Curbside Consult with Dr. Jayne 1/30/23

I’m putting my travel schedule together for the next few months, and I’m pretty excited about some upcoming conferences. Although HIMSS is back in Chicago, the other two are in cities that I don’t get to as often as I’d like. I’ll be attending the American Telemedicine Association (ATA) in San Antonio in early March, and then the CHIME/ViVE event in Nashville later in the month.

I typically register for conferences as early as I know I’ll be attending so I can get the early bird discounts – and for ViVE, the discount is just about a necessity. It’s one of the more expensive conferences I’ll be attending and I hope it lives up to the hype (as well as the cost).

Usually, the decision to attend a conference is based on a directive by an employer or a client, rather than me looking at specific sessions or content. Because of that, I don’t always look at the agendas in detail until they get closer. Depending on the conference, some of them don’t even post agendas until shortly before, meaning that many people make the decision to attend without all the information that would help them make a good decision.

Even though I’ve been doing work in the telehealth space for half a decade, I haven’t attended the ATA meeting. I dropped by their website today to think about what I might like to attend, and the first thing that caught my attention was the tagline on the home pages of “Telehealth. Is. Health.” Which is interesting since the organization has seemingly decided to stick with the “telemedicine” moniker.

Organizations rebrand all the time and spend lots of money doing so, as we recently saw with the rebrand of Intermountain Healthcare to Intermountain Health. The substitution of the word “health” where organizations previously used “medicine” or “medical” seems to have happened just about everywhere else, starting with the transition from electronic medical records to electronic health records. The change indicates that an entity is about something more than just medicine or medical practice.

The realm of telehealth has become significantly larger in the last five years and now includes more than just medical practice. Some of the hottest areas for growth aren’t even “telemedicine,” but include all the other ancillaries that patients need for comprehensive care. Some of these include remote monitoring, psychotherapy, counseling, occupational therapy, physical therapy, speech therapy, nutrition consultations, pharmacist visits, dental advice, and more.

In most states, these areas wouldn’t be considered as “medicine” under the state medical practice acts, so the broader term of telehealth makes more sense. It makes me wonder if the ATA is just keeping with tradition or if they think a rebrand isn’t worth it, or if they don’t see value in going with the broader terminology. From a marketing standpoint, they would still be the ATA, so at least that’s easy. Some of the possible domain names they’d need for a rebrand aren’t in use, although it can sometimes be tricky to get a domain you want if someone is already holding it, so that may be a factor. They do use “telehealth” throughout their publications, at least.

ATA shifted the dates of the Annual Conference and Expo this year, moving it from a Sunday through Tuesday format to a Saturday through Monday format in an attempt to reduce the number of days people need to miss from a traditional work week. Depending on where you are traveling from, however, as well as how much of the conference you are planning to attend, many of us will still miss two weekdays due to limited travel options. Flying into San Antonio isn’t as easy as going to Chicago, Las Vegas, or Orlando, so I guess that’s the downside of having it in a smaller metropolitan area.

The full agenda is available and there certainly isn’t a shortage of good sessions to attend. A couple of my medical school colleagues who are now involved full-time in telehealth will be there, so I’m looking forward to it. Not to mention that San Antonio’s climate in early March is a lot more alluring than the Midwest, as is the Tex-Mex scene.

As for CHIME/ViVE, the value of the ViVE side of the equation is a little more difficult to judge. I really enjoyed CHIME in the fall, especially the low-key vibe and the ability to have high-quality conversations with peers. ViVE is only in its second year and they have really been pushing hard for registrations. I was a on a CHIME/ViVE call last week that was advertised as a way for people to understand the value of attending, but ended up being entirely too salesy. If I heard one more person talking about how it was “curated just for people like you” I thought I was going to scream.

We are less than two months out and they don’t have a full agenda published yet, so it’s hard to judge the value on a day-to-day basis. It’s also hard to schedule meetings and times to connect with colleagues, because it’s inevitable that the time I pick will end up being in conflict with a session I’ll ultimately want to attend. The agenda “themes” are published and several are eye-catching for me. One has a tagline of “delivering virtual care with intention,” but I’m not enamored with its actual title, which is “That’s so Meta.” I’m also interested in sessions on: recruiting, retention, and team development; managing chronic care costs; technology cohesiveness and efficiency; and using technology to advance health equity (although I’m not a fan of using the new buzzword “techquity” to encompass it).

I’m looking forward to visiting Nashville for the conference, as I haven’t been there in years and it’s a good excuse to hang out with one of my shoe-loving besties who happens to be a local. The last time I attended a conference there, it ended up being one of the most crazy drunken vendor user groups ever, so I’m hoping for something significantly more tame. I’m sure my friend will give good advice for off-the-beaten-path adventures that will still let me be vertical the next day. It sounds like Nashville has become quite the foodie city since I last visited, so that’s something to look forward to as well.

What are you looking forward to about upcoming conferences? Is it the food, the people, or the content? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/23/23

Non-compete clauses have been a hot topic around the virtual physician water cooler. I was glad to see Mr. H’s newest poll looking at the issue and am eager to see the results. Physicians are used to being stuck with non-compete clauses in their employment agreements, although they can be highly variable. Having been in the clinical trenches for a couple of decades now and having advised plenty of other physicians, I’ve seen quite a few variations on the non-compete.

In a solo practice where I was employed by a health system, the restriction prevented me from practicing with any corporate competitor within a 20-mile radius of the practice. However, it didn’t prevent me from staying in my same location and creating my own private practice entity. It also specified that if I wanted to do this, I would have to pay 50 cents for each chart, which seemed ridiculously cheap.

Many of my colleagues had similar clauses, and after establishing their practices, they went out on their own. Given the non-punitive nature of the exit agreement, they continued to remain on staff at the sponsoring hospital and referring patients for services. Overall, this arrangement seems like a win-win.

As an emergency department physician contracted with a physician staffing agency, I didn’t have a non-compete at all. At a given facility, those contracts often change every few years, which often results in the physicians remaining with the facility but being employed by or contracted by a different firm. This also happens quite a bit with anesthesia groups and critical care groups if the hospital outsources those services. In that situation, when the hospital’s contract changed and I was left in the lurch because the new agency didn’t want to employ part-time physicians, my group even worked to help me find a new placement at a competing health system.

As an urgent care physician working for a local practice with two locations, the non-compete clause only specified that I could not go on to own or have a management role at an urgent care center within 30 miles of either location. Since I knew there was no way I would want to do either of those things, I had no problem signing it. In fact, that employer’s contract was only three pages long, and was one of the smoothest contract negotiations I ever experienced. When I was ready to quit (which was quickly, once I realized that there were some interesting financial practices), it was also the easiest practice I ever left. I simply wrote a letter and said I was no longer available to be scheduled for clinical shifts. They acknowledged via email and I literally never heard from them again.

My most recent urgent care employer also had the prohibition against owning or managing a competing urgent care within a set mileage radius. However, it included a clause that specifically said employees were able to work elsewhere during their employment period, provided that scheduling didn’t interfere with their responsibilities. I thought this was unusual until I realized that a good chunk of the workforce was actually employed at multiple places – perhaps with an EMS agency and with the urgent care, or with an emergency department as well as the urgent care. It made for some interesting transitions as employees would try out other employers to determine whether the grass was greener elsewhere before giving notice.

As a consultant, I refused to do business with any organizations that tried to include anti-competitive clauses in their agreements. I was constantly amazed at the number of organizations that didn’t understand what it meant to be an independent contractor and that when you’re not an employee, it’s much more difficult to try to place restrictions on you. That doesn’t mean they didn’t try, however. I have no problem signing agreements around intellectual property and not using it elsewhere, but I wasn’t about to sign a contract that tried to block me from working with other organizations that might remotely be considered competitors. Engagements like I did as a consultant have to be based on trust, and if a health system trusts me enough to give me access to the information I need to do my job, they need to trust that I’m not going to use it inappropriately.

Among my physician peers, however, I still see some pretty terrible non-compete clauses. The worst are those that still apply even when a physician is downsized. A local health system had a “reduction in force” following COVID and terminated 10% of employed physicians. Those impacted included well-regarded physicians, a beloved pediatrician, and the health system’s only pediatric gynecologist. The latter had a packed schedule with a nine-month wait for appointments, so it didn’t seem to make a lot of sense. Rumor has it that the health system included reminders about non-compete language in the termination notices, but they immediately backed down when confronted with legal action. Honestly, I think that if someone is laid off due to a reduction in force, non-competes should never apply.

A friend of mine was recently impacted by a draconian non-compete that did not allow for any practice of medicine within 30 miles of any location where any employees of the health system practice. When she originally signed the contract, the health system was concentrated in a major metropolitan area and centered on its academic medical center, which didn’t seem like such a bad deal. However, during the intervening decades, the health system acquired hospitals across a 90-mile radius and opened satellite clinics up to 120 miles away. She never thought to renegotiate that non-compete, and when she wanted to open her own private practice, she was out of luck. Instead, as an empty nester, she has entered the world of locum tenens physicians, and practices all across the US. I have to say, I’m jealous of the side trips she has made from some of her assignments, including such national parks as Badlands, Acadia, and Theodore Roosevelt.

Health systems argue in favor of such restrictions because it’s expensive to recruit and retain physicians. I don’t disagree that it’s expensive. However, over the 20-year course of her employment, the health system certainly made enough money off of my colleague and her referrals as to make up for any expense of recruiting her and starting her practice. Even if a non-compete was limited to a certain period of time, perhaps five years, to allow an employer to recoup those startup costs, they could have the unintended consequence of forcing employees to stay who might not be a good fit for the practice. I’ve also seen physicians leave medicine entirely due to a non-compete, which is its own special kind of tragedy.

The real answer here is to eliminate non-compete clauses and other restrictions on clinical practice. There’s already a shortage of certain kinds of clinicians, such as primary care physicians, and that shortage isn’t going to improve any time soon. Forcing clinicians to stay in a situation where they’re burned out and unable to serve patients effectively because of a non-compete doesn’t help anyone. Unfortunately, corporate healthcare employers aren’t going to see it this way anytime soon.

What do you think about non-competes for clinical employees? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/19/23

Most workers in the healthcare IT trenches are familiar with the US Meaningful Use program and its successor, the Medicare Merit-based Incentive Payment System (MIPS). A new study in the Journal of the American Medical Association says that MIPS gets it wrong by penalizing physicians who care for patients with complex medical needs. Researchers from Weill Cornell Medical College noted that “MIPS scores were inconsistently related to performance on profess and outcome measures, and physicians caring for more medically complex and socially vulnerable patients were more likely to receive low MIPS scores even when they delivered relatively high-quality care.”

If there’s one thing I learned as a CMIO, it’s that the team needs to be top notch at collecting the right measurements, which may or may not align with what is really important to patients and their care teams.

I’ve watched patients be treated in ways that aren’t necessarily appropriate for their situation, in the name of satisfying measures. I’ve seen physicians trying to maintain tight control of blood sugar in elderly diabetic patients because they didn’t understand how to exclude them from the measures and the physicians didn’t want to get dinged on their clinical quality metrics. The sometimes-mindless devotion to metrics just illustrates how misaligned the incentives in the US healthcare system can be.

For the love of all those elderly patients who are being overtreated due to poorly implemented clinical decision support in the EHR, if you’re in clinical informatics, please make sure your clinicians know how to properly exclude a patient to whom the recommendations do not fully apply. It will be interesting to see what comes after MIPS – I know clinicians are sick of it and primary care practices waste countless hours on the program every year.

Speaking of primary care physicians, many of my colleagues have come together for regular conversations about how to prevent burnout and promote wellbeing among physicians and office staff. When I started in solo practice, I had 2.5 full time support staff just to run the office, and I paid for a central business office to handle the back end of the revenue cycle. Most of the primary care physicians in my area are employed by one of three large health systems or a large investor-owned provider group, so they’re no longer in charge of their own destinies.

Due to the staffing crisis everyone is seeing, most of them are down to 1:1 support with a medical assistant. One of the doctors I recently spoke with is allocated 40% of a medical assistant’s time to support her 3,000-patient primary care panel. It’s frankly absurd, and she’s looking to leave when the school year is over. She has to give 90 days’ notice, so she will be resigning soon, and I can’t imagine how they are going to be able to recruit a replacement if they let the candidates visit the office and see what’s happening.

She has one child in college and one who has been in the workforce for a couple of years. One of the hot topics with her family over the holidays was the idea of a “slow work” mindset. Her eldest child works at a company that has adopted a four-day work week, which evolved after a couple of years of “focus Fridays,” where employees were encouraged not to have meetings but to give their effort to priority projects or personal development. At that employer, meetings have been either compressed into 20-minute check-ins or expanded into multi-hour collaboration session where people are encouraged to get the work done as a team rather than individually push things along an inch at a time.

Her youngest is interviewing with companies that have been deliberate in their communications about workplace flexibility and how they don’t want to be in the business of babysitting their employees. Despite stories in the media announcing the death of remote work, it seems like a lot of companies are still offering it. I know from experience that I’m more productive in a remote environment. I have fewer interruptions and can use break time productively, whether it’s rotating loads of laundry, baking a loaf of bread, or knocking out a little yard work on my lunch break. Once I’m back at my desk, I’m more focused and it seems like time flies compared to when I was in an office and had constant face-to-face interruptions from co-workers. Sure, there are interruptions, but I can manage a Slack message and respond in 1-2 minutes when I’m finished with my current train of thought versus having to immediately turn to an in-person contact and let that train run right off the tracks.

I get a ton of unsolicited emails and calls, mostly from people trying to sell me services I don’t want or need. Pro tip for those folks responsible for composing corporate communications: starting your email with “Dear Dr. HIStalk,” will at least keep me reading, where “Hey Jayne,” is going to be a direct trip to the “Block Sender” button. Sales and marketing people everywhere, please take a look at your templates and let’s all agree to make professional communications a part of general business discourse again.

Frankly, the Girl Scouts coming to my door with their much-awaited cookie order forms are doing a better job than some of the sales reps who’ve approached me lately. If you’re wondering, Samoas (Caramel deLites ) are my favorites, followed by Tagalongs (Peanut Butter Patties). Depending on which baker services your region, names may vary. And if you’re interested in appropriate wine pairings for your cookies, may I suggest this handy guide.

Several of my friends are in academics, and we recently got into a discussion about sabbatical leave. I was telling them about the sabbatical programs at some well-known tech vendors and they were surprised that sabbaticals exist outside the university world. It’s an interesting idea for companies that want to differentiate themselves and who want to make a clear statement that they want employees to be with them for the long haul. A recent opinion piece talked about the lesser-known effects of sabbaticals, including providing an opportunity for coworkers and teams to shine. The author had spent 10 years at a marketing agency and received an eight-week paid sabbatical upon reaching that milestone. She notes that in addition to providing “a proactive hedge against employee burnout, an antidote for attrition, and a protection from career wanderlust” her time away made her more passionate about her work and workplace than before.

In observing that those who managed her workload while she was out, the writer found that upon her return, those co-workers had increased confidence and willingness to provide leadership for projects. Experts agree, and she cites several studies that have reaffirmed the benefits of sabbaticals. Proponents of the practice find that sabbaticals are an investment in employee wellbeing. According to sources cited in the article, only 5% of employers offered paid sabbaticals with 11% offering unpaid leaves. When you consider how much it would cost to replace a valued employee, two months’ salary seems a relatively economical investment.

There’s a lot of discussion about the value of time away from work, particularly with recent announcements from Microsoft that it is expanding its unlimited time off policy to all US-based employees. For many, such a policy makes it tempting to take days off here, which may lead to fewer employees taking longer vacations. Research from the travel industry indicates that many individuals need at least three days away from work to de-stress, which is nearly half of the traditional week off. For most of my friends, having several four-day holiday weekends in close succession made people feel a little spoiled, and it will be hard to have only two-day weekends for a while.

Does your employer offer sabbatical leave? How has the experience been, not only for the person on leave but those left behind? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/16/23

As a CMIO, one of my primary responsibilities is to make sure the EHR is configured in a way that makes it easy for clinicians to do the right thing. This involves everything from determining the content and display order of an order set to creating documentation templates and workflows that make sense for a given specialty, subspecialty, or particular type of visit.

In a large healthcare organization, managing this content can be complex. It can seem like we never have enough money, time, or personnel to do everything we want to do. We have to juggle priorities and manage conflicting requests from teams that might be in conflict with organizational priorities. Some days are easier than others, but when the going gets tough I’m glad that I have my “village” of fellow CMIOs that I can reach out to for advice.

During a recent call, one of them brought up this study that was recently published in the Journal of the American Medical Informatics Association. The title was eye-catching: “Behavioral ‘nudges’ in the electronic health record to reduce waste and misuse: 3 interventions.” The authors, working with the EHR team at an academic medical center, identified three workflows that might be driving users towards medical errors, waste, and misuse. They modified the system to try to nudge providers towards high-quality outcomes. but with varying degrees of success.

They had a couple of strategies for how they updated the EHR. “By changing the direction of these nudges – in one case, via making the less appropriate order more difficult to find and use; in the second case, by making the more frequently desired imaging easier to find; and in the final case, by presenting an easy to find alternative – we attempted to nudge providers toward reduced waste and misuse.”

The first situation dealt with a blood test. There were several variations of the test available and having an alphabetical order display that placed the least-desirable option higher on the list was likely contributing to erroneous orders. The modification removed the less-appropriate option, replacing it with an order panel that included educational content to help the provider make a better choice, including pre-checking the more desired test.

The second situation addressed the issue of providers erroneously ordering a CT scan of the abdomen when it was more likely that they wanted to order a CT of the abdomen and pelvis. The researchers assumed that alphabetical placement was an issue here as well. They reordered the list to place the more desired option higher in the list.

In the third situation, the authors looked at prescriptions of benzodiazepines that are given to help patients with anxiety during medical procedures. Prior to the intervention, the default quantity for the medication order in the EHR was what one would prescribe for a patient who was taking the medication on a routine basis rather than just taking it before a procedure. This led to prescriptions for more pills than would be appropriate for the situation. The team created a new order that made it clear that the intent was for pre-procedure use. It dispenses two pills with no refills and includes an additional comment that it is to be used as needed for anxiety prior to a procedure.

The authors noted some challenges in determining how effective the nudges were. For the anxiety prescription, there was a very short baseline, so it was difficult to determine the level of improvement. They also commented that the benefits of changes to the system have to be balanced against the cost of implementing them. There was a fairly dramatic difference in the time needed to create each solution: six hours for the blood test, three hours for the imaging order, and 16 hours for the anxiety medication order.

The changes were presented to end users as part of general educational guidance that is released with monthly EHR updates. In my experience the uptake of monthly update documentation can be variable, so there’s a good chance that some users simply stumbled upon the changes in the system. It would be interesting to look at how different specialties interacted with the new orders. For example, whether they made more of a difference among physicians in a specialty that interacted with the orders at a higher frequency than those who ordered the tests less frequently.

In the article’s discussion, I was interested to learn that “as compared to interruptive alerts, nudges in the EHR literature have not been as well described.” That’s an interesting point, because alerts that interrupt the workflow have become general annoyances for many clinicians, where nudges can be embedded in the design to the point where users might not even perceive them as having been deliberately placed. I wasn’t aware of the “Nudge” group at the University of Pennsylvania, but I’ll definitely be keeping an eye out for writeups of their work.

I also hadn’t thought of some of the work I recently incorporated into my own EHR as being nudges, but in hindsight, they are. I got the idea from a presentation I saw from one of the nation’s premier children’s hospitals and extrapolated a piece of it to the work that our clinicians do. It hasn’t been live long enough for me to know how well it’s been received, but I’m looking forward to finding out.

Another interesting dynamic to explore would be whether there were any specific complaints from end users about the incorporation of the nudges. For items that appear in a list, changing the order or removing an item can interfere with muscle memory and will feel bothersome to those who had adapted to finding the right choice in the list in their own way. It can take time for those users to re-adapt to the new presentation. For items that appear as part of a search, changing those can be less bothersome.

Since the study was done at University of California, San Francisco (UCSF) Health, I’d be interested to hear from anyone who was on the team responsible for the changes or from end users who experienced it.

What user-facing nudges or interventions are you working on for 2023? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/12/23

I volunteer with a couple of community organizations. Although I find the work gratifying, it can also be frustrating for those of us who are used to workplaces where time is seen as precious and communication is key.

One of my organizations keeps sending out “friendly reminder” emails telling recipients that “if you haven’t taken care of XYZ yet, please do so, but if you have already done it, disregard this message.” I’ve certainly seen this approach in business situations as well, so those who are guilty should be on notice. For those of us in fast-paced situations who tend to juggle way too many balls, it can be difficult to know if you did it or not – especially if the original request was some time ago. Sending the email only to the people who actually need to take action would be more useful and would avoid wasting other people’s time.

From Jimmy the Greek: “Re: telehealth. Check out this company that will set you up with a video chat with a doctor, and then sell you a bunch of prescription meds to keep on hand  ‘just in case.‘” Duration Health describes itself as “a mission-driven organization with a deep belief in patient autonomy.” Following a consultation, they prepare a customized kit from their list of 60 medications so that you can have the good stuff on hand in the event of trouble in the backcountry, natural disaster, or all civil unrest. They note that their formulary “contains the medications most prescribed at urgent cares for acute, non-emergent conditions, along with a select set of potentially life-saving medications for emergent scenarios where help is limited.” The list includes such favorites as antibiotics, antifungals, antimalarials, steroids, epinephrine, antihistamines, laxatives, altitude sickness treatments, emergency contraception, and anti-nerve gas agents. They focus their sales on those who anticipate traveling outside the US, into the backcountry, to an area at risk for natural disasters, or to a medically underserved area as defined by HRSA. Their OFFGRID promo will net you a hefty discount if you’re interested.

Here’s some good news for those of us who spend a lot of time at our desks. A recent study published in Nature Medicine shows that even short bursts of vigorous activity as part of daily life can help reduce the risk of death. Activities might include climbing stairs, brisk walks during a commute, and more. Participants wore wrist-based accelerometers that helped measure the amount of vigorous intermittent lifestyle physical activity (VILPA). More than 25,000 people aged 40 to 69 years participated in the study and wore the devices more than 16 hours a day for at least three days during a weeklong period. The “nonexerciser” group said they didn’t exercise during leisure time and they didn’t walk more than once weekly for recreation. The researchers compared mortality rates between those nonexercisers who did and did not have spurts of VILPA recorded by their devices. They also looked at data from another 62,000 research subjects who self-reported that they exercised regularly. The subjects’ health outcomes were tracked for approximately seven years.

The study found that even in nonexercisers, having engaged in bursts of vigorous activity was associated with a nearly 50% decrease in mortality from cardiovascular disease. Although the study can’t show causality, it’s hopefully interesting enough to help set a framework for additional investigations. The authors noted some limitations of the study. Only about 6% of people invited to participate actually accepted, so the subjects might not represent the general population. Additionally, some bursts of activity such as carrying something heavy like a shopping bag might not have been accurately captured by wrist-based devices.

It looks like every bit of movement during the day counts, so I’ll keep that in mind when I’m racing to the laundry room to rotate a load of towels in between conference calls or scurrying down the driveway to bring the recycle bin in before one of my neighbors calls the city inspector for leaving it out past dusk.

Of no surprise to anyone: MyChart message volumes decreased at UCSF Health after the organization began billing for them, even though the number of messages that actually generated charges were small. A research letter published in the Journal of the American Medical Association found that although charges occurred about 2% of the time, the overall number of messages declined from 59,648 to 57,925. The authors propose that the decline was likely due to “awareness of the possibility of being billed.” Interestingly, they found no significant changes in the numbers of scheduled visits or unscheduled telephone calls. They note that “future research should investigate overall costs under different payment models and the effect of billing for messaging on outcomes, health equity, and patient and clinician satisfaction.”

In speaking with my peers around the virtual water cooler, it doesn’t seem like patients understand the burdens that primary care physicians are facing including the deluge of messages that has happened since COVID appeared. Patients are unaware that a majority of primary care physicians are taking work home with them and continuing to manage phone messages, insurance preauthorizations, and visit notes well into the evenings. As I coach physicians on trying to make documentation more efficient, I keep hearing themes about not only lack of office staff, but lack of highly qualified staff, which pushes more work onto the physicians.

One physician I spoke with recently has had to perform all patient care tasks in his office, including patient intake (history updates, vital signs, etc.) because his medical assistant is on medical leave and the health system employer claims they can’t find anyone to serve as a temporary replacement. He’s thinking about resigning because he can’t get caught up and other physicians in the practice are unwilling to share their staffing capacity. I know that my former clinical employer still has a percentage of its locations closed because it can’t staff them, so I’m not surprised about any hiring crises I hear about.

Is your organization charging for messages, and how are patients receiving the change? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/9/23

I read a number of articles this week that addressed various hot topics about how people spend their time and how employees should be treated.

It was quite ironic that the best thing I saw on Facebook this week was a link to a piece in The Atlantic titled “The Age of Social Media Is Ending.” I have a love/hate relationship with social media depending on how much I feel like I’m being forced to use it versus how much I’m electively using it to keep up with things I care about. I despise it when community organizations (including our local schools) decide that Facebook is the best way to communicate important information. They don’t seem to understand that Facebook isn’t a static place you go to view things, like a bulletin board. The algorithm serves up different things to different people at different times and depending on your settings it’s possible to miss information unless you’re stalking a particular group or page on the daily.

I also dislike the fact that social media posts from individuals have become newsworthy. Outlets like MSN are constantly posting stories about things that people share on TikTok. Often, these stories are about happenings that we’re supposed to find outrageous, but I can’t take any more earnest-appearing people complaining about things that aren’t really that outrageous. I enjoy social media when I see updates from friends I don’t often see or use various groups or forums to get advice about my hobbies. Rather than broadcast to the entire universe on Twitter or Facebook or Instagram, I prefer to be part of smaller platforms that let me connect in a deeper way with my actual friends, like private workspaces on Slack or chats on GroupMe. I still can’t figure out why Twitter thinks I want to see most of the tweets it recommends for me, or what behaviors to exhibit to see content I would actually read.

The piece from The Atlantic talks about the evolution of social media from the early days of collecting friends to the recent explosion of its use as a “latent broadcast channel” where “all at once, billions of people saw themselves as celebrities, pundits, and tastemakers.” Social media has certainly made it more difficult for primary care physicians to do our jobs, with the constant barrage of headlines touting so-called “things your doctor doesn’t want you to know about” and the proliferation of people trying to make a buck with pseudo-medical “wellness” offerings that physicians have to spend time debunking.

The author notes that “as the original name suggested, social networking involved connecting, not publishing.” The evolution to “social media” happened around 2009, according to the article, “between the introduction of the smartphone and the launch of Instagram. Instead of connection – forging latent ties to people and organizations we would mostly ignore – social media offered platforms through with people could publish content as widely as possible, well beyond their networks of immediate contacts.”

The piece notes that the 2006 introduction of Twitter “amounted to a giant, asynchronous chat room for the world.” It goes on to discuss “the data-driven advertising profits that the attention-driven content economy created,” including the influencer economy, where people are essentially paid for sharing marketing messages or for product placements, creating the idea that becoming an influencer “became an aspirational role, especially for young people for whom Instagram fame seemed more achievable than traditional celebrity – or perhaps employment of any kind.”

It talks about the potential decline of social media given the current state of things, and what a remodeling might look like – drawing an analogy from the cultural changes needed to drive a decline in smoking across several decades. The idea that social media could play a smaller role in our lives is an interesting one. Many people check their accounts, feeds, and streams compulsively and I wonder what they would do with all the time they might get back.

Speaking of time, I also enjoyed this read from Forbes: “Companies Fret About Time Theft – But Who’s Taking From Whom?” Time theft has traditionally been defined as the hours when employees do things like managing personal business while on the company clock, or otherwise wasting time that is seen as belonging to their employers. With the rise of remote work, employers have taken to doing things like monitoring laptop use, the time spent in various applications, or the calendars of employees.

The article looks at the idea that time theft can go both ways. It talks about employers who demand work outside of normal working hours, but who don’t provide additional compensation or mandating unpaid training. It notes that “this kind of time theft more often affects marginalized people who are asked to go the extra mile and work harder than others to be considered for advancement opportunities.”

The author describes the pathway by which people who are constantly battling additional demands “grow weary of their work time encroaching so insidiously on their personal time…They lose their desire to shine and they focus on self-preservation instead.” I’ve worked in plenty of organizations like this, including one health system where the IT team was constantly expected to deliver the impossible. The teams sacrificed themselves on the altar of this principal and what resulted was global burnout and the departure of key leaders and high performers from the organization.

The author notes that “Workers shouldn’t feel that their private time can be snatched from them at a moment’s notice for questionable reasons, and that if they balk at putting in those additional hours their chances of advancing in the organization will be compromised.” In my experience, healthcare IT organizations are particularly at risk for this due to the 24×7 nature of our work. When someone has to be on call, it’s easy to reach out to them as opposed to thinking carefully about whether the situation needs to be addressed immediately or whether it can wait until the next business day.

Also in my reading, I came across a number of articles about the proposed end to non-compete clauses. Companies seem to love them, workers hate them, and states have done variable jobs regulating them. Most physicians are subject to non-compete clauses.

When I left the medical practice that I had built from the ground up (literally it was a slab when I started), one of the things the health system used to sweeten the deal was voiding my non-compete clause. I’m not a fan of them, especially in medicine, because they jeopardize the patient-physician relationship. They force employees to decide between uprooting their families and preserving their livelihoods and I’ve seen them hasten the demise of numerous relationships. Employees who feel handcuffed aren’t going to be as productive or successful as those who feel they’re remaining at their employer by choice. The best way to keep an employee from leaving to go work for the competition is to treat them with respect, pay them fairly, and support them.

Those concepts were among the topics at the most recent session of my leadership intensive. The theme of one of the presentations was “What fills your bucket?” We were asked to visualize our psychological bucket and the things that fill or drain it. Your bucket might be filled by support from co-workers, knowledge of a job well done, or completion of a difficult task. It might be drained by an overly demanding boss, stressful working conditions, or a chaotic environment. When people feel forced to remain in situations where they can’t fill their bucket, letting them leave might be the best option for all parties. There are plenty of other things that can fill or drain our buckets, including our own habits. When thinking about social media or time theft or a number of different things, it’s useful to determine the impact they have on our buckets.

What has filled your bucket lately, and what has drained it? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/5/23

I’m a big fan of my Withings blood pressure cuff, which captures readings wirelessly and syncs them with health management software. It is useful to show my physicians what my blood pressure actually runs at home, as opposed to the elevated values I have when I walk into a healthcare facility and start having anxiety symptoms related to the last few years I spent working in emergency department and urgent care facilities.

Withings has announced U-Scan, which it claims is “the first hands-free connected home urine lab.” The device is 90 mm in diameter and is placed in the toilet bowl to provide “an immediate snapshot of the body’s balance by monitoring and detecting a large variety of biomarkers found in urine.” It also promises to offer “actionable advice for health improvements.” The unit contains a cartridge that holds “test pods” and chemical reagents, along with a reader that transmits data by Bluetooth or Wi-Fi. The cartridge and its battery are designed to last for three months and the website notes that it is “designed to be compatible with most Western-style toilets” and can be mounted with an included fixation arm. The battery can be charged via USB-C during periodic cleaning and maintenance.

Other language on the website notes it can follow menstrual cycle-related monthly hormonal fluctuations and deliver “key hydration and nutrition biomarker analysis, recommended actions based on cycle phases, and data correlation for an optimized menstrual cycle.” Since none of this data is protected by HIPAA, as a woman of reproductive age, I would be leery of giving a private company access to this data, but I’m sure a number of potential users won’t even think of that as a problem.

It also promises to give information on hydration status, but I was surprised to see that the smartphone app featured on the website recommended the “eight glasses of water” each day that has been widely debunked. As someone who has medically managed cohorts of people doing strenuous activities in the backcountry, I know that people can also learn a lot about their hydration status by following the collective wisdom to keep urine “clear and copious,” and that advice is free to boot.

Withings makes it clear that the Nutri Balance and Cycle Sync cartridges are not considered medical devices and are intended to encourage a “healthy lifestyle,” which is the same advertising speak used by a lot of quasi-medical items including nutritional supplements and non-regulated devices. Nutri Balance will measure specific gravity, pH, ketones, and vitamin C, but to be honest, I’m not sure how useful those markers are to the average person. The site doesn’t make it clear how often it will be testing which components, but states that each cartridge includes “more than 100 biomarker results” which should be a three-month supply “when following the recommended measurement plan in the Withings App.”

They do mention that they have a U-Scan for Professionals cartridge for monitoring of urinalysis data, which is likely where the real utility of this device might lie. The website notes that remote patient monitoring will be subject to “appropriate regulatory clearances.” They’ll be unveiling the device at the Consumer Electronics Show (CES) this week, with a plan to move to a public launch in Europe during the second half of the year. The consumer-grade starter kit contains one cartridge and a reader for 500 Euros ($526), with a 30 Euro monthly subscription. Pricing for the professional model is by request only. I’m sure plenty of people will be lining up to purchase one, though if nothing else than to have something that’s latest and greatest, especially if they are deeply into analyzing their quantified selves.

The New Year always brings out plenty of articles for predictions about the coming year, and I got a chuckle out of one that surveyed a few dozen investors, founders, and other startup and corporate folks for their take on 2023. The best question in my book: If Elon Musk were to buy and operate one healthcare company (for better or worse), what company would you suggest he buy? Oscar Health came in first, with Epic and Bright Health tied for second place. UnitedHealth Group ranked third, with the next cohort being a tie between Cerebral, Athena, and “Will not happen/please stay away from healthcare.” Based on recent events I don’t think Mr. Musk will be buying any companies soon, so we are safe at least from that kind of drama.

My second favorite question was “Where will VBC be on the Gartner hype cycle curve at the end of 2023?” with 55% of respondents saying it will be in the “trough of disillusionment.” Let’s face it – preventive care and the kinds of routine chronic care that are the hallmark of value-based care are not sexy and they are not big moneymakers, and many primary care providers agree that short of something miraculous or stemming from massive government regulations and a complete realignment of incentives, we are never going to be at the forefront as we’d need to be to really drive change. Needless to say, I won’t be leaving clinical informatics for the primary care trenches any time soon.

The New Year came in with a bang in my area with spring-like temperatures and the chance to take care of some yard cleanup tasks that didn’t happen before the holidays. It was good to get outside and do something that created a visible change. Sometimes in healthcare IT, we work on large projects for a significant amount of time, but since the work is largely behind the scenes, it doesn’t feel as productive as it might be if it were more visible. Still, we create tangible changes that benefit users and patients regardless of whether they see them or not.

Sometimes we work on projects that don’t even see the light of day. I’ve had entire upgrade projects that were shelved when organizational priorities shifted. During my career I’ve helped build two complete EHRs that never saw broad adoption. The work helped me get where I am today, and some experiences can only be learned through the school of hard knocks.

Here’s to hoping the new year brings us projects that are complete successes, upgrades that are smooth, and projects that run on time and on budget. What are you most excited to work on in 2023? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/29/22

I’m pleased to report that I made it through the usual family holiday events with a minimum of drama and no outbursts from unruly drunken relatives.

Unfortunately, I just received my first “hey, I’m positive for COVID” text message, so we’ll have to see if there are more on the way. That particular family gathering had way too many people in a small space and too many adolescents who were constantly wrestling around with each other and then going back to the food table, so I’ll be crossing my fingers that everyone else stays healthy. I’ve got a fat stack of COVID tests ready for whatever symptoms make an appearance at my house.

There are a lot of providers ordering expensive respiratory testing panels to try to sort out Influenza from RSV from COVID, but unfortunately in many cases, knowing what specific virus is present doesn’t change the management plan for the patient. Running the test increasees overall healthcare costs and increase the anxiety for patients who “just want to know what virus it is.” There are so many viruses beyond the big three that are running rampant now. Many of us in the trenches refer to them in aggregate as “the crud” and keep advising patients on pushing fluids, rest, and symptomatic treatments.

Apple is being sued over the potential that the Apple Watch’s blood oxygen reader is ineffective on people of color. The class action claim was filed in New York and bases its merit on known issues with pulse oximetry technology, even though it’s unclear whether the Apple devices use the same technology as other devices that are increasingly coming under scrutiny. The suit seeks a jury trial and alleges violation of New York state law as well as a federal law regarding deceptive business practices.

The US Food and Drug Administration (FDA) placed pulse oximetry technology under review back in February of 2021, after studies found that the devices display higher oxygen readings when used on individuals with darker skin tones. Although there were questions about accuracy prior to the pandemic, the pandemic caused rapid expansion in the use of the devices in homes and other settings, which may have magnified the issue. An update by the FDA was issued last month following a virtual public meeting.  When patients have high readings that don’t reflect their actual state of oxygenation, they might not receive oxygen or other treatments that could improve their condition. The problem is believed to affect devices used by medical professionals as well as consumer-facing devices.

Speaking of consumer-focused offerings, many healthcare organizations are seeing the expected surges in requests for on-demand telehealth visits following family gatherings. Based on my experience as a telehealth physician, there are still a number of people who struggle with completing telehealth visits. Sometimes there are glitches with software and video connectivity, sometimes the patient doesn’t answer when the telehealth platform calls the patient to start the appointment, and sometimes patients are multitasking and not paying attention to the visit or the clinician trying to help them. A recent study published in JAMA Network Open looked at whether implementation of a telehealth navigator program would help improve the number of successful video visits.

The program, established at Beth Israel Deaconess Medical Center, was built around scheduled video visits. The navigator was tasked with contacting the patient a day prior to the visit to offer technical support, answer frequently asked questions, and to walk through the steps required for a successful connection. The three-month pilot ran from April 19 to July 9, 2021 in primary care and gerontology clinics. Researchers looked at over 4,000 adult patient visits. Approximately 25% connected with a telehealth navigator prior to the visit. Successful video visits were present in 92% of navigator-enabled visits but only 83% of the non-navigator control group. The cancellation rate was 6% in the navigator group and 9% in the control group. The rate of missed appointments was 2.5% for the navigator group and 8% for the control group. Overall, the navigator group had a 21% increase in successful video visits compared to the control group. In addition to providing greater care for patients, the increased volumes of the navigator group resulted in higher revenues, with a return on investment greater than the navigator’s salary.

Although this specific approach is best applied to scheduled visits, I’ve seen navigators used during on-demand visits too. Some organizations are using medical assistants to virtually “room” patients, gathering and entering the patient’s chief complaint, vital signs, and medical history data elements. One system I worked with that employed this approach reported greater patient satisfaction but some frustration on the physicians’ part if they had downtime between visits while the patient was still working with the medical assistant. Keeping a physician on schedule and reducing patient wait times is challenging whether you’re seeing patients in person or virtually. I’m looking forward to seeing more studies that help identify the best practice approach and whether organizations will adopt flows that have been successful elsewhere or whether they will continue to reinvent the wheel.

Although most of my clinical reading revolves around surging viruses, preventive care, and strategies for better conducting telehealth visits, sometimes it’s nice to come across an article that covers a completely different aspect of medicine. A recent study published in JAMA Internal Medicine illustrates the relationship between major motorcycle rallies and organ donation. The authors estimated 21% more organ donors and 26% more transplant recipients per rally day compared with the four weeks before and after rallies. An accompanying editorial calls on organizations that are associated with high-risk sports to encourage members to consider organ donation.

Looking at the donor demographics, 71% were male and the mean age was 33 years. Recipients were 64% male with a mean age of 49. The most common organ transplants were kidney, liver, heart, and lungs. The authors looked at data from seven major rallies, including the Atlantic Beach Bikefest (SC), the Bikes, Blues, & BBQ (AR), Daytona Bike Week (FL), Laconia Motorcycle Week (NH), Myrtle Beach Bike Week Spring Rally (SC), the Republic of Texas Biker Rally, and the Sturgis Motorcycle Rally (SD). Needless to say, they did not include data from the Cushman Club of America’s 2018 rally in Sturgis, where the riders were generally low speed as well as low key. Here’s a shout-out to my favorite Cushman rider for teaching me what I know about having fun on two wheels.

Are you an organ donor? Have you discussed your wishes with your family? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/22/22

Home health is a hot topic for many healthcare organizations as they look to maintain control over all aspects of the patient care continuum. Some are trying to maximize the use of technology to not only better serve their patients, but to help solidify an ongoing relationship.

They may be using platforms which are extensions of their EHR, such as an integrated patient portal. They may be using third-party solutions such as chatbots or other add-ons. A recent report from the Office of the Inspector General (OIG) of the Department of Health and Human Services looked at how home health agencies responded to the challenges of the COVID-19 pandemic.

Like most care delivery organizations, home health agencies struggled with staffing during the pandemic, and those challenges haven’t been resolved. Their use of telehealth has expanded, particularly due to flexibilities granted by the Centers for Medicare & Medicaid Services (CMS). For the report, OIG surveyed a sample of 400 home health agencies, nearly all of which participated in Medicare. They did more in-depth interviews with 12 agencies, and also interviewed staff at CMS about their perspectives on home health during the pandemic.

In addition to staffing challenges, OIG found that infection control was a major concern. The survey found that various incentives were useful to help retain staff, including offering paid leave. Staffing challenges were also mitigated by updates to regulations that allowed an expanded set of provider types to perform some patient assessments, and to order home health services.

The addition of telehealth provided a boost to many organizations. The report recommended that CMS further evaluate how telehealth fits into the overall home health landscape and better understand the types of patients who benefit from those services. It will be interesting to see what happens with the proposed extension of telehealth flexibilities and whether other solutions such as chatbots or automated patient engagement will bring the results that agencies hope for. From an employee perspective, it would be great if organizations continued to look at people and process solutions as well, including better compensation for home health workers and expanded benefits such as paid leave.

Speaking of paid leave, the virtual physician lounge was buzzing this week with discussions about whether physicians should work while sick. One physician colleague was describing how she was at work with a fever and chills but avoided testing herself for influenza because she didn’t feel she could go home if her test was positive. She figured that since she was wearing an N-95 respirator the risk of exposure to patients was low.

It’s a sad situation when a physician has to choose between feeling like they’re letting their patients down and burdening their colleagues or taking care of themselves. A recent Medscape article looked at this phenomenon. They polled physicians and found that 85% have come to work sick during 2022, with most coming to work sick on multiple different occasions. Nearly a third have worked with a fever and 7% have worked with both strep throat and COVID.

Concerns about inconveniencing patients were at the top of the list for reasons to work sick, along with concerns about staffing and revenue. A whopping 76% of physicians stated that that going to work sick was expected in their workplace, with 58% saying there wasn’t a clear policy about coming to work while ill.

At one of my previous employers, which had a fairly toxic culture, providers would routinely receive IV fluids on the job so they could keep working. I know that if I was sick enough to require fluids, I don’t think my mind would be as sharp as it should be to safely care for patients.

There is also the issue of informed consent for patients. They should be aware that they are being asked to see a provider who is not 100% or who may have a communicable disease, but my employer never provided that information to patients. Providers who did this often bragged about it on the company’s internal social media platform, and it certainly wasn’t discouraged by management. Unfortunately, I don’t see improvement on the horizon for the issue of working while sick. The realities of short staffing and coercion by leadership make it a near certainty.

I was horrified this week to learn about Google’s efforts to secure access to a collection of pathology samples from veterans of the US armed forces. The situation dates back to 2016, when Google had the idea to turn the Joint Pathology Center’s collection of pathology slides into an exclusive digital archive featuring Google’s AI technology. Staffers at the Department of Defense have appropriately identified the ethical concerns around this process, since the service members in question most certainly didn’t consent to having their medical specimens used by a private organization.

The collection contains more than 31 million blocks of human tissue and 55 million slides, dating back decades. (For reference, many healthcare organizations only maintain their specimens for 10 years.) The collection has been tapped to determine the genetic sequence of the 1918 Influenza virus and contains samples of significantly rare diseases.

Discussions about Google’s use of the samples have had their ups and downs, with Google lobbying legislators for greater access to the collection. Google’s various proposals would have resulted in giving access to the coveted resources without a competitive bid, which raised red flags. Other scientists balked at the information requested by Google – including diagnoses, images, gender and ethnicity information, birth dates, and death dates – that could allow identification of supposedly de-identified samples. Google also demanded exclusivity, as well as payments from the government to store and access the information. The ProPublica article notes the similarities between the use of military specimens without permission and the situation of Henrietta Lacks, whose cells were used without permission for research and commercial endeavors.

The rest of the article is a good read, with plenty of intrigue, undue influence, sketchy job offers, and whining when Google wasn’t selected during an open bid process. Google even went as far as claiming it as a matter of national security that they be allowed to be part of the process. Google-funded lobbyists continue to try to influence the process, leading the pathology repository’s team to craft a publicity campaign to call attention to the situation and its ethical concerns. There’s even mention of a Shakespearean plot at the end. If you’ve got downtime during the holiday season, I would recommend reading through it. I thought it was a fascinating commentary on how technology companies are weaving themselves into parts of our world we never even think about.

What do you think about Google obtaining exclusive access to sensitive information and pathology specimens belonging to members of the US armed forces? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/19/22

I’m participating in a leadership intensive over the next six months. We recently had the first meeting of the course. It’s been a long time since I’ve participated in this kind of program other than as the person responsible for delivering the content. I was looking forward to meeting everyone and seeing what the vibe would be among the people leading the course.

I’ve worked with quite a few dysfunctional clients over the years. My Spidey sense for first impressions is usually spot on. Even when they are trying to put a good face on a total disaster, it’s difficult for most organizations to mask dysfunctional behavior. You can usually get a feel for how the leaders interact with each other and pick up on some subtle body language or comments to identify whether there are things simmering below the surface. For organizations that are well tuned, that becomes apparent when you see the interactions on Day 1.

For our first session, we had two hours together. After an informal “gathering time” of snacks and drinks, the activities were centered on getting to know the overall goals of the organization, understanding what to expect during the next six months, and answering any questions about the program.

The first thing that caught my attention was that the opening presentation was well prepared. There were four presenters, and each knew their part of the presentation cold, with no overlap and no stepping on one another’s material. Still, they came across as warm and engaging and it didn’t feel stilted or overproduced, which can be an issue when a presentation is over prepped. They spent a good amount of time reviewing the expectations and making sure that everyone understands what is expected of them and the communication plan that needs to be followed if they get into trouble with assignments.

They spent a lot of time on the overall agenda and the need to stay on time and on task during the group sessions to ensure everything gets covered. I’ve been in enough courses where the faculty struggles to stay on agenda, so I was impressed to see them literally talking the talk as they stayed right on time. To me, starting and ending meetings on time and staying within your allotted box on the agenda is a sign of respect, so it was nice to know that the message from the leadership was supportive of this idea.

At the mid-morning break, they gave the class the opportunity to vote on whether we wanted a longer break and to finish on time, or a shorter break and to finish early. As a meeting participant, being able to have a say in how the group planned to operate made me feel valued. Even in its shortened state, the break was long enough to allow organic interactions and “getting to know you” moments among the attendees.

When I’ve participated in programs like this, there has always been a fair amount of group work. My experience is that the idea of group work is polarizing. People either love it or hate it. Most of us that are in the “not a fan” cohort either have been burned by group work when people don’t pull their weight or have busy schedules that make it difficult to find time to work together.

I was pleased to hear that there wouldn’t be any group work. Rather than having a group work on a larger project, each of us will be working on a smaller segment, but will be responsible for making sure that it integrates with the larger body of work. Over the last two decades, I’ve seen that being able to do individual work that is part of a larger context also allows people to make the most of their personal skill sets and results in a richer output than that produced through group think. When working in teams that operated this way previously, I did well, so I was glad this was going to be the plan. It seemed like the rest of the attendees were receptive to this as well.

A big part of this course involves presentation skills. I liked that we have the option to use whatever presentation modality we want, even if it’s low tech. There’s no forced use of PowerPoint, and no mandatory creation of slide decks. The faculty illustrated the importance of allowing people to present the way they work best by delivering similar presentations with drastically different visual aids. One did a traditional PowerPoint presentation using standardized slides provided by the parent organization. Another took the same presentation, but customized the slides to match their own personal presentation style. The third used flip charts as an aid, and the fourth used an old-school science fair board.  That final presenter used a single piece of foam board that was set up with four panels with strips of balsa wood in between to create the look of a window with four panes. Each pane was covered with a card that was removed when it was time to discuss that pane.

Guess whose presentation was the most compelling? The one with the windows, in part because it was a different vehicle than what we’ve all been pummeled with during the last three years of remote work. It was a good reminder that the message and the medium need to be in harmony to maximize how the audience interacts with the content.

The final part of the session involved a discussion of some of the overall precepts of the program and how the organizational chart is deliberately set up to support it. Roles and responsibilities are clear, with each person understanding their work and its importance in its own right, as well as how it is necessary and important for the overall success of the endeavor. There’s definitely not going to be crowdsourcing going on and it’s clear who the decision-makers are and where their scopes of responsibility begin and end.

Although we are expected to collaborate and support each other, we are also expected to be accountable for our own work and to avoid causing confusion and delay by not staying in our respective lanes. The way it was presented was similar to the “good fences make good neighbors” adage, but with a reminder that we’re all expected to make sure our houses and lawns are neat and tidy because it reflects on the entire neighborhood.

Throughout the presentation, various deliverables were mentioned by different individuals. They each promised to send the materials after class, which can lead to confusion if you have to wait and figure out which ones have or have not been received. I was pleased to see that by the time I made it back to my car, a link to a shared drive with all the deliverables was waiting in my inbox. This will allow each of us to work at our own pace, especially those of us who like to jump into something while our thoughts are fresh and our minds are focused.

Overall, I was impressed by the level of organization and am looking forward to the next monthly session. I’m sure there will be bumps along the way, but based on my first impression, I’m excited.

What is the best leadership program you’ve ever attended and why? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/15/22

The clinical informaticist virtual water cooler is abuzz with conversations about how to address radiology decision support, given the fact that the Centers for Medicare and Medicaid Services (CMS) announced that it is “unable to forecast when the payment penalty phase will begin” for requirements to use Appropriate Use Criteria (AUC) for certain types of diagnostic imaging. For many organizations, the indefinite delay is prompting them to question whether they should remove decision support from their clinical workflows given the burden they add and the level of burnout among clinicians.

One of my colleagues has pressed its institution’s vendors to provide return on investment data to convince her why they should continue to pay for a product that angers clinicians. Depending on where a set of clinicians were at baseline with regard to ordering the impacted tests, there may be little proof that the solutions reduced inappropriate testing or improved efficiency. For those of us looking to help our clinicians any way possible, de-installation is certainly tempting.

My protected health information was included in a data breach that occurred last year at a large health system. In the notification I received several months ago, I was invited to submit a claim for the eligible time and expenses involved in monitoring my credit, cleaning up any problems, etc. Today I received a check as part of the settlement for the data breach litigation. I’ve been part of many data breaches over the years, but this is the first one where I got any monetary compensation, and I’m always happy to have a little extra cash this time of year. Of note, the check is void after 60 days, so I hope other recipients make a beeline to the bank or take advantage of mobile deposit quickly.

One of the organizations that won’t be getting any part of my recent windfall is Aspirus Health, since the website featured on the invoice I recently received takes me to a dead link. The system’s explanation includes migration to a new site. Of all the links you would want to test and validate, I would assume that the bill pay link should have been included, or the statements should have been updated. I’m not about to spend time contacting them to let them know, so I’ll wait until I can circle up with the family member that incurred the charge. Hopefully I can make a payment on their behalf through the patient portal, but putting more work on a patient (or guarantor) trying to pay timeline is never the answer to the question of how to optimize your revenue cycle.

Since emergency departments are packed across the US as the “tripledemic” of Influenza, RSV, and COVID creates havoc, telehealth is a hot topic. Despite its broad use since 2020 and the growth in proficiency by providers and patients alike, there is concern about its quality. A recent study published in JAMA Network Open looked at whether emergency department follow-up visits that are conducted via telehealth versus an in-person office visit would lead to return visits to the ED. The authors found that in this particular situation, patients who had telehealth follow ups after ED visits were indeed more likely to return to the ED, as well as being more likely to be admitted to the hospital.

The retrospective cohort study looked at adult patients who visited one of two EDs within an academic health system between April 1, 2020 and September 30, 2021. Patients participated in a follow-up visit with a primary care physician within two weeks of their ED visit. Approximately 70% of patients followed up in person and 30% via telehealth. For those receiving in-person follow-up, 16% returned to the ED and 4% were admitted to the hospital within 30 days. For those with telehealth follow up, the figures were 18% and 5%, respectively. Additional analysis showed that telehealth follow ups were associated with more ED return visits and hospitalizations per 1,000 encounters.

Before coming to conclusions, it is important to look further at the design of the study. It controlled for how acute the patient’s condition was, their associated comorbid conditions, and sociodemographic factors. Additionally, the authors adjusted models based on age, sex, primary language, race, ethnicity, Social Vulnerability Index, insurance type, distance to the ED, billing codes for the original ED visit, and the time from ED discharge to follow up. They note the need for further evaluation of telehealth’s effectiveness in this specific scenario of continuing care after an initial ED visit for acute illness. In the discussion section of the paper, they note that the findings “need to be considered in the context of a substantial body of science demonstrating the benefits of telemedicine” and specifically call out research demonstrating the value of the modality in managing chronic diseases such as diabetes, heart failure, and more.

They go on to propose a potential mechanism for the observed phenomenon: “the inherent limitation in the ability of clinicians to examine patients, which may compel clinicians to have a lower threshold for referring patients back to the ED for an in-person evaluation if they have any ongoing symptoms.” They also mentioned that patients who had telehealth follow-up visits tended to live farther from the ED than those who had in-person follow-up, proposing that “from the patient’s perspective, the remote nature of the encounter may cause them to seek further care for questions or concerns that they were not able to address via telehealth.” They note that future research is needed to understand whether patient-side or provider-side factors are influencing the decision for telehealth follow-up.

They also note that “telehealth clinicians may not be able to communicate as well with patients, leading to an inability to fully evaluate or intervene on evolving illness and leading to deterioration in patient condition and subsequent need for hospitalization.” I was intrigued by the comment about communication and reached out to a couple of colleagues who are on faculty at different medical schools. Both of them confirmed that their programs are not teaching telehealth skills to medical students, although they did say that some level of telehealth education was included in residency training programs for primary care. It will be interesting to see if that changes over the next few years as more clinicians are expected to render telehealth visits as patient preferences shift in favor of virtual visits. In reviewing the limitations, the authors note that discrete EHR data can’t capture complex social determinants of health, how well a patient feels, or whether they have social support or other resources needed for an in person visit. Additionally, conducting the study at a single academic medical center might not result in generalizable findings.

Healthcare technology is increasingly tied to the use of smartphones. I’ve been in a lot of conversations about what age is appropriate to allow minors to access their own health records via patient portals and how practices should consent to minors corresponding with their care teams. The COVID pandemic has raised questions about children and screen time along with the role that social media plays in anxiety and depression, so I’m always interested in strategies to help families make good decisions. AT&T has teamed up with the American Academy of Pediatrics (AAP) to offer a questionnaire to help with this decision making. It’s located on the AT&T website along with other resources for online safety, digital harassment, and parental controls.

The questionnaire asks about who is initiating the conversation about a phone, whether a parent feels one is needed for the child’s safety, whether it would help with connections to family or friends the child can’t see in person, the child’s level of responsibility and rule-following with regard to media, the child’s level of judgment and impulse control, whether the child readily admits mistakes, and whether the parent is prepared to set parental controls and manage online use. Even if the result indicates that the child and parents are in the “Ready Zone,” they are presented with resources such as healthychildren.org to learn more about technology use by children. Kudos to AT&T and the AAP for taking this on.

What’s the hot technology item on your or your family’s wish list? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/12/22

I was interested to learn about new legislation that was introduced in the US House of Representatives this week. HR 9377, the National Patient Safety Board Act of 2022, establishes an independent federal agency dedicated to the reduction and prevention of healthcare-related harms through use of data-driven solutions. The goal is to create a body similar to the National Transportation Safety Board (NTSB), which looks at transportation-related accidents and issues recommendations aimed at preventing future accidents. The NTSB also takes part in transportation safety research and looks at transportation-related topics, such as worker impairment and equipment failures.

Medical errors have long been a leading cause of death in the US, ranked as high as number three in the pre-COVID years, with numerous organizations leading their own “preventable harm” efforts. However, those processes typically look at events happening within a healthcare organization versus the entire delivery system, and may be skewed by local, regional, or other biases. Honest investigation of certain medical incidents might even be hampered by our patchwork of state and local rules and laws. The proposed National Patient Safety Board (NPSB) would be empowered to look systemically at medical errors, which are estimated at costing upwards of $17 billion each year.

Many experts estimate that patient safety has worsened during the COVID-19 pandemic. I’ve certainly seen firsthand how exhausted clinicians bypass alerts designed to help them and make poor decisions due to mental fatigue. They also sometimes have to choose between multiple non-ideal therapeutic options due to supply chain, financial, and other issues, all of which impact patients. The dramatic rise of interoperability in an effort to de-fragment the healthcare system has also created some potential safety issues that don’t always get the attention they deserve, including patient matching errors, incompatibility of units of measure, erroneous diagnoses, and more.

The proposed NPSB would be designed to be collaborative and non-punitive, empowered to work with other federal agencies and independent patient safety organizations rather than to replace them. It would include a public-private partnership team, the Healthcare Safety Team, designed to achieve consensus on patient safety measures, data collection strategies and solutions, and more. Topics that the Board would be expected to wade into include, but are not limited to, medication errors, wrong-site surgeries, hospital-acquired infections, laboratory errors, and safety issues created during transitions of care.

A coalition of healthcare, business, educational, and technology organizations is rallying in support of the Act. Members run the spectrum of healthcare-related entities, including think tanks, professional organizations, EHR vendors, integrated delivery networks, quality organizations, business consortiums, and more. According to the coalition’s website, “We have seen many valiant efforts to reduce the problem of preventable medical error, but most of these have been focused on the actions of the frontline workforce. This reliance on individuals is part of why efforts to sustain, spread, or standardize progress have been unsuccessful. The healthcare workforce is in crisis, and healthcare safety is suffering.”

The proposed NPSB would have five members, nominated by the President with Senate approval. Members would serve a six-year term. A chair and vice-chair would be designated by the President from among the members and would serve three-year terms in those roles. The Board would be staffed by an organization grouped into various bodies: an Office of the Chair, a Patient Safety Event Monitoring Division, and Study Division, a Patient Safety Solutions Division, an Administrative Division, and regional offices.

The text of the bill goes into further detail about the various divisions and their composition. Other elements that caught my eye included the maintenance of a Patient Safety Reporting System to be used by patients, providers, non-clinical staff, or others wanting to report patient safety events, along with a data access portal to allow state and local entities to submit data. The bill is one of the shorter ones I’ve read, at only 10 pages of standard-formatted text (19 if you read it in the peculiar column formatting found in typical legislation). The bill also includes draft appropriation amounts for setting up the body and its ongoing operation. Although the monetary figures are large, those of us in the healthcare trenches might argue that we can’t afford to not spend money on large-scale analysis and remediation of medical errors.

Not a day goes by that we don’t hear some kind of story about a medical error. If it involves a celebrity, it might even make national headlines, but there are hundreds of stories unfolding every day in the US. As an example, one of my physician colleagues has been reeling this week after being told that nine days after surgery, half of the samples that were taken during a sentinel lymph node biopsy procedure are missing. The pathology department has been supposedly tearing the department apart looking for the sample, but that doesn’t change the patient’s level of anguish, the potential for additional costly and invasive procedures, and the resulting diagnostic uncertainty.

Many patients don’t even know they have experienced a break in protocol unless they know what is supposed to be happening, such as when I was hospitalized and the nurse was scanning the medication barcodes after administration rather than before. Understanding the root causes behind such behaviors is critical to preventing them in the future, and the proposed Board might be uniquely positioned to accelerate the analysis needed to change behavior.

The bill has been referred to the House Committee on Energy and Commerce, and also to the House Committee on Veterans’ Affairs and the House Committee on Education and Labor. I was surprised to see a lack of co-sponsors listed – Representative Nanette Barragan of California appears to be out there on her own on this one. It will be interesting to see if other legislators will help carry this forward or who might introduce a companion bill in the US Senate. It’s been a long time since I’ve been deeply involved in policy work, so I don’t have a good handle on what might be going on behind the scenes with this effort or whether there are forces that are aligning against it. I’ would be interested to hear from readers who are closer to life within the Capital Beltway and who might have tidbits they would be willing to share.

What do you think about the creation of a National Patient Safety Board? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/8/22

More stories of absurdity from the patient trenches this week. A few weeks ago, I had the sudden onset of a cluster of itchy blisters on one side of the base of my neck. Being part of the generations that had chicken pox and knowing that if it was shingles it needed to be addressed quickly, I was lucky enough to have a next-day appointment with my dermatologist. She diagnosed it as insect bites and sent me on my merry way (of course after also examining every speck of skin to make sure all was well).

Today, I received a letter from my insurance company informing me that they would not pay for the visit because they need to know if it’s related to an accident or injury. I’ve seen these letters before, especially when there are traumatic injuries and the payer is trying to make sure it’s not due to a motor vehicle accident or a work injury, but I’ve never seen one for an insect bite. It just goes to show the lengths a payer will go to in order to avoid paying for a medically appropriate service.

Just when I thought that was strange enough, I ran into another patient-side issue. I received a notification that I had a new document in my patient portal record, which made sense due to my recent outpatient procedure. On one hand, I like seeing the documents from the patient perspective to make sure they match what I was told during the visit, especially if there was a chance that I was still in a post-anesthesia fog after the procedure. On the other hand, I always like to see how other physicians are documenting, and whether they’re using templates or dictation.

I went to look at the new document and it was indeed a procedure report. Unfortunately, the details of the report simply said, “there is no information for this result.” I think that takes the idea of “no news is good news” way too far. What’s the point of having a result on the chart if there’s no information?

From Jimmy the Greek: “Re: Slack. Did you see the write-up about Slack CEO Stewart Butterfield leaving Salesforce? One of the reasons cited in a Slack message to employees: ‘I fantasize about gardening.’ It’s more like ‘I’m a billionaire many times over, why would I continue to work?’” Why would one continue to work, indeed. I’m sure most of us could come up with a list of fulfilling things to do if we didn’t depend on a steady paycheck. I have a long list of volunteer work that I would become fully immersed in if I had that kind of money, but for now, I’ll have to stick with my current “one hour per week” volunteer responsibilities, which have never been as low as that.

From Holidazed: “Re: holiday gift. Check out what NYU docs received. It’s a collection of speeches and letters from the CEO to students and staff, as delivered over 15 years that he’s held the position. It strikes me as great hubris. It’s a hugely glossy, heavy book. I can’t imagine how much it cost to craft this vanity project and mail it out.” The reader included a copy of the card, signed by Dean and CEO of NYU Langone Health Robert I. Grossman, which states, “In 2007, when I assumed the role of Dean and CEO, my intention was to unify the NYU Langone community around a common goal of fulfilling our true potential for greatness. I began writing In Touch with that in mind, as a way to share the progressive glimpses of what I care about, believe in, and hope for. Fifteen years later, I’m enormously proud of what we’ve achieved together. NYU Langone would never have become the top academic health system in the country without each and every one of you. Now, as we look to the future and seek to hold our position at the top, it’s worth taking time to reflect on the past. I hope this collection of In Touch essays provides an opportunity to take stock of what we’ve been through – both the challenges we’ve overcome and the opportunities we’ve seized – and inspires you to keep striving.”

Holiday gifts have become a hot topic in the virtual physician lounge over the last couple of weeks, as many of my colleagues as for opinions on how to celebrate their staff members. There are also plenty of posts about ridiculous things that hospitals have given employees, including challenge coins, visits from therapy dogs, and endless pizza parties. I polled a couple of colleagues to see what happens in their tech-related firms to see if it’s any different than what we are seeing in health care. Some of the things happening out there include time off for teams to volunteer together, small parties or dinners, and virtual celebrations that include food delivery gift cards for those team members who work remotely. One firm has an “Ugly Sweater Soiree” and I can’t wait to see the pictures of that one.

I’ve been around the block as far as corporate gifting, and what I’ve seen has been all over the map. One employer sent out leather tote bags. but made assumptions on who should have versions for men versus ladies. Although I’ve gotten a lot of use from the one I received, I would have preferred the other option. Last year I received a fruit basket that had decayed by the time it made it to my door. One former boss made a significant charitable donation in honor of our team, which was very touching. Of course, gift certificates are always a hit since they allow for an element of personal choice. By far the gift that has been the most useful was from a health system employer, who gave each worker a set of high-quality jumper cables. The first person I assisted was my EHR vendor’s rep when his truck died in our office parking lot the following January. They have been used at campgrounds, school parking lots, and to teach basic automotive skills to neighborhood kids, so they will always remind me of my decade in that particular workplace.

What do you think about holiday gifting? What are the best and worst corporate gifts you’ve seen? As an employee, what is really on your wish list? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/5/22

This weekend was all about starting some end-of-year organization and making a plan for conferences and travel for 2023.

I’ll be attending many of the same conferences I did this year, but might throw in a couple of new ones if the dates work out. I had mentioned after the HLTH conference that I was disappointed in the lack of COVID precautions, so I was happy to see that HIMSS has an entire Health and Safety section that attendees must agree to. We all know that many people don’t read the details of “terms and conditions” type documentation, and even if they do, there’s no guarantee that they will follow the rules. However, it’s good to see a common sense approach to public health since it addresses not only COVID, but other communicable diseases.

Long story short: If you have symptoms of any communicable illness, including COVID, within five days preceding the conference, you need to stay home. You should also stay home if you’ve tested positive for anything, or if you’ve been in contact with anyone who is confirmed or suspected of having a communicable disease.

These are generally good rules for any gathering. I think that many people want to push back against any kind of health and safety measures because we’re all fatigued from talking about it the last few years. However, we seem to have forgotten the crud that everyone used to catch at HIMSS and bring home with its associated sore throat, runny nose, and fatigue.

HIMSS left the door open for other measures, including the possibility of “vaccination, proof of COVID status, self-monitoring, biometric screening, symptom checkers, contact tracing, use of personal protective equipment and social distancing, or other similar measures.” These will be determined at the time of the conference and will meet or exceed local public health requirements.

My in-person clinical colleagues are absolutely drowning in sick people right now, and the numbers they’re seeing in the emergency department and urgent care settings are commensurate with what they were seeing during the worst COVID surges. Flu is surging in my area and I’m not seeing any public health messaging encouraging people to stay home or to get tested, so I guess we’ve just collectively decided to let it rip.

This time of year, things are generally fairly slow in the realm of healthcare IT. Most of the large healthcare organizations I’ve worked with are out of money by now if they are on a calendar-based fiscal year and are waiting until January rolls around to sign contracts and start new projects. Given the economy, there are a lot of hiring freezes in place, and I don’t see that changing soon. Even in organizations that have fully funded and staffed healthcare IT projects that they were going to complete in December, I’m seeing things placed on hold because the clinical teams that the projects would involve or impact are being absolutely buried. If the flu season curves hold the same shapes they have had in pre-COVID years, it might be several months before these initiatives are pulled off the back burner.

I also spent part of the weekend trying to clean up an ever-ballooning inbox. It seems like when I unsubscribe from a newsletter, two new ones take its place. I was happy, though, to stumble across this article from JAMA Network Open which looked at “Accuracy in Patient Understanding of Common Medical Phrases.” Now that patients have full access to most of the notes and documents generated in the course of their care, it is more important than ever for clinicians to write in a clear manner that patients can understand. The authors surveyed 215 adults outside the medical setting and gauged their understanding of commonly used phrases (in case you are curious, the outside venue was the Minnesota State Fair.) Where 96% of patients knew that “negative” cancer screening means they didn’t have cancer, fewer patients (79%) knew that “your tumor is progressing” wasn’t good news. An even smaller number (67%) knew that having positive lymph nodes meant that cancer had spread.

The authors discussed the possibility of confusion around words such as “negative,” which means something good when it is associated with a screening test, but means the opposite in other contexts, such as “negative reviews” or “negative feedback.” They also spent some time discussing medical jargon and noted a concept which was new to me: that of “jargon oblivion,” which refers to the mismatch between our intent to avoid jargon and the reality of our frequent use of it.

While medical jargon is one thing, acronyms are another entirely. I’ve seen plenty of patient-facing notes that have acronyms that don’t immediately register with me as a clinician, so I can only imagine the confusion that patients have as they are trying to understand it. If I search something and it’s four or five entries down on the Google results, then I would feel safe in suggesting that clinicians probably shouldn’t be using it. “NPO,” which is a Latin-based phrase for “nothing by mouth,” was one of the items tested. Other medical words such as “febrile” were included. The researchers noted that the use of the phrase “occult infection” was interpreted by those surveyed as having something to do with a curse than being associated with a hidden infection.

The authors noted a concern for bias since they selected state fair attendees who were attending a university-sponsored research exhibit. A more generalized sample of the community might produce differing results. Participants who agreed to take part in the survey received a backpack with the University logo. As a visitor to several different state fairs, I think I woud be more motivated to participate if there was the potential for a funnel cake or perhaps a fried Twinkie at the end.

The authors suggest that further studies would be helpful to boost understanding of how patients understand medical jargon, as well as to test recommended alternatives to improve communication with patients. The study involved both audio and written test questions and there was no difference in the results, allowing researchers to conclude that the less time-intensive written approach would be valid for future studies. If anyone is looking for a research assistant who knows how to deep fry things, I might know someone who is available.

What’s your favorite state fair food? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/1/22

There has been a lot of discussion in the patient engagement world, as well as around the virtual physician lounge, about the announcements of some health systems that they are going to start to charge for patient portal messages that involve medical advice.

Most physicians I’ve spoken with agree that the surge in patient portal messages during the last three years is contributing to burnout, not only among physicians, but with staff. EHR vendors have been hard at work helping their clients understand the types of messages they are receiving so that clients can work on optimization efforts. At least one vendor has even gone as far as working to filter out messages that contain little more than “thank you” in an effort to reduce the sheer volume of messages in clinician inboxes.

The elimination of the thank you-type messages is fairly controversial. Some clinicians like them and see them as a small bright spot in the drudgery of the inbox, but others see them simply as an annoyance.

Despite the information that is available to organizations about the types of messages they are receiving, quite a few organizations I’ve worked with aren’t even taking the basic steps needed to help tame the inbox beast. Let’s take medication refills, for example. In some systems, this is a good chunk of patient portal requests. I don’t see people looking deeply at why patients are asking for refills via the patient portal. For years, even going back to the world of paper, practice management experts have advocated for providers who treat chronic conditions to issue up to a year of refills during the chronic condition visit. People still don’t do this, and when I shadow in physician offices, I hear statements like “just call us when you need a refill,” which is absurd in this day and age.

As organizations moved to EHRs, there was a migration to have refills requested through the pharmacy, where the transaction could come electronically and be vetted against the patient’s existing medication list for a quick refill. That workflow led to tools that were deployed on top of the EHR (one of the best ones I have ever seen was homegrown at a New York provider group in the late 2000s) that would evaluate certain metrics such as recent lab results and past visits and give the nursing staff a red-yellow-green indicator on whether they could issue refills through a standing order or a delegated refill policy. Other solutions followed, but organizations still didn’t fully embrace them.

Now the pendulum has swung back to where we were in the 1990s, which is the patient asking for a refill in narrative form via a patient portal message. This is the equivalent of calling the office and speaking with someone or leaving a message on a voice mail “refill line.” Patients aren’t even being asked to select a medication from their current medication list, but instead are typing it out. They may not have the name or dose correct, which increases the work for the practice as well as the risk of medical errors. Often there are better tools within the patient portal, but they simply haven’t been deployed yet because leadership feels they are not a priority.

Fast forward to every day in a primary care physician office, where everyone is at their breaking points. Physicians are spending hours each day, often at home, handling refills and messages. Two decades ago, we thought this was infrequent and somewhat subjective, but now our sophisticated EHRs can deliver reports about provider work after hours and it’s clear that a good portion of the workday is occurring in places other than the clinician office.

Often that after-hours work involves what we traditionally define as patient care, which includes explaining or re-explaining things to patients, looking through charts for information to send to a patient, coordinating referrals and follow-ups, and more. This is uncompensated work and it makes sense that clinicians are pushing back against it, leading organizations to consider hiring staff to assist in managing the inbox. Thse resources cost money, hence the move to charge for what has largely been uncompensated care. I say largely uncompensated because in value-based care models, compensation for these non-visit efforts is included in the payment equation in other ways.

In looking at some of the health systems’ documentation on how they plan to charge for patient portal messages, most of the approaches are well reasoned. Organizations are clearly saying that they will charge if a response requires the medical expertise of a licensed provider and requires more than a few minutes of time. Looking at one institution’s website, I found some details. Messages are primarily being billed to health insurance, with varying charges being passed on to the patient. For most Medicare patients, those messages will have no patient cost or a small charge ($5 or so), but for Medicare Advantage plans, it might be up to a $20 co-pay. Medicaid resulted in no charge to the patient, and private insurance ranged from a standard office visit co-pay up to a full $75 charge if the patient has not yet met their deductible.

That particular system is using the CPT codes for online digital evaluation and management, which are time-based. The codes can be billed cumulatively every seven days, so if a message generates a lot of back-and-forth responses, the work can generate a higher level of service. The websites are typically clear on what kinds of conversations will generate the code, including a new issue or symptoms requiring clinical assessment or referrals, medication adjustments, flares of chronic conditions, and requests to complete forms. The latter is a huge time suck for primary care offices and many practices have been charging for completion of forms for years, so I’m not surprised at all by that one. Refill requests or conversations that lead to a scheduled visit aren’t charged, nor are follow-ups related to a surgery with a global billing period.

This type of process is going to be an adjustment for patients because they are used to not having to pay the full value of the services they’re receiving. The presence of insurance in our society has led to a general lack of awareness of the value of provider and staff time, as well as the cost of truly delivering care. Consumers are already used to seeing surcharges on restaurant bills and other invoices for work that was previously free, so at this point, it shouldn’t be as much of a surprise as it feels like. Everyone’s just trying to stay afloat, and it will be interesting to see how the use of these charges plays out over time.

Is your organization charging for certain services delivered via the patient portal, and how is it going? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/28/22

I mentioned last week that I was getting ready for an outpatient procedure, and I’m happy to report it went without a hitch. I was impressed by the professionalism of the surgery center staff as well as their efficiency.

One of the nice touches was a card that was apparently with my patient folder. Each staff member signed the card and indicated the role that they played in the procedure. The card was included in my discharge packet.

I was looking forward to recognizing some of them individually via the patient experience survey that was almost certain to follow. Unfortunately, the link that was texted to me later in the day didn’t work, and the review site’s help functions were of little help, which was disappointing. Knowing that physicians are often graded on patient reviews, I felt bad about not being able to contribute in a positive way.

Mr. H mentioned this JAMA opinion piece last week, which questions whether the focus on patient satisfaction measurements might be harming both patients and physicians. The authors note that “patient satisfaction is an integral element of care, and scholars have argued that positive patient experience represents an important quality dimension not captured in other metrics.” However, they note that many survey instruments were created nearly two decades ago, and “Measures can lose value as they age, and just like the Google search algorithm, patient satisfaction measurement strategies need to be updated to remain useful.”

Unfortunately, many organizations don’t seem too interested in updating their surveys. I’ve experienced this with clients who can’t seem to make updating their surveys a budgetary priority. I’ve also experienced it as a patient, when I was asked how the office performed on aspects that weren’t relevant to the visit. For example, asking about COVID precautions following a telehealth visit, or asking about procedural elements that weren’t part of a given office visit.

My biggest pet peeve about patient experience surveys is when they don’t offer an answer choice for “not applicable,” “did not experience,” or something similar. All clinical encounters don’t contain the same elements, and if you don’t allow me to opt out of a question or respond that it wasn’t applicable, then the data you’re going to get is skewed. When confronted with something they didn’t experience, patients might rate it low, high, or neutral depending on how they interpret the prompt.

Another pet peeve about such surveys is how certain organizations use the data. At one of my previous clinical employers, anything that was less than an overall four-star review generated a “service recovery” call from administration. Since our surveys were constructed in a way that a score of three meant expectations were met, this created a lot of focus on visits that were generally acceptable in the patient’s point of view but didn’t meet the criteria of being exceptional.

In the event that a patient responded with a low score, such as a 2, the immediate assumption by administration was that the physician had done something wrong, even if the low score was a result of the provider giving good care. For example, not providing an unnecessary antibiotic or being unwilling to provide controlled substances without a clear medical need. Administrators always called the patient first, which often led to an accusatory call to the physician, who was on the hot seat to explain the situation.

Having practiced in urgent care and the emergency department for 15 years, I have a pretty good sense of when a patient is dissatisfied with a visit. I make sure to put a lot of detail into the chart note about the visit, what was discussed, the patient’s response to the care plan, and more. It’s easy to read between the lines and see that I already sensed there was going to be a problem and took proactive steps to address it. Still, it felt like our leadership never even looked at the chart and we were always put in a situation where we were on the defensive, which isn’t ideal.

Patient satisfaction surveys aren’t inherently bad. Studies have shown that high satisfaction is associated with lower readmission rates and lower mortality. It should be noted that an association doesn’t mean something is causal, a fact which is often missed by healthcare administrators. The authors also mention a well-known study “The Cost of Satisfaction,” which demonstrated that patients who gave the highest ratings often had higher costs and mortality rates.

One of the specific data elements mentioned in the opinion piece was advanced imaging for acute low back pain. Although such services drive higher costs of care and have little clinical benefit  — to the point of being featured on several prominent lists as things that physicians shouldn’t order — they also yield higher mean patient satisfaction scores.

The authors also mention that many of the survey tools in use were designed to measure aggregate performance and weren’t intended to evaluate individual physicians or care teams. They go on to explain that some instruments in standard use result in skewed data, where a physician can score highly but because of the distribution of responses be considered to be in the bottom 50% of performers. When everyone is high performing but some will be penalized regardless, it creates a continuum of responses with complete withdrawal on one end and something akin to “The Hunger Games” on the other.

The piece also notes that small patient populations or small response rates can create a disproportionate impact on a physician. In my past life, when I transitioned from full-time to part-time practice, this became readily apparent as I spent more time working in clinical informatics and less in the primary care office. Patients were also disappointed that I wasn’t as accessible as before and this showed in satisfaction scores, regardless of the quality of care that patients received. It certainly was a contributing factor in my decision to leave primary care and transition to the emergency department, since I didn’t want to spend half of every visit discussing why I was only there one day a week and the fact that patients refused to see my partners.

While the authors note that patient satisfaction scores are an important component of quality, their use in a “high-stakes” environment “renders them at best meaningless and at worst responsible for physician burnout, bad medical care, and the defrauding of health insurers by driving up use.” They call on payers to reconsider their use in determining quality and payment factors. The authors ask the Medicare Payment Advisory Commission to annually evaluate measures currently in use to make sure they are still fit for purpose.

Although I agree, I know that it’s always easier to keep the status quo, so I’m not hopeful for significant changes. There have also been a number of studies looking at elements of bias in patient satisfaction surveys, and how physicians of certain demographics perform less well than others regardless of outcomes. Until those issues are addressed, patient satisfaction scores will continue to be controversial.

What do you think about the incorporation of patient satisfaction scores in the determination of quality bonuses and payments? Is there room for meaningful transformation? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/21/22

I’m back in the patient trenches again, getting ready for an outpatient medical procedure and loathing the process. I’m an active patient of the physician who will be performing the procedure, with an up-to-date chart at the practice. The ambulatory surgery center where the procedure will be performed is owned by the physicians (although it’s a separate legal entity than the practice) and I’m also considered an active patient there due to a previous procedure.

Even though it would have been perfectly easy for the performing physician to send an appropriate History and Physical document to the surgery center (and for all I know they might have done so), I received an enormous “snail mail” packet to complete that basically treats me like a brand-new patient. Once could claim that it was an artifact of trying to keep the surgery center separate from the practice entity, but all the paperwork has both entities’ logos on it, so that claim doesn’t hold water.

The surgery center called me on Wednesday to pre-register me for the procedure, which is pretty typical. Unfortunately for me, I was still in Las Vegas, so the call came in at 6 a.m. local time and my grogginess was probably entertaining for the registrar. The staffer basically asked me all the information that is already on my chart, although it was from the perspective of confirming existing information rather than being from scratch. I asked about the paper packet, and she indicated that it was mailed from the practice side of the organization rather than the surgery center, and that I should plan to complete it.

I enjoyed answering the COVID screening questions, since I was at a conference with probably 8,500 unmasked people compared to the few of us who might have been masking when we could, and certainly I was exposed to someone with COVID. Another great question was whether I have a Healthcare Power of Attorney, but they didn’t seem interested in knowing who my personal representative is or having me bring a copy. The call took less then five minutes, though, and I was able to get another half hour of sleep before I needed to get ready to head to the airport.

As I went through the paper packet today, I noticed the addition of a new form that might actually be useful to patients, especially those who might not have a lot of experience in our fragmented and messy healthcare system. The page listed out all the different entities that will be involved in my care – including the physicians, the surgery center, the anesthesia group, and the pathology group. Each column had the name of the entity, a description of how they fit into the procedure, the services they provide, and the fact that I will receive a separate bill from each group.

Although it fully illustrates the absurdity of healthcare in the US, I appreciate the fact that they’re trying to educate patients prior to their having a procedure so that there are fewer surprises down the road. I found it interesting that only the surgery center requires payment of my portion of the estimated co-insurance in advance. If I recall correctly, the anesthesia group waited until just shy of the timely filing deadline to submit their claim, so any hopes of wrapping up the procedure and payments will likely be delayed until well into 2023.

I’ve been keeping it low key since I got back from HLTH, partly to avoid having a COVID-related reschedule for the procedure. I’ve heard from two colleagues who brought COVID home from the HLTH conference as an unwanted souvenir, although based on the notifications from the contact tracing app, I suspect there were more cases than we will ever know.

It’s been a good opportunity to catch up on email and some of my virtual water cooler venues. The hottest topic seems to be Amazon’s foray into message-based virtual visits. Most of the physicians I’ve connected with aren’t impressed by the offering, since it’s more of a marketplace than a cohesive service. They’re concerned about the further fragmentation of patient care since these records won’t be making it back to primary care physicians, and the fact that patients may end up receiving care from multiple providers or practices as part of the marketplace arrangement without fully understanding the concept.

There were also some concerns about the business model and how it makes sense for the physicians who are part of the offering. The fees are low, which is good for patient access, but are set at a level which drives physicians toward high-volume processes in order to make it tenable as a major source of income. The virtual visits also include the ability to “message your clinician with follow-up questions at no additional cost for up to 14 days” which further lowers the desire to participate for many physicians, who want to practice telehealth urgent care in a “one and done” type model. Several colleagues guessed that the provider organizations are likely using considerably greater numbers of nurse practitioners rather than physicians.

The main patient-centric concern that was voiced was that of clinical quality, but given the fact that this is Amazon we’re talking about here, I also have concerns about patient privacy. The Amazon Clinic site has a lot of information on how they use Protected Health Information. Things I didn’t like included the fact that patients are asked to accept an authorization for disclosure of contact information, demographic information, account, and payment information, and “my complete patient file” to Amazon.com Services LLC and its affiliates. It notes that “information disclosed pursuant to this Authorization may be re-disclosed by the recipient, and this redisclosure will no longer be protected by HIPAA.” Although I’m not an attorney, it sounds like a bad idea to me. The FAQ page says this authorization is voluntary, but if patients want telehealth services but to not sign the authorization, they will need to reach out to the healthcare providers directly. I’m betting (as I’m sure Amazon is betting also) that patients will just click through the fine print. Patients are exhausted and often just want to get care in the quickest and cheapest way possible, and no one likes to read a wall of text.

What are your thoughts about Amazon Clinic? Will it revolutionize healthcare or just further fragment the patient experience? Leave a comment or email me.

Email Dr. Jayne.