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.

Curbside Consult with Dr. Jayne 2/7/22

As a consulting clinical informaticist, one of the things I’m often tasked with is EHR optimization. Sometimes clients have robust structures for receiving feedback from clinical users as well as teams who are tasked with assessing workflows and recommending changes. In those situations, I might provide clinical input as they work through issues, getting proposed changes polished before we take them out to stakeholders for feedback. That’s a lot of fun, because the end users appreciate having a fully vetted solution presented to them versus having to be involved in the details of process.

Other times, clients need someone to help them create a structure to handle feedback and recommend solutions. Those projects are also rewarding because users really like feeling like they’re being heard and that someone cares, even if the process you’re creating is just getting started.

One of the hot topics in optimization right now is figuring out how to lighten physician documentation requirements. It’s been a year since the Centers for Medicare & Medicaid Services modified the Evaluation & Management coding requirements with the goal of simplifying documentation. Many clinicians thought the changes were too good to be true and I don’t blame them. Coming from a large health system background, I felt that the years of internal compliance audits had created a certain level of fear around under-documenting or over-coding. We had been conditioned to make sure we were documenting more than enough Review of Systems and Physical Exam checkboxes just to be on the safe side. This was made more complex when one needed to document an element that could be counted in two different systems, and most of the physicians I know had come to dread any conversation around coding.

Now that there has been some flexibility, and people have learned that auditors aren’t waiting around every corner to catch someone who isn’t documenting correctly, physicians are eagerly pushing their organizations to remove the excessive clicking that physicians and their support staff members have been complaining about for years. As people have reassessed their priorities during the pandemic, clinical users have been increasingly vocal about how much they feel technology is contributing to burnout. With staffing levels as dire as they are in some organizations, those organizations have figured out that they can’t afford to not listen to what their employees are saying. Those organizations who have consciously looked at how their users work have also figured out that so-called “note bloat” makes it harder to care for patients since notes that contain extraneous information make it harder to find the data elements that are important.

Physicians and other users who had created extensive macros to satisfy the previous E&M requirements are now spending time trimming down the content of those macros to better reflect what they do in a typical patient visit. Adjusting those configurations takes time, and end-users are eager to have an analyst or super user make the changes whenever possible. Depending on the EHR, the effort needed to do this can range from straightforward to cumbersome. Not surprisingly, I see more progress on “easy” systems than I do on those that require greater involvement of IT or other teams. Sometimes the level of difficulty to make a change is murky, though. The fact that I’ve worked in so many different EHRs is certainly an advantage when analysts push back and try to make it seem like it’s more complicated to make a change than it really is.

I also see more physicians who are using time-based coding since figuring out how to document that has become a bit easier. In the past, you had to keep track of how much of the visit was face-to-face, how much was counseling and coordination of care, etc. Now the majority of elements performed by a provider on the day of service count, making it much more likely that a physician might choose to code based on the duration of effort. This has led to greater number of high-level visits being coded by physician. Although one would think this should lead to greater pay for physicians, I’ve seen a number of organizations figure out ways to avoid paying their clinicians more. Some have made adjustments to keep physician salaries relatively flat, keeping a greater portion of the payments for the organization versus passing them on to the people doing the work.

When I hear that the latter is happening, I try to push optimization as much as possible in order to ensure the end users feel some relief. Even if they’re not receiving better compensation, I can hopefully make their days at least a little bit shorter and their visits a little easier.

There have been a couple of times recently when I’ve felt really torn when working on an optimization project. I’ve gotten a sense that administrators will perceive that the physicians are doing less work, will translate this to a perception that the physicians have greater capacity, and then continue to shift work towards them. We saw a great shift of low-level clinical work to physicians at the beginning of the Meaningful Use program, and physicians had to fight hard to get organizations to agree that they needed their support staff to take on some of this work. The idea of working at the top of your license could be used to show that physicians were expensive, and if you had more staff, you could see more patients and those changes were revenue neutral or even positive.

Now that there is such a labor shortage, finding capable staff at a price organizations and administrators are willing to pay can be tricky. Not surprisingly, physicians have filled the gap because it’s the right thing to do for their patients, but it’s hard to convince decision makers to look for unicorn-like staff members in this market when they know the physicians will do the work for free. No amount of optimization is going to improve clinician morale if they feel like they’re being pulled into a black hole of ongoing work with no help in sight. I’m interested in understanding how large organizations have optimized their systems based on the changes to the Evaluation & Management codes.

Are your ambulatory physicians writing the shortest notes of their careers with the same billing codes? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/3/22

For many companies, HIMSS preparation is in full swing, if my inbox is any indicator of the situation. Multiple marketing people have reached out inviting me to visit their booths for demos or conversation. I must say that the invites for happy hour appetizer and beverage events seem to be lacking, so I’m wondering if HIMSS is clamping down on food and beverage service in the exhibit hall due to COVID. If that’s the case, I’ll definitely be missing the scones.

As for booth invitations, I’m more likely to respond if a company has a compelling pitch and understands that I have to visit them anonymously versus trying to get me to make an appointment, since that undermines the whole anonymous blogger vibe. No invites for after-hours events yet, so I’m not sure how this year’s social scene is shaping up just yet.

For frontline physicians, the creation of Prescription Drug Monitoring Programs (PDMPs) brought to life key pieces of technology that made a tremendous difference in patient care. I keep receiving emails from my local PDMP, asking me to approve delegate requests for nurse practitioners and physician assistants that I worked with at my former practice. Our state won’t allow non-physician providers to have an account unless they’re sponsored by a physician, which in many cases was me. There has been a lot of turnover in the physician ranks and apparently some of the new supervising physicians either don’t have PDMP accounts and therefore can’t delegate to the midlevel providers, or somehow don’t think it’s important for the providers they supervise to be able to look for patterns of controlled substance abuse or diversion. This has been going on for more than eight months, and I feel bad for the providers who don’t have access to this vital information. It’s yet another illustration why a patchwork of state laws isn’t always the best thing for patient care. On the other hand, it’s also a pretty telling commentary on the leadership of my former practice, who could solve the problem by requiring that everyone makes use of the PDMP and that appropriate operational structures are in place to support the effort.

From Jimmy the Greek: “Re: this week’s Snowmageddon. I’m tired of seeing organizations talk about their ‘inclimate’ weather” preparations. Spelling counts. Take a look at this email – not only is the inclimate weather virus spreading, but now I have contact information for 200+ patients.” Jimmy forwarded me an email from his local physical therapy provider, who apparently doesn’t understand patient privacy or how to use blind carbon copy functionality on an email. The body of the email made it clear that the addressees were patients with appointments scheduled today or tomorrow and also mentioned that they’d be contacted to reschedule. I hope Jimmy gives them an earful when he receives his call.

Hot on the heels of my weekend piece about healthcare organizations that aren’t giving their employees time to recover from illness and injury, I’m mentoring young physician informaticist who emailed with some questions about professionalism. He was on a training call with one of his organization’s tech vendors. The lead presenter seemed tired and out of it, and about 20 minutes into the call, admitted that he was COVID-positive and was having a difficult time focusing and asked if they could take a break so he could hand off to his backup. As a physician, my friend was surprised that someone who was obviously symptomatic would be working, especially in a non-essential role. From a business perspective, he was surprised that the vendor hadn’t asked to reschedule the call, or that they didn’t start the session with the backup presenter in the first place.

Even with people working remotely, if they’re not well enough to work, they shouldn’t be working. In this situation the presenter knew well enough that they weren’t 100% that they arranged for a backup presenter. This situation speaks not only to poor individual judgment (which I guess you could probably attribute to COVID-induced brain fog), but potentially to corporate policies that push people to work even when they shouldn’t.

My young colleague was wondering about what he should have done if there hadn’t been a backup presenter. Should he have called a stop to the presentation after realizing the presenter was in some distress? He was also questioning whether he should say something to others at the vendor about what had happened. I think compassion dictates asking a struggling presenter if they need a moment, and if they don’t realize there’s an issue, then I’d probably ask them if we could reschedule. It’s difficult where a medical condition is concerned and one doesn’t want to pry or appear inappropriate pointing out that things aren’t going well, so I’m not sure if there’s a great answer here.

This ties in nicely to an article I read about the CDC’s recent update to workplace guidelines for COVID-positive healthcare personnel. Although many assume those roles are largely occupied by physicians, nurses, therapists, and others who are performing hands-on patient care, the CDC guidance also includes “persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting,” including administrative and billing personnel. This also may include a lot of healthcare IT workers depending on their roles. Many healthcare workers who aren’t in the weeds on the recommendations might not realize that work restrictions for healthcare personnel are broken into three categories:

• Conventional standard. Those with COVID-19 should be restricted from the workplace for 10 days or for seven days with a negative test – assuming asymptomatic, mild, or moderate illness with improving symptoms. Many organizations interpret conventional as applying when there is adequate staff or personnel are non-essential.
• Contingency standard. Those with COVID-19 may return after five days if asymptomatic, mild, or moderate illness with improving symptoms.
• Crisis standard. There are no work restrictions, but there may be prioritization considerations, such as having COVID-positive staff only work with COVID-positive patients.

We’re starting to come down from crisis standards of care to contingency in some parts of the country, and in others, it may be time to see a change from contingency to conventional standards. Regardless of the definition, if people aren’t able to perform the essential functions of their job, they shouldn’t be working. We need to stand up for each other when we see someone in the workplace who probably shouldn’t be.

How would you handle someone who is obviously too sick to work? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/31/22

A physician friend has been waiting patiently to have a surgical procedure, which has been cancelled multiple times due to COVID. The first time it was due to the rapidly rising omicron peak, and the second time due to overall staffing challenges.

She has been patiently dealing with the delays despite the fact that she’s in a great deal of pain, and also despite the disruptions it’s causing to her practice, when she had to cancel and reschedule six weeks’ worth of patient visits, only to have to try to get them back on her schedule after the procedure gets canceled. Her patients love her and have been accommodating, but now that some of them have been through the cycle twice, I’m sure their patience is wearing thin.

In addition to moving her work schedule, she’s had to rearrange the schedules of others who had planned to come stay with her post-op, rearrange planned meal deliveries, rearrange delivery of durable medical equipment, and more. People who don’t understand what goes into procedure scheduling might not understand all the dominoes that fall when there’s a change to what should be a standardized process. Labor shortages in healthcare continue to be an issue, and she’s hoping the surgery goes ahead this week as planned so she can start recovering and getting back to the things she liked to do before her injury.

Her experience has made her more aware of what’s going on in her health system and how both individuals and the organization are responding to those who need to take medical leave. From talking to others in similar positions, it’s a reflection on what’s happening in the workplace as a whole, and why so many people are choosing to be part of the Great Resignation that’s under way.

When she first tried to schedule surgery, she had immense push-back from her department. It sounded out of proportion given that she’s a 20+ year employee who has never taken more than her usual accrued vacation time – no family leaves, no medical leaves, no bereavement leave.

Even though it’s not department policy, her department chair expected her to make up her on-call days, and went as far as to tell her she should double-up on call before she goes out (despite the fact that she is already having difficulty doing her very physical job due to her injury). She had to check her contract and threaten to get an attorney involved before they backed down. The contract clearly says that she’s not on the hook for call that she can’t take during a time of disability or incapacity. Her department is large, and she’s certainly done enough coverage for her colleagues for their various leaves over the years, so I encouraged her to not feel guilty about taking the time she needs to recover.

One colleague went to far as to tell her that since they can do some visits via telemedicine, she shouldn’t take a medical leave and should just work remotely and cover her own inbox and messages. I guess that colleague thinks it’s OK to practice medicine while taking post-operative opioid pain medications. Apparently, they also missed the part in medical school where we’re supposed to understand that patients need to rest and recover for optimal healing.

We were chatting about this on a virtual happy hour with a couple of other physicians when another friend mentioned that her hospital-owned group had told women who were on maternity leave that they had the option of coming in to see hospital consultations that had been requested. The administrators felt those visits were quick and shouldn’t take too much time each day. I thought she was kidding until she shared her screen on Zoom and showed the proof. They weren’t even subtle about the fact that they were addressing women only. Maybe that was a rogue manager, but even so, their boss should be all over them.

That certainly seems contrary to all the messaging that healthcare providers are getting from their administrators about the need to practice self-care and build resilience. I guess those suggestions only go so far until they interfere with the hospital’s ability to move patients through the system, and at that point, self-care (or care for an infant) isn’t important.

I’m not a labor attorney, but it feels like trying to coerce someone who is on family or medical leave into performing work probably isn’t the right thing to do, regardless of what your human resources department might have suggested. Those kinds of behaviors aren’t the kind of thing that makes an organization the employer of choice in a tight labor market, either.

As physicians, we’re wired to do our best to help our patients, but I hope that physicians and other clinicians continue to just say no when those suggestions are made. I don’t think having a sleep-deprived parent who would rather be home with their newborn leads to the highest quality care. Nor does having a clinician who is in a rush to get home before their childcare resource has to leave. There are plenty of studies that show that at a certain level of sleep deprivation that people are as cognitively impaired as they would be if they were under the influence of alcohol.

If this level of pressure is being applied to physicians who have a high level of education, autonomy, financial resources, and insight, it makes me wonder what strategies administrators might be using on staff members who might have less understanding of their rights or who are more afraid to push back.

What makes this even more shocking is how starkly it contrasts with what I’m seeing in other parts of the industry, where companies pride themselves on their culture and on making sure their employees feel valued. Being able to recover properly after surgery shouldn’t be a boutique ask from a culture-centric employer, it should be a basic human right. Similarly, being able to take one’s federally protected family or medical leave shouldn’t involve coercion, pressure, or the guilt treatment.

It will be interesting to see whether these organizations figure out that their tactics are counterproductive, or whether they continue to run their workforce into the ground.

Have you seen any unusual HR tactics during the labor shortage? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/27/22

ECRI has released its 2022 list of Top 10 Health Technology Hazards for hospitals, medical practices, and home health organizations. Cyberattacks are at the top and no one should be surprised by some of the others on the list: supply chain limitations, insufficient emergency stockpiles, and issues with disposable gowns and inadequate barrier protection. The fact that we’re still dealing with some of these issues in Year Three of the pandemic is a travesty. My local nurse friends keep me apprised of the personal protective equipment situations at their various hospitals. At one hospital, it has only been in the last two weeks that there have been enough N95 respirators available so that medical/surgical nurses can have a fresh respirator every shift. Previously, they were limited to one per month. One can’t help but wonder whether the fact that so many nurses were out with COVID infections played a role in opening the supply cabinets.

Nearly every industry has been impacted by the labor shortage, and healthcare is no exception. An article published at the end of 2021 in Mayo Clinic Proceedings: Innovation, Quality & Outcomes looked at “COVID-Related Stress and Work Intentions in a Sample of U.S. Health Care Workers.” The study looked at 20,000 workers across more than 120 organizations, surveying them between July and December 2020. The authors found that burnout, increased workloads, and concern about infection were associated with plans to reduce work hours or leave the field entirely. The presence of anxiety or depression were also associated with those plans, as was a higher number of years in practice. Nurses had the highest intention to reduce work hours followed by physicians and advanced practice providers. Surprisingly, administrators had the lowest intention to reduce hours.

I was in a conversation recently with early career physicians who were contemplating changes to their workloads. Both women and men in the discussion were eager to learn more about nontraditional practice opportunities including job share arrangements or part time work. Considering the physicians I’ve worked with over the years, the proportion of physicians who view medicine as a calling and who are willing to make great sacrifices for their careers is shrinking. While some view this as an erosion of professionalism, others view it as a healthy acceptance of reality by people who are navigating challenges that previous generations could not have envisioned.

Based on the survey results, nearly one-third of physicians, advanced practice providers, and nurses intended to reduce their work hours. Ten percent of physicians and 20% of nurses intended to leave practice entirely. The authors note that feeling valued by the organization was protective, lowering both the intention to reduce hours and the intention to leave. They conclude that additional research is needed to determine whether mitigation strategies can prevent a healthcare workforce crisis. In speaking to physician and nurse colleagues alike, many are looking for tangible changes to improve working environments. These include improvements to staffing ratios, expanded access to employer-sponsored childcare, and protection from workplace violence. It would benefit administrators to work on these issues in depth rather than continuing with their ineffective strategy of pizza parties and challenge coins.

Maybe they can take advantage of the $103 million that the Department of Health and Human Services has allocated to reduce healthcare worker burnout. The funds are part of the American Rescue Plan and will be granted to organizations serving providers in underserved and rural areas. Over $28 million will go to programs to promote mental health and well-being, $68 million will go towards burnout reduction and resilience, and the remaining $6 million will be used to create the Health and Public Safety Workforce Resiliency Technical Assistance Center. Most of the burned-out healthcare workers I know are tired of hearing the word resilience, so maybe they can think of something else to call the Center.

In telehealth news this week, the US Court of Appeals for the District of Columbia Circuit ended efforts by telehealth provider RemoteICU to obtain Medicare coverage for services rendered by virtualist physicians outside the US. The company had alleged that an emergency rule allowing Medicare to pay for critical care services via telehealth extended to physicians outside the US. The judicial panel stated that RemoteICU “failed to present its challenge in the context of a specific administrative claim for reimbursement of services” and failed to meet the criteria laid out for judicial review of Medicare claims. As always, the devil is in the details where Medicare is concerned.

I had several people reach out to me regarding the EHR performance issues I wrote about earlier this week. I checked in with my colleague this afternoon to see how things were going after his vendor’s interventions. Despite the changes, the organization continued to have issues with sluggish chart loads and delays in rendering various screens, but it seemed better overall. A couple of times a day, the system would come to a screeching halt, though. With additional eyes on the issue, they identified a potential cause they hadn’t captured previously. Because of changes in childcare schedules, a worker who typically handles billing processes at night had been working during the day. She had no idea that the processes she was running were resource-intensive since she had always worked nights and no one had ever mentioned it. Her supervisor was similarly unaware, working during the daytime.

Once that was addressed, performance stabilized, and although the crushing delays had stopped, the system was still slower than was ideal. Average chart load time was improved by about 50%, though, so the users were borderline ecstatic per his report. The performance team has continued to make various adjustments in an attempt to improve things further, but they’re trying not to make too many changes at once, which is prudent given everything the organization has been through. I wonder what they’re doing for the rest of their clients who might also be struggling with volume-related challenges, and whether the improvements made for this organization will be propagated to others proactively or only when things become dire.

Is your technology team proactive or reactive? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/24/22

Many healthcare organizations are struggling with the recent COVID surge due to the omicron variant. The focus is often on staffing issues, especially when large numbers of workers are out due to personal illness, caring for sick family members, or providing care for children whose schools have shifted to virtual learning. Other struggles include supply shortages, especially with personal protective equipment, medications and therapeutics, and occasionally cleaning products, all of which are shocking at this stage of the pandemic.

More recently, though, a number of organizations are seeing infrastructure challenges due to the sheer number of patient visits that are occurring.

I spent some time over the weekend trying to calm a CMIO friend whose ambulatory organization is in complete crisis. In the past, they had a robust IT department and hosted all of their own applications. In a round of cost cutting, the parent organization decided it would be better to outsource all of those functions. At the same time, they moved many of their internally hosted systems onto web-based platforms where available.

Their primary ambulatory EHR was one of those systems. It wasn’t just moved out of their data center — it was also transitioned to a SaaS model with multi-tenant architecture. This was fine for a number of months, but recently their system has been grinding to a halt at various times during the course of a day, and the user community is becoming increasingly frustrated.

Many of their outpatient clinical offices are back to pre-COVID productivity, through a combination of in-person and virtual visits. Because this organization is conservative, its conducts all of its telehealth visits by video, which take up more bandwidth than an audio-only visit. Their urgent care and same-day facilities have been seeing high volumes throughout the pandemic, but they have been fairly stable numbers for the last few months since operational leaders wisely capped daily volumes in order to preserve staff sanity.

I’m sure they have lost some patients to other facilities in town, but they consider the leakage acceptable if it keeps staff from resigning. They made these decisions based on experiences from earlier in the pandemic when they didn’t cap volumes, which led to some pretty significant burnout and nearly insurmountable levels of turnover. They weren’t about to put their newly rebuilt staff through the same experience, and for that I commend them.

Still, they were puzzled why they were having such poor system performance with stable volumes. As a hosted client, the IT team was opening performance tickets left and right, but with few answers. System latency continued to increase along with user frustration, as it was taking up to 30 seconds to load patient charts or 20 seconds to navigate from screen to screen. Even basic controls such as pick lists and pop-ups were also sluggish. Performance would improve at times and they would feel like they were moving in the right direction. The urgent care locations, which run seven days a week, reported some slight improvement on the weekends, but not much.

After many conversations with the vendor and a number of executive escalations, it became clear that the way the vendor’s system is architected is the problem. After moving from their own data center onto the SaaS model, the group is experiencing lags related to the out-of-control visit volumes other clients. They are feeling performance impacts that are caused by organizations who had doubled or tripled their daily visit volumes, putting additional load on the infrastructure. Since many of us didn’t anticipate how quickly the COVID curve would climb with the omicron variant, and how many people would be sickened in such a short interval, planning for such volume surges was inadequate.

Sometimes solving infrastructure problems can be as challenging as solving staffing problems in the hospital. Especially if the system is already running towards the higher end of capacity, there might not be available hardware that can be incorporated quickly. In the crisis situations that many 24×7 organizations are working in, it’s not easy to schedule a downtime for an upgrade or to modify resources. A lot of things can be done behind the scenes, but the reality is that most of us never planned for a peak that looks like what we are experiencing.

I can’t imagine what the staff at these doubly- or triply-busy practices are going through. They have got to be at wits’ end, because increasing throughput to that degree requires more staff, better processes, or less care being delivered. Based on what we know staffing looks like, and the difficulty in doing significant process changes during a crisis, I’m guessing care might be taking a hit. That would certainly mesh with the discussions I’m seeing on physician-only social media, where the number of mentions of moral injury has climbed along with the number of posts in which physicians are asking for advice on how to break their contracts.

My CMIO friend’s vendor was supposed to try to some maneuvers over the weekend that would create relative isolation for his organization so that they wouldn’t be so dramatically impacted by what is going on with other clients. I’m trying to wrap my head around what their architecture might look like to make that happen. It makes me grateful for all the deeply techy people I’ve worked with over the years who understand better than I how those pieces of the healthcare IT world run.

I wouldn’t want to be on the tip of the spear, whether it was my fault or my vendor’s, because an angry end user is an angry end user regardless of where the root cause of the problem lies. Regardless, I can offer a sympathetic ear, a soft virtual shoulder, and reassurance that his communication strategy was solid and that he had considered all of the things that I would have considered were I in the same unenviable position. He’s going to let me know mid-week how things are going, and for his sake, I hope they’ are improved.

Have you encountered infrastructure challenges related to booming visit volumes? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/20/22

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/17/22

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/13/22

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.