?
• Are there risks for a poor-quality visit?
• Are the post-visit instructions clear and delivered to the patient quickly?
• Is the communication back to the rest of the care team timely?

This week I had to put my patient hat on again, and it was an experience that made me wish that healthcare executives spent half the time thinking about the in-person patient experience that I’ve spent thinking about telehealth over the last six months. The opportunities for improvement spanned the spectrum of people, process, and technology.

For background: my visit was for a radiology procedure at a large academic medical center and had been scheduled six months ago. I transferred care there last year after some medical misadventures elsewhere and didn’t know exactly what to expect.

The first miss on their part was the fact that they don’t use the capabilities of their EHR and patient portal to manage basic pre-registration and appointment confirmation tasks. Instead, I had to start playing phone tag with the registration team four days prior to the procedure. I missed their first call because I was working, and then they called again before I even had a chance to listen to the voice mail. I couldn’t answer that call either, and then when I did have time to call back, I was routed through a complicated phone tree before I finally reached a human who was able to verify my insurance and demographics. I asked about arrival instructions since I hadn’t been there for this particular procedure before, and all they could tell me was to stop and ask at the information desk because the person on the phone couldn’t see what specific procedure I was scheduled for.

Two days prior to the visit, I got another call, this time with the pre-visit instructions I had been looking for earlier in the week. Because I use Google Assistant to screen calls from unfamiliar phone numbers, I could see the beginnings of the transcript and picked up. Fortunately, it was a long looping recording that I was able to listen to a second time to make sure I had all the information. It did give more information about the arrival process, including parking information and some additional details about where to arrive at the hospital. I’m not sure how the call would have worked out had I not picked up, though, since it would have rolled to voice mail partway through the recording and likely would have been cut off.

On the day of the visit, I left in plenty of time because I knew traffic would be dicey. It wasn’t as bad as I thought, but I needed every second of extra time because there was hardly any available patient parking at 8 a.m. I made it to the registration area 30 minutes before my appointment as recommended, then had to sit for another 20 because the registrars were on break.

In the mean time, I got to observe challenges other patients were facing. One gentleman was there for laboratory testing but didn’t know the name of his physician, so the staffer couldn’t figure out his orders. Apparently they can’t be looked up by patient, only by ordering physician. The patient knew the orders were from the urology department, but the staffer said they couldn’t do anything until he could give the physician’s name. The patient had to call upstairs to the office and find out what clinician’s name the orders were under, and then they could take care of him. It seemed a little ridiculous to me, but I don’t pretend to understand how their systems are set up.

Once the registrars were back from break  — which continued an extra 3-4 minutes while they watched TikTok in the waiting room right in front of me — I was called back. There must not be an indicator as to whether patients completed the pre-registration process by phone, because I was asked if I did it, and despite saying yes, I was asked all the same questions again. They asked me to sign several consents on a signature pad without offering a readable copy of the consent. Seriously, is it even a valid consent if the patient was never given the document to read? I think it’s unlikely.

The registrar handed back a blue ticket with my insurance card and photo ID, but didn’t explain what it was. I quickly figured out that it was for parking validation, but first-time patients might appreciate some explanation. I was sent on my way with a complicated set of instructions for finding my next destination deep in the radiology department.

There I was met by another receptionist who handed me two paper forms to fill out. Neither had been generated from the EHR, so they didn’t have any of my demographics or historical information. I had to fill out all the basics again, including name, DOB, address, medications, allergies, name of my PCP, name of the referring physician, and more. All of these things could have been handled through the patient portal they day before and placed into the system for the team to review had they not already existed in the EHR. At a minimum they could have printed a pre-populated form for the patient to just update in person rather than having to start from scratch.

When I turned in my clipboard, I got chastised by the registrar for not having a visitor sticker on. I had one when I initially arrived, but I guess it fell off after moving through multiple different stations and putting my tote on and off my shoulder repeatedly.

Once I made it into the actual MRI suite, I was taken to a set of lockers and verbally given a complex set of instructions on how to use the lockers, which had recently been made keyless. I was given gowns to change into, but no scrub pants like I was used to at my previous radiology department. The tech told me they quit using pants for cost reasons, and now they just give people two gowns. Having pants definitely makes for a more pleasant patient experience, so I asked about bringing my own next time. I was told that is not allowed.

After changing, I had to find my way to the IV station, where they reviewed my allergies. The screen still showed an allergy that had been retired almost a year ago during testing by an allergist at the same academic medical center, and which I had requested be removed via the patient portal as well. The nurse updated the screen (hopefully for the last time), got the IV going, and took me to an internal waiting room.

At some point in the pandemic, every other chair in that waiting room had been taped off by placing a banner around the arms to block the seat. The banners said something about social distancing, but I didn’t retain the message because I was too busy being floored by the amount of dust and dirt that had accumulated on the unoccupied chairs. We’re talking mini-tumbleweed dust bunnies here. I know people haven’t been sitting in the chairs, but I am guessing that no one has been wiping off any of the other chairs either, because I can’t imagine a worker who was tasked with wiping chairs ignoring something that looked like that. I would have taken a picture if my phone hadn’t been impounded in the locker.

I was finally taken back for my study,. After getting situated for the MRI, I had to specifically ask for a blanket to cover my bare and freezing legs. I wonder how many patients know to ask for that.

The MRI was not entirely uneventful, but I’ll leave that story for my closest friends over cocktails. After I finally made it out of the machine, the staff confirmed that I wasn’t having any other tests or procedures that day, so they could remove my IV. Good thing I wasn’t still dizzy and feeling crummy from the test because there were no chairs in the room. I had to bend over and rest my arm on a counter for the tech to pull the IV. Had I been an elderly patient or someone with a tendency to faint with procedures like that, things could certainly have gotten bad very quickly.

After that, I had to find my way back to the locker room area, where an older patient was struggling with the lockers because she couldn’t remember how to get it to unlock. There weren’t any posted instructions, so I coached her through it before retrieving my own clothes. I changed quickly because at this point, I just wanted to get out of there.

The staff had said there was no checkout process and I was free to go, but the signage didn’t clearly tell me how to get back to the initial waiting area. I made a wrong turn and wound up in a back corridor, where they were transporting an intubated patient in a hospital bed. I quickly turned around for privacy reasons and headed back into the maze of corridors, finally making it through the waiting area to the main hallway.

Upon turning left to exit, I ran into the same transport team in the main corridor wheeling the intubated patient (whose gown was hanging half off) through the main atrium, where I’m pretty sure there aren’t supposed to be patients in hospital beds. Maybe there was a broken elevator or maybe something else was going on, but I felt bad for the gentleman’s lack of privacy as well as the other patients and visitors who probably have never seen a gravely ill intubated patient and might have found it shocking. If that’s indeed how hospitalized patients are transported to MRI, then shame on the architects for their design.

After dealing with my parking ticket (the magical blue card covered only $1.50 of my fee) I was even more eager to just get out of there. There was a line at the elevator, so I took the open staircase in the elevator atrium. When a parking garage has closed-off stairs, I expect them to be a little grubby and usually poorly lit, but these steps in the open atrium were dirtier than any big-city subway station I’ve ever visited. There was trash on the ground, used masks, and enough road salt granules to make the stair treads somewhat slippery. It made me wonder when someone from hospital administration last used those stairs and what they thought about it. It also made me wonder what the big-time donors whose names are on the building would think.

Overall, I would give my patient experience no more than 3 out of 10. If I encountered the level of dirtiness I saw at the hospital at a restaurant, I’d walk out the door. As healthcare consumers, however, we are expected to tolerate it.

If you are a hospital or health system executive, I urge you to walk the proverbial mile in your patients’ shoes, in-person as well as virtually. Fix the little things like wayfinding signage and locker instructions. Offer blankets rather than waiting for patients to ask. Let patients bring their own scrub pants for MRIs if you’re not going to provide them. And for the love of all things, use the expensive EHR to the best of its capabilities rather than continuing decades-old processes. You can bet I’ll be sharing my experience fully when the patient survey arrives.

If you’re an administrator, have you walked in the patient’s shoes, and were you shocked by what you saw? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/3/22

Plenty of HIMSS exhibitors are talking about ways they can support clinicians including through virtual scribes and artificial intelligence. Burnout remains a hot topic, with Medscape ranking the most burned-out specialties. Based on comments from my physician friends, they’re in agreement that burnout is everywhere, with 100% of them using the word “exhausted” at least three times in casual conversation. Medscape surveyed physicians from June to September 2021, so these are pre-Omicron numbers. Top causes of burnout included too many bureaucratic tasks, lack of respect, long work hours, lack of autonomy, insufficient pay, EHRs, and government regulations. Topping the list:

1. Emergency medicine (no surprise due to COVID).
2. Critical care (also no surprise due to COVID).
3. OB/GYN.
4. Infectious disease tied with family medicine.

Beleaguered medical practices have been in the news over the last two years, but there is some encouraging news of a potential rebound. Kaufman Hall’s latest Physician Flash Report shows higher patient volumes helping drive revenue growth in 2021. Physician work relative value units (wRVUs) grew more than 20% per full-time equivalent physician compared to the last quarter of 2020. Primary care practices in particular showed a 13% increase. These increases are partly attributed to patients presenting for care after deferring it during 2020 and early 2021. Unfortunately, expenses also grew, with the metric of total direct expense per physician rising 16% versus 2020 numbers. Word on the street is that physician groups are still cutting salaries and asking physicians to do more because of ongoing staffing shortages. I don’t see these factors positively impacting burnout rates anytime soon.

News of the weird: If you’re a physician, this headline is definitely going to catch your eye – “Healthy Man Dies After Mistakenly Drinking Equivalent of 100s of Coffees.” The patient in question had a misadventure using caffeine powder in his pre-workout drink, resulting in caffeine toxicity. He suffered cardiac arrest and was taken to a hospital, where he ultimately died. A coroner’s report listed his caffeine level at four times that which is considered deadly.

I’ve received several recruiting emails over the last couple of weeks for “a leading Government Systems Integrator” who is in need of multiple clinical informaticists. The opportunities are for a full year with up to 50%  travel “depending on the phase of the implementation.” The job involves “performing assessments and evaluation of workflows and content to support the deployment of EHR systems, facilitate process change and provide change management consulting as well as working with hospitals and/or ambulatory and clinical business units to support deployments. Cerner experience is required, so I’ll give you fewer than two guesses at who is now trying to hire the informaticists to address issues that could have been avoided had they employed the right resources in the first place.

A United States Government Accountability Office report to Congress last month found that the Department of Veterans Affairs didn’t adequately ensure the quality of migrated data as it populated the new Cerner system. Clinicians reported challenges in accessing the migrated information as well as concerns with its accuracy. The GAO watchdog noted that “the challenges occurred, in part, because the department did not establish performance measures and goals for migrated data quality.” As a result, the system being deployed “does not meet clinicians’ needs and poses risks to the continuity of patient care.” There were also apparently concerns with ensuring that clinicians knew what data was migrated and how to find it as well as not having appropriate security rights to see critical patient care data, such as immunizations.

Other concerns included data duplications, errors, and inclusion of a greater amount of data than clinicians actually needed. The bulkiness of the transferred data made it harder for clinicians to find what they were looking for. I’ve worked on more EHR data migrations in my career than I care to remember, and making sure the data is not only accurate but winds up in a place where clinicians can actually use it is critical. The GAO’s findings also illustrate the importance of training to ensure end users can hit the ground running. Role-based training would have been particularly helpful here, as would ensuring adequately trained and staffed super users to support clinicians who may not have fully absorbed all the material during training.

The GAO recommended that the VA adopt performance measures and goals so that data quality meets clinician needs in future deployments. It also suggested that the VA “use a register to improve the identification and engagement of all relevant EHR modernization stakeholders to address their reporting needs.” As a consultant, ensuring stakeholder alignment is critical to the success of any project. I still see way too many projects that don’t adequately balance technology, operations, clinical, and other needs while trying to solve complex problems. I thought a project of this magnitude and visibility might have done better, but it just goes to show that the more things evolve, the more they stay the same.

In travel news, Cleveland Clinic is examining an opportunity to open a patient lounge at Cleveland Hopkins International Airport. The facility would allow construction of a nearly 400-square-foot space to replace seating and Rock and Roll Hall of Fame murals. Staff would help coordinate travel to the hospital and provide support for families and caregivers. Approximately 3,000 patients seek care by flying to Cleveland each year from across the US and from more than 180 countries. The Mayo Clinic has its own welcome center at Rochester International Airport, so hopefully Cleveland Clinic will be able to keep up with the destination healthcare Joneses.

I’m finalizing my HIMSS travel plans and also my evening social plans. Invitations are still a little slow, but that’s to be expected given the concerns about the decline of in-person attendance. Orlando can be a tricky destination for party planning since many of the desirable venues are away from the convention center and hotel areas. At HIMSS19, there was one night when cell service issues created rideshare outages, which was extremely frustrating. Traffic is always horrible, and to be honest, the convenience and location of multiple event venues is one of the reasons I actually like Las Vegas as a HIMSS location (as long as it’s not in August).

What’s your favorite HIMSS venue? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/28/22

I spent the week wading into the world of post-operative care at home, as I stayed with a friend who is recovering from surgery. I know plenty of people in healthcare who are enthusiastic about discharging patients quickly and getting them home to recover. It certainly cuts down on the risk of hospital-acquired infections and can help patients psychologically as they return to a familiar environment. However, it can be challenging for people who don’t have family or other support, and I think we sometimes overlook those factors when we’re considering hospital at home and other initiatives.

My friend is a physician who had the misfortune to severely injure her knee on an escalator at a London tube station several months ago. She initially had difficulty being scheduled for an orthopedic evaluation due to the rise of COVID cases last autumn, and once she jumped through all the hoops and was able to get an MRI and a definitive diagnosis, her health system had stopped performing any elective surgeries. Her planned recovery was complicated by the fact that she needed to be non-weight-bearing for six full weeks, compounded by the fact that she is single and has no family in the town where she practices. She also lives in a two-story home, so had to think about that in her recovery plans as she worked to figure out what her strategy might be. Even though she is a physician, she hadn’t had surgery before and wasn’t sure what to expect regarding post-op pain or other potential complications.

Her large, multi-state health system has a hospital near her parents, so she was able to have her local physician arrange for an orthopedic surgeon in the other city to review her studies. Following a telehealth visit, he agreed to perform the surgery once scheduling opened up again. In the mean time, due to the physicality of her job (she is also a surgeon), she was unable to do her usual work duties, which was stressful. Once the hospital started scheduling elective procedures, she was finally able to get on the schedule due to a cancellation. The operating surgeon’s office arranged to have a variety of medical equipment delivered to her parents’ house, including a wheelchair, walker, ice circulating machine, continuous passive motion machine, and more. By the day prior to surgery, only half of it had arrived, which created stress for everyone. On the day of the procedure, her parents had to decide who would stay home and wait for the rest of the equipment and who would accompany her, which added to the stress.

Fortunately, the procedure went well, and by the time she arrived back at home, nearly all the equipment had arrived. For someone non-medical who isn’t used to making follow-up calls, having to track down the rest of the supplies would likely have been more stressful than it was for her. She wasn’t having to use a lot of opioid pain medications, so she could advocate for herself on the phone, but not everyone is in that situation postoperatively. At least the magic ice machine had arrived, so she was able to rest without worrying about changing out ice packs. The next day, when she got ready to use the passive motion machine, she noticed a discrepancy between the instructions she had been given before the procedure and those in her discharge instructions, which led to a call to the surgeon’s office and difficulty getting a straight answer. She also began doing injections of blood thinners due to her forecast immobility. As a physician, not a big deal, but probably more challenging for other patients.

Prior to the procedure, my friend had suspected that two weeks with her parents would be more than enough family bonding, so she arranged for friends to help during the next few weeks after she returned to her own home. She had set up an inflatable guest bed in her first floor living room, and fortunately her home has a full bathroom on the first floor. Unfortunately while she was away, the bed had sprung a leak, leading to an emergent online order and a Target run by her next caretaker. After getting that situated, she had to figure out logistics for navigating the house in a wheelchair when the house hadn’t been adapted for it. Doorways were too narrow, the laundry room was impassible, and there were a couple of other challenges they had to work through. She would have liked to use the walker more, but was having some wrist pain after a slip while transferring, prolonging the use of the wheelchair. Fortunately, her friend was able to stay for several days until I arrived for the handoff.

By the time I came on the scene, they had figured out quite a few ways to further adapt things, including just storing dishes on the countertop versus using cabinets and rearranging the refrigerator to make things more accessible. As a physician with a good income, ordering takeout or grocery delivery wasn’t an issue, but we discussed how a lot of our patients don’t have that option. Not everyone can put their frequent flyer miles to use and fly someone across the country to stay with them or have the relative luxury of paying a neighborhood kid to manage trash and recycle cans. Not to mention, what if she had been the primary caregiver for children or another adult? Without this level of support, patients might elect not to have a procedure, especially if they don’t have paid sick time to cover the entirety of their recovery.

Because of the nature of the procedure and her pre-existing good health, my friend wasn’t eligible for any kind of home health or other services. Due to the pandemic, her physical therapy was delivered via video visit, removing another possibility for personal contact. Although I did enjoy following along with the video PT and seeing what another EHR’s technology looked like, it made me think quite a bit about what this experience looks like for other patients who might not be as tech savvy or medically aware. She was also fortunate to not have any postoperative complications, so it was relatively smooth sailing while I was there. She’s not scheduled for an in-person physician visit for another two and a half weeks and I was surprised that the orthopedic surgeon’s team hadn’t followed up with her to see how she was doing.

I handed off over the weekend to one of her physician colleagues, who came to stay for a couple of nights while her own family was out of town. Those days will get my friend to the end of the four-week milestone and she’s feeling more confident about being alone, although still worried about what would happen if she fell and no one else was around. Hopefully the rest of the six weeks will be uneventful, but we both know that’s when the real work starts, as she has to start using her leg again and figuring out how to get the strength back to spend long hours in the operating room. While I was there, she got to experience a taste of what being a CMIO looks like and admits she doesn’t envy the eight hours of calls and meetings each day. I’m glad I was able to help, but it did give me quite a bit to think about as I help my clients with their telehealth and in-home care strategies.

Have you experienced hospital at home, or a prolonged recovery? What did you think, and how did your caregivers fare? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/24/22

Lots of activity on the HIMSS22 preparation front as people start to get serious about scheduling meetings, identifying sessions to attend, and attempting to draw people into their booths.

I’m often asked what would get me to come to a booth and look at a solution. First, I always remember that I’m primarily at HIMSS on behalf of my clients. It’s not just about the shoes and parties (and looking at HIMSS22, the schedule for the latter is decidedly lacking). I’m more apt to visit a booth for a vendor that has a potential solution to a client’s problems, or to a generalizable healthcare problem that’s important to me as a physician.

Second, companies need to consider the mechanics of how they let people know that they have a solution that might stimulate some interest. I at least eyeball the emails that come through from HIMSS vendors. If there’s a problem with the email formatting and the subject line doesn’t render correctly in the inbox, it goes straight to the trash. Marketing teams definitely need to be on top of testing this before they send their blast communications.

If the subject line seems compelling enough to open it, but I find formatting issues in the email itself (such as a poorly constructed salutation), it’s likely to go straight to the trash as well, since I find that highly annoying in addition to the fact that it conveys a message that a company isn’t attentive to detail. If they can’t manage the little things like formatting their communications, can I trust them with my clients’ outcomes? I understand that marketing is far from being considered a little thing and there’s a lot of complexity involved, but thousands of companies are able to do it right every day, so it can be done.

There used to be a lot of direct mailings to CMIOs in the weeks before HIMSS that included invitations from vendors to visit their booths and teased potential announcements. Some of the big spenders would even send goodies ahead of the meeting. Some would fall along the lines of “HIMSS survival kits,” including energy drinks and water bottles. Although eye-catching and fun, I’m not sure how much the average CMIO really used them or whether they thought they were a waste of money and postage.

I always liked hearing about the booths that were hosting events or activities to benefit a charity, such as “come by to stuff a backpack for a deserving school” or something similar. Those definitely got my attention because they were not only fun to do, but a good diversion from a long day at HIMSS.

Other mailings were a little kitschier, especially if the meeting was scheduled for Las Vegas. This includes vendor-branded casino chips to bring to the booth. I don’t know how many people actually carried those to the show, let alone took them to the booth, but I saw them year after year so they must have been effective, at least to some degree. Cards to bring for a drawing were also popular, and it’s been interesting to see how those drawings have evolved over the years. In 2011, it was IPad city, and I was lucky enough to bring one home. Over time, Fitbit devices became popular, then Bluetooth speakers, Apple watches, and more. I’ve seen a couple of vendors give away designer handbags, which is a fun twist. There was one company that gave away jet ski and one that gave away Vespa scooters. I’d definitely stop by to get a Vespa pic if someone offers one.

Mailings have definitely fallen off over the last several years. For HIMSS19, many of the mailings were late and were waiting for me when I returned home. Although HIMSS20 was a casualty of COVID, I received fewer than a dozen mailings. HIMSS21 brought less than a handful of postcards. I haven’t received any mailings this year, although it’s still early. I feel like physical mail is likely going to disappear, but would be interested to hear from any marketing professionals on whether they still feel there is a role for it. It’s certainly a differentiator if you’re one of the few vendors who does it and is likely to garner a little more attention than the flood of emails that we all receive.

In thinking about being actually at the show and what makes me want to visit a booth, my list is fairly well harmonized with what Mr. H publishes nearly every year. Friendly and engaged booth staff who are outward facing as people walk by makes the top of my list. Nothing says “we don’t want to talk to you” like being heads-down on your phone. Even the tiniest booths will get my attention if they look remotely interesting and the staff actively tries to engage clients. Hopefully the HIMSS badges will be printed this year in a way that booth staff can see our titles, because I think that helps a bit in the exhibit hall dance as well.

The booth needs to be clean and organized, with no clutter on tables and definitely no overflowing trash cans. If you have swag to give away, it needs to be organized and not look like a yard sale. Small tchotchkes that make the show easier are always appreciated – hand sanitizer, lip balm, Tylenol packets, etc. Little pieces of chocolate are always a fan favorite, especially if you need a pick me up after several hours of cruising the exhibits. I’m not a big fan of glossy paper take-aways simply because I don’t want to carry them around, not to mention the environmental impact of those. I might take a picture of materials to remind me of a vendor, so maybe having something that displays the vendor, its core offering, and its website in a way that can be easily captured would be useful.

Of course, I always make sure to visit the booths of our HIStalk sponsors and I’ve enjoyed seeing our signage over the years. I test drove my new HIMSS shoes last week so now all my boxes are checked and I’m ready to put my exhibit hall strategy together.

What are your plans for HIMSS22? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/21/22

I’ve had a fair amount of work-related travel in the last few weeks and have noted the distinct lack of business travelers in the friendly skies. Others in the industry have noted the same, as companies have shifted away from in-person meetings in favor of ever-present videoconferencing software.

Airlines have been strapped for business during the pandemic and are trying to capture revenue from the pent-up demand of individuals wanting leisure and family travel. As a result, we’re seeing some overall changes in routes and schedules. We’re also seeing changes to flights after they’re already booked, which might be tolerated by leisure travelers, but which creates a mess for those of us traveling for work.

In the last week, I’ve received four flight change notifications that shift my departures or arrivals enough that I need to fly in a day early or stay a date later in order to meet the client’s meeting request. It feels like the days of being able to fly in and out of some cities on the same day are soon going to be over, if they’re not already. Even if the flight change notifications are acceptable, I’ve run into issues with airline websites not updating appropriately to allow travelers to update their Outlook calendars with the new flight information. It’s a small thing, but when you add up a number of annoyances, it definitely compounds.

With declining numbers of business travelers, the whole airline experience feels messier and more disorganized. I’ve been in several TSA PreCheck lines with people who don’t understand the process and start unpacking their laptops and liquids, which aggravates not only their fellow travelers, but the TSA agents, who seem a more aggravated than their baseline state. Boarding processes seem to take longer as people fumble with their phones and their overstuffed carry-on bags. People seem to be less attentive, probably more focused on their phones or music than on what’s happening around them.

I had to coach some newbie Southwest Airlines passengers through the fact that there aren’t any assigned seats on that carrier. Clearly, they missed the four different announcements that were made by various gate agents and flight attendants during the process and seemed upset that they didn’t have reserved seats. I’m guessing they didn’t make their own reservations since the lack of seat assignments is pretty obvious during the Southwest booking process.

I always joked about creating the all-business airline if I ever arrive at a position where I am insanely wealthy. I would pay more to fly with people who could board quickly, stow their luggage efficiently, and not act sassy to the flight crew. Being able to deplane quickly and move past the jetway exit without having to stop and adjust one’s overflowing open-top tote bag would also be a plus. After the things I’ve seen this week, I think zippers or some other mechanism of secure closure should be mandatory on all carry-on bags, but that would be asking a lot when we can’t even get people to exhibit civil behavior.

One of my flights this week almost had to go back to the gate due to a belligerent passenger who refused to wear his mask. Whether you agree with masking or not, thinking that you’re going to be able to bully a flight crew isn’t a good idea. Had we been forced to return to the gate, I think some of the passengers might have also considered taking justice into their own hands, given the number of short connections at the other end of this flight.

At least I’ve taken enough trips recently that I feel like I’ve got my travel mojo back and am back to my usual packing efficiency. I did somehow forget toothpaste on a flight earlier this month, but it was a good excuse to visit a local pharmacy and to also pick up some dark chocolate as well as the necessities. The workplaces I’ve visited are significantly more casual than they were pre-pandemic, with jeans being the norm at several places where we would have received glaring looks had we worn them before.

I’m working with a couple of companies that have embraced an outdoorsy vibe and I’m hoping for longer-term engagements where hiking pants can be a permanent part of my business travel wardrobe. I’ve had to make some adjustments in how many snacks I pack for a trip, though, because airport concession offerings remain significantly limited at most of the places I’ve been. My home airport still has half its restaurants and about a third of the newsstand shops closed, and you never know what you’re going to find when you arrive somewhere you haven’t been in a while.

For me, one of the biggest adjustments of traveling has been operating exclusively on my laptop. Over the last couple of years, I’ve apparently become spoiled by the setup in my home office, which includes not only a screaming-fast PC, but monitors that make me feel like I’m working at mission control rather than in a converted spare bedroom.

When I do have to do videoconference meetings with clients while I’m traveling, it’s a trick to balance the meeting software with any materials I might need to use while still being able to see the faces of the team I’m meeting with. I keep experimenting with different approaches and maybe something will stick, although it seems to be easier to get things the way I like them with Zoom than when I have to use Teams or GoToMeeting. I’d be interested to hear what usability experts think of the various conferencing software options – there are definitely some I like better than others, and of course a couple that I’d be happy never having to use again.

For those of you who are traveling again, what are the most striking changes you’re seeing with your clients and your travel patterns? Have you come up with new hacks that make things easier? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/17/22

I enjoyed this short piece on “Overrated tech: 5 tools execs think hospitals should skip.” Suggestions given by health system executives include proprietary technology, augmented / virtual reality, applications written for on-premises use, and niche technology. Rounding out the list was the undead of business equipment: the fax machine. I’m always amazed when hospital or medical licensing forms want a fax number. No matter how hard we work to get away from them, the little machines soldier on.

If I had to add a couple of overrated technologies to the list, I’d suggest the following: freestanding patient portals that don’t integrate with the EHR, home monitoring devices that don’t have a neat and tidy way of sending data to the responsible physician, and emergency department wait-time displays on billboards and websites. If you have time to compare wait times, then it’s less likely that the emergency department is the right location for your care.

The new calendar year has set my continuing medical education counter back to zero, so I’ve been keeping an eye out for good online presentations that also deliver CME hours. Despite the fact many of us have been working virtually for years now, I still see quite a bit of bad behavior on webinars. You would think that with all our collective experience, people would have gotten better at being professional when on large group webinars. I’ve seen enough annoying habits that I could write a “tips and tricks” document. The highlight reel:

• If you are a host or presenter and know you’re not going to allow verbal audience participation, please set up the webinar so that the audience is in listen-only mode. If you forget to do this, hopefully you know how to mute everyone. There will always be some person driving, making lunch, or taking their phone and the webinar to the restroom.
• For audience members, pay attention to what the presenters say about fielding questions. If they ask you to put your questions in the Q&A area as opposed to in the chat, please do so. As someone who runs a lot of webinars, it’s hard to manage multiple streams, so usually we pick one way to handle things. Our organization’s policies might keep us from locking down the other functionality or hiding it from you, but you’ll get a better response if you do as the presenter asks.
• Also for hosts, the whole idea of “we’re going to start about five minutes late to allow people time to join” is extremely disrespectful to those who were prepared and on time. Although you might think you’re doing us a favor and telling us that so we can multi-task for a few minutes, the reality is that a good chunk of your audience is aggravated by it, while another chunk will delve into email or texting and you won’t get them fully back when it’s actually time. If everyone started on time, maybe latecomers would learn a lesson.

Speaking of pushing deadlines, HIMSS has extended the registration discount for HIMSS22 through February 22, citing organizational budget and travel permission issues. I know a number of organizations that are still under no-travel restrictions. Although COVID cases are easing, hospital staffing is still a struggle. Teams are exhausted and there’s often no hope for replenishing the bench. I think leaders are increasingly aware of the optics of jetting off to Orlando while their teams are still underwater.

HIMSS also notes they are adding programming and speakers, including sessions on aging and loneliness, policy updates, and international perspectives. I’m not sure that the addition of those topics would make me want to go if I hadn’t already booked, so it also feels like a “registrations are low, let’s see how many other people we can drag through the door” type maneuver.

HIMSS also continues to send emails trying to get attendees to sign up for events that require additional fees, such as the Women in Health IT Networking Reception. It costs $55 for a 90-minute event, which despite the advertising, doesn’t seem like enough time to “share stories, recognize and celebrate your peers, and form valuable connections that will last a lifetime.” Maybe I’ll engineer my schedule to eyeball the event during peak entry and exit times, though – I’m sure there will be some outstanding shoes to be seen.

Thinking about these events makes me wish Mr. H would reconsider the idea of throwing an HIStalk kegger in some parking lot. There’s an undeveloped lot across the street from my hotel that would be perfect. That would be a real way to make memories that would last a lifetime, I’m sure.

A lot of my work as a CMIO revolves around using EHRs and related technologies, such as clinical decision support, to reduce variability in patient care. A recent piece looked at how physicians within a single health system often make different treatment choices for identical patient scenarios. Certain physicians were much more likely to use recommended standards of care than their peers, which can be concerning if not following the standards leads to variability that worsens outcomes.

The authors looked at 14 “straightforward” clinical scenarios (as opposed to complex cases) to score physician performance. Some of the scenarios looked at surgical procedures, where the top surgeons opted for non-surgical interventions at greater rates than their low-performing peers. This supports the idea that wasteful spending is often tied to inappropriate care. It will be interesting to see how hospitals respond to this since they make a good amount of money from the questionable surgical procedures compared to the non-surgical interventions.

An intrepid reader sent me this picture from a healthcare facility that should remain nameless. It looks like they’re having an issue with their emergency call system, so they hit the Home Depot and stocked up on stick-on doorbells. The handwritten label is a nice touch. I’m not sure what The Joint Commission or any other accrediting body would think of the solution, but it does have a certain resourcefulness to it.

What kind of entertaining solutions have you seen when your organization just needs to make do? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/14/22

I started the HIMSS22 vaccine verification process today, and we’ll have to see if it works this time. Last year, when I still planned to attend the event in person, I started the process and never received conformation that my vaccine submission had been validated. The current process includes uploads of both a government-issued ID and the vaccine card. I tried using my passport this time to see if it works any better than my driver’s license did last year.

The emails I’m receiving from HIMSS22 vendors have started to increase in frequency, but I have yet to see a marketing campaign that really stands out. I’m trying to do a little planning every day so I can stay ahead of the game and avoid a flurry of organizing at the end.

This weekend’s hot topic in the virtual clinical informatics physician lounge is a petition to extend the so-called “practice pathway” for board certification in clinical informatics. The practice pathway, which is scheduled to expire in 2022, allows a certification mechanism for those of us who didn’t complete formal fellowships in clinical informatics. To be eligible for certification, physicians must demonstrate three years of practice in the field, with at least 25% of professional time in informatics. Physicians can also be eligible if they complete a 24-month master’s or PhD program in biomedical informatics, health sciences informatics, clinical informatics, or a related subject.

A number of clinical informaticists are supportive of extending the practice pathway, particularly due to the disruption caused by the COVID-19 pandemic. They note issues with the availability of residency and fellowship rotations that disrupted the ability of participants to complete their programs. Proponents cite a shortage of certified informaticists and the expected need for roles in thousands of hospitals and clinics. They also note the large number of physicians who have been practicing clinical informatics but who might not have the time or financial resources to pursue a fellowship. Others are concerned about the ability of fellowship programs to ramp up enough to be able to train the numbers of informaticists required to staff the workforce.

Others are opposed to leaving the practice pathway open. Some feel that the option hurts fellowships, leading to decreased applications and filled positions. Personally, I think the low salaries paid to fellows are at least partially responsible for decreased applications, not to mention the disruption to your career if you’re already practicing in the field. There is also concern that the practice pathway creates a lower standard. In my experience employing clinical informaticists, I’m not sure the board certification really makes a difference. It’s more of a check-the-box formality for some, but I’m perfectly happy hiring a seasoned informaticist who can do the job that needs to be done regardless of their certification status.

I obtained my certification through the practice pathway, having practiced clinical informatics exclusively in the seven years prior to certification. At that point in my career, there was no chance that I would consider leaving an EHR implementation at a major health system to complete academic pursuits. I used the Board’s content outline to craft a study plan and spent nearly six months reading more than a dozen college-level textbooks to prepare for the exam. Other than some specific and highly technical questions, the majority of the board examination involved topics that I dealt with on a daily basis in my informatics practice. One physician commenting on the issue noted that as data experts, we should be looking for proof that there are differences in outcomes when clinical informaticists are certified through the practice pathway versus through the fellowship pathway.

Board certification is a hot topic for physicians in general. Most boards require physicians to participation in a process called Maintenance of Certification. Depending on the board, physicians have to participate in continuing medical education, complete performance improvement projects, document evidence of professionalism, and complete a demonstration of knowledge. Those knowledge demonstrations vary. Some still require the traditional high-stakes examinations, and others allow longitudinal assessments. Most physicians aren’t interested in cramming for a high-stakes exam, especially when we’re tested over content that is no longer part of our daily practice. There is no immediate feedback on questions that are missed and it’s a generally miserable experience.

The last time I took one of those exams, I had a pat-down by the testing center employees and was treated like a criminal before even entering the testing room. There have been recent reports of physicians who were treated poorly at testing centers, including one lactating physician who was offered “accommodations” for pumping that failed to include a private area, a table or counter, or even an electrical outlet for the pump. She was forced to pump in a bathroom stall and the time spent counted against her limited exam breaks. I can’t imagine the mount of stress that added to the situation.

Specialty boards are trying to update their Maintenance of Certification processes to make them less onerous for physicians. However, there isn’t evidence that participating in the process makes physicians better at their jobs. I agree that for those of us participating in the longitudinal assessments, the process helps physicians become more proficient at finding information they don’t know.

Since I’ve been in urgent care for the last decade, I can handle most of the board questions that cover the musculoskeletal, digestive, and respiratory systems without blinking. Trauma is also a slam dunk and I’m solid with dermatology, infectious disease, and psychiatry. For maternity care, which I haven’t practiced in a very long time, I end up resorting to reference materials to handle those questions, just like I consult with practicing maternal care physicians in real life. Hopefully, the process is teaching physicians how to find information when they don’t know it off the tops of their heads, and to do so efficiently. However, it sometimes just feels like a game that we have to play.

Has there been any chatter about clinical informatics board certification in your organization? Are you for or against extending the practice pathway? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/10/22

The Centers for Medicare & Medicaid Services released details on the status of Accountable Care Organizations. CMS promotes the fact that 66 new ACOs joined the program and 140 renewed their agreements, bringing the total number of programs to 483. Looking at historical data, however, that’s small growth (six programs) since last year, but an overall decrease since 2020’s count of 517 programs. Doing the math, that means 60 organizations left the program.

In speaking with colleagues who are closer to the ACO world, even when ACOs don’t renew, it is likely that upwards of 50% of clinicians will move into a different ACO. That’s good news for patients who value continuity. The overall ACO initiative has a long way to go to meet its goals of providing coverage for the majority of Medicare beneficiaries in the US. It will be interesting to see how the program continues to evolve and how quickly it can build that kind of coverage.

Telehealth is hot in the news this week. The first story involves telehealth gone bad, with a Georgia nurse practitioner being found guilty of $3 million in fraudulent activities. Charges include healthcare fraud, identity theft, illegal kickbacks, and false statements. The Operation Brace Yourself sting operation targeted providers who were unnecessarily ordering durable medical equipment for patients they had never evaluated. The criminal conspiracy involved targeting senior citizens through telemarketing, then using their personal information to submit claims for orthotic braces. The convicted nurse practitioner signed over 3,000 orders related to falsified medical records in exchange for money. Despite what was said in the 1990s, greed is NOT good.

Amazon’s telehealth efforts were also in the news as it announced plans to expand Amazon Care’s in-person services to more than 20 new cities this year. Its virtual services are already available across the country. Amazon’s blurb says, “Care Medical doctors and nurses across the country are dedicated to treating Amazon Care customers, so patients are able to build lasting relationships with their health care providers over time.” Hopefully, Amazon’s model for employing physicians and nurses is more flexible and rewarding than some of the employment practices we hear about at Amazon’s warehouse and delivery operations. Keeping patients happy over time involves keeping their care teams happy over time, which is a difficult nut that healthcare organizations have struggled to crack for decades.

Anthem also announced its plans for virtual primary care services for its members in 11 states. The virtual offering includes an initial health check with creation of a personalized care plan and is being offered at little or no cost to members. Anthem talks about delivering services through its Sydney health app, which can handle secure chat for urgent care as well as support for scheduling. However, it’s unclear how its offering will integrate with patients’ existing medical records or care providers such as subspecialists. Both Anthem and Amazon seem to be targeting employer-sponsored plans. Since employers have a vested interest in trying to reduce healthcare spending, it will be interesting to see what adoption of these programs looks like.

I serve on the health advisory committee for my local school board. We had an interesting conversation this week about the role of testing in the current phase of the COVID-19 pandemic. With the explosion in at-home testing and the fact that those tests are generally not reported to public health authorities, overall testing numbers and positivity rates are becoming skewed. My colleagues in public health informatics have already struggled with the knowledge that we’ve been underreporting cases throughout the pandemic, and the boom in home-based testing isn’t helping. Local schools have been looking at positivity rates to determine whether to hold classes in-person and whether to require masks and those decisions have become more complicated. We’re starting to talk about using percentage of vaccination as another indicator, but it’s difficult to get people to self-report their vaccination status. The last couple of years have been agonizing for educators and I don’t envy the decisions they have to make on a daily basis.

We’re also seeing a boom in patients who think they might have COVID but don’t want to be tested because they can’t afford to be off of work. This also applies to people who don’t want their children tested because they don’t have backup childcare options if the students have to be kept out of school. This also creates decision-making challenges and was on my mind when I read a recent JAMA article looking at the number of adults who thought they had COVID-19 but actually didn’t. About half of unvaccinated adults who thought they had been infected were found not to have antibodies, which are expected to be present at least at some level for about nine months after an infection. Conversely, 99% of people who had a test-confirmed infection had antibodies. Of note, 11% of people who thought they had never been infected had antibodies. The data is from pre-Omicron days, so I will be interested to see what it looks like after the current wave.

Working from home has certainly given me more time for pastry therapy. Now that many of us have been fully remote workers for a couple of years, it’s interesting to think back about how things used to be. We’ve all become used to some of the quirks of this new normal, from sharing broader views of our colleagues’ home lives to joining them in the carpool line as they pick up children from school. It’s been interesting to see how some organizations have evolved to new ways of working, with guidelines around whether meetings have to be video or whether they can be audio only, etc. Some have policies about how/when to use phone versus collaboration solutions versus email. Some organizations have become casual and free form with meetings, where others observe more formal meeting disciplines.

I ran across a situation the other day that I hadn’t encountered. I was on a client call with my normal working group and we were just doing our thing. Out of nowhere, someone joined the meeting, and although initially I thought they were a Zoom-bomber, I noticed they had a company logo on their pullover. Since I wasn’t the facilitator or the host, merely a member of the working group, I didn’t say anything. I figured I would wait to see how long it took for them to introduce themselves or for someone else on the call to say something. We weren’t discussing anything sensitive or proprietary, so I felt comfortable waiting. A full 38 minutes later, the meeting ended, and I never did figure out the identity of the mystery person other than their name caption. I’m still surprised that no one said anything, but that kind of thing is what makes being a consultant interesting.

What do you do when random people show up in your meetings? Leave a comment or email me.

Email Dr. Jayne.