Curbside Consult with Dr. Jayne 10/4/21

It’s been a rough weekend at Casa Jayne, with some bothersome side effects from my end-of-week Pfizer booster.

Don’t get me wrong — even with side effects I still like the vaccine odds better than the odds for naturally occurring COVID-19, and I’d do it again in a heartbeat. This time around it was a family affair, as my parents were able to get appointments within a few minutes of mine, so we got to spend some quality time in the observation room together. I was grateful that they were able to get their boosters on a beautiful sunny fall day rather than having to drive through snow and ice and stay in a hotel across the state, as they did for previous vaccines. It was good to catch up in person rather than by phone or text. My dad mentioned that the local farm and home store has a sign that warns people not to use ivermectin on humans. I’ll stick with my FDA-approved drugs (whether they’re under an Emergency User Authorization or not) any day. Except for one person who had a recent “breakthrough” case, we’ve all avoided infection. Now just crossing my fingers for a speedy approval for the Moderna booster for my grandparents, followed by quick scheduling at their retirement community.

Because most of my symptoms involved my dominant arm, I didn’t get much done over the weekend that didn’t involve reclining on the sofa with a pillow under my arm. Big thanks to the hospital auxiliary who made “cough” pillows post-op patients the last time I ended up in an operating room – it was the perfect size for a post-vaccine prop. I did however get a lot of reading done. I finished one novel, downloaded three more freebies, and started going through mountains of email.

One email reminded me to read the HealthIT Buzz blog from ONC, which had some good information on how ONC plans to better communicate with stakeholders. Moving forward, ONC plans to have additional options for communication and education, including more frequent FAQ postings; plainer language on blog posts aimed at non-legal, non-technical audiences; regular leadership blogs reviewing progress on implementation of the regulation; active outreach for public events and stakeholder meetings; and my favorite – “focused posting of Myths vs. Facts on social media to dispel inaccurate information and direct stakeholders to authoritative resources in a timely manner.” Maybe we need a cross between MythBusters and TikTok for ONC to reach both seasoned healthcare informatics folks as well as the newest generation in the workforce.

Another email took me deep into the rabbit hole that is the Theranos trial. There are so many summaries and recaps out there, I certainly had my choice of news sources. I do think that the delay in holding the trial, partially due to the pandemic and partially due to legal maneuvers, might be helping Elizabeth Holmes as she tries to defend herself. There have been many specific questions about individual recollections of conversations and events which occurred years ago, and when those recollections don’t match emails which are later entered into evidence, it certainly reflects on the credibility of the witness testimony.

The overall picture is one of desperation at Theranos, where they so wanted their solution to succeed that they were willing to go to great lengths to make it look like it was performing better than it was. In reading about some of the patient impact, my heart breaks for the women who had erroneous tests of the pregnancy hormone human chorionic gonadotropin. In one case, the patient’s values were off by a factor of 10, leading her to believe she was experiencing a miscarriage. Although she later received a corrected value, it’s hard to undo the level of anguish that someone experiences when receiving the news that she did. Some medical practices figured out quickly that there was trouble at Theranos, but others continued to use the lab, magnifying their exposure for inaccurate results.

The Theranos trial is also a good reminder that work email is not a safe place, and phone records might not be either. There were plenty of emails between Holmes and her boyfriend, former Theranos Chief Operating Officer Ramesh “Sunny” Balwani, that some might find fairly cringeworthy when viewed in the light of day and with consideration of the current situation. Holmes apparently found him to be her breeze, in the desert, her water, and her ocean. They also texted about being able to “love” and “transcend” even in the middle of a major whistleblower investigation. None of the documents I came across included any sexting, so at least we can be grateful for that. But it’s a reminder of how people might want to be careful and avail themselves of other modes of communication than non-secure texting.

The last email that caught my attention was from local government, letting me know that county council meetings would no longer be available on YouTube due to its recent push to remove videos that spread certain types of medical misinformation. The “public comment” portions of the meetings have been so chock-full of conspiracy theories, bad science, and false claims that they ran afoul of the terms of service. YouTube will still allow what it calls “personal testimonies,” but will not permit content that promotes vaccine hesitancy or promotes misinformation. Commentary that vaccines cause cancer, infertility, or contain microchips will also be banned.

Although my vaccine yet again failed to improve my wireless connectivity or make me magnetic, I’m glad I was able to get one quickly and close to home. It was good to have some downtime, albeit forced, because I had loads of end-of-quarter work earlier in the week and probably needed a mental break more than I would admit. I caught up on some TV watching as well – “Blue Bloods,” “Endeavour,” and “Inspector Lewis” to name a few. I’m on a bit of a crime drama kick, I suppose. Of the three, “Endeavour” is my favorite, although it’s so full of details you have to be careful if you’re nodding off while watching, because it will lead to a lot of rewinding.

What’s your favorite TV show for sofa-based recovery time? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/30/21

Due to critical shortages of healthcare personnel and ICU beds, several states have declared “crisis standards of care,” including Alaska. As if they don’t need one more thing to worry about, a new virus has been detected in the state. Dubbed “Alaskapox” by the media, the virus was found in two additional patients who sought treatment at a Fairbanks urgent care clinic. The symptoms include skin sores, fever, joint pains, and swollen lymph nodes. Both patients recovered within a few weeks, but it’s worrisome as these cases are similar to an initial case in 2015 and another one five years later. The virus has been identified as one from the same family as smallpox and cowpox. Epidemiologic investigation linked the virus to outdoor cats who may have picked it up from cows or other mammals, including voles. Just goes to show that public health was important before COVID-19 and will continue to be important in the future. Let’s hope governmental entities show up with their pocketbooks to fund the kinds of investigations needed to tackle emerging illnesses.

A new report from AHIMA, AMIA, and EHRA asks for consensus on the definitions of “electronic health information” and “designated record set” to better help organizations operationalize the requirements found in the 21st Century Cures Act. The organizations had formed a task force last year in preparation for key compliance deadlines. The task force will be asking stakeholders for feedback on the report and will continue to refine their work as the 2022 deadlines for compliance to the information blocking portions of the Act approach. The health information export portion of the Act kicks in at the end of 2023.

I’m glad to see that EHRA is participating since its members are the ones that actually need to incorporate the definitions in the systems we use each day to care for patients. Especially given the need for interoperability and portability for patient data, it’s critical that vendors use a common set of definitions. Having worked with dozens of healthcare organizations over the years, there are so many other definitions that are nebulous, including the definition of the legal medical record. I’ve got some clients that think that the final “visit notes” that you can print from the EHR are the legal medical record, completely disregarding the idea that there is a lot of other information in the system that becomes part of the legal medical record. I can’t count how many hours I’ve spent trying to educate clients on this, but until recognition of the concept is required, there will continue to be confusion.

Looking back to 2019, physicians were already exhausted trying to do everything they needed to do to care for patients – managing in-office visits and managing non-visit encounters including telephone messages, patient portal messages, refill requests, pharmacy communications, insurance communications, and more. Throw 18 months of a pandemic on top of that and we’re seeing some serious burnout. A number of my close colleagues have left the clinical trenches, choosing to either retire early or leave medicine altogether. Someone sent me a recent article from the Journal of the American Medical Informatics Association that looked specifically at objective EHR measures (including time, volume of work, and proficiency) and whether they are associated with exhaustion and cynicism. The study was done in 2018 within the primary care clinics of a large academic medical center. It found that over a third of clinicians had high cynicism and more than half had high emotional exhaustion. Those that had the highest amount of after-hours EHR documentation time and those that had the highest volume of messages had greater odds of high exhaustion. No specific measures were associated to high cynicism.

I would think that cynicism is more likely to be associated with factors that can be difficult to quantify, including having to jump through regulatory hoops, having to deal with administrators that don’t have solid experience but are trying to push the latest and greatest thing they heard in their master’s program despite never having worked in healthcare, and having to deal with the moral injury that stems from not being able to deliver the care we were trained to provide.

As far as exhaustion being related to having high volumes of patient messages, I’ve seen it first hand. A while ago, I worked with a large national organization that was looking to optimize its EHR. Whenever I start one of those engagements, I begin with a current state assessment where I observe a variety of users – extremely proficient ones, middle of the road ones, and those that are struggling. I also observe providers at various visit volumes and across various subspecialties.

The first thing I found was that the organization had different policies depending on whether you were part of the “northern” medical group or the “southern” one. One set of clinics allowed their staff members to do preliminary triage of all messages and handle all the back and forth, while the other required the licensed clinicians to handle every single message in the inbox queue. It’s not difficult to figure out which clinicians were less satisfied and felt more overworked. The organization had never looked at whether it made sense to have different policies for the different regions, it had just evolved over time due to lack of overarching governance. I tried to engage them in a discussion of how modifying the policies could be helpful far beyond any optimization we might do with the EHR, but they weren’t interested.

They also weren’t interested in strategies that have been proven to enhance their patients’ ability to adhere with medication regimens – simple things such as providing refills through the next scheduled visit or providing medications for a year in stable patients. They absolutely refused to consider the idea of a delegated refill policy, where nurses or other clinical staff could check various parameters defined by policy then refill accordingly. They were perfectly happy to push the work up to the physicians rather than to embrace change.

After numerous discussions, it was clear that they just wanted to demonize the EHR. I left them with a lengthy report that included some changes they could make in their system that would help micro-level workflow on the screens, but the vast majority of changes that needed to happen were operations and cultural. They weren’t thrilled with my recommendations, but frankly their technology was in pretty good shape, although their people and processes were not.

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Curbside Consult with Dr. Jayne 9/27/21

Last week’s biggest medical news was the approval of COVID-19 booster shots for certain groups who had previously received the Pfizer immunization. When the announcement was made, one of the first things I thought about was how my clients would handle the need for outreach to populations who are now eligible. Certainly there would need to be some reporting to identify eligible patients, followed by communication, self-scheduling, and all the workflows we mastered earlier in the year. I wondered how long it would be before one of them reached out to me for assistance.

In the meantime, since I plan to be doing some in-person clinical work next month, I decided to schedule a booster dose for myself. Word on the street is that local pharmacies are throwing away doses due to lack of eligible patients, and if they’re going to waste a dose, it might as well go directly into the arm of a frontline physician.

I hopped online to see what my options were. The first place I looked was Costco, since I had a great experience there with my flu shot. Their website walks you through your vaccination history, but doesn’t ask anything about whether you are immunocompromised (which would have made you eligible for a third dose for several weeks) or your age. Instead, it gave me a happy green banner at the bottom of the screen that said, “Congratulations! You have received the recommended number of COVID-19 vaccine doses. You are officially vaccinated and do not need to schedule another appointment.”

The next place I checked was CVS. After a question about current symptoms and exposure status, I was asked whether I need to start the series, schedule a second dose, or whether I need to schedule a booster dose under the new criteria. Kudos to their IT team for updating the system quickly – things were looking promising. They also asked if I wanted to add a flu shot to the appointment (if available), so kudos for co-administration as a way of promoting public health. After keying in my date of last vaccine and that I had received the Pfizer product, it took me to a scheduling screen, where I quickly learned that there were no timely or convenient appointments at any of the three locations closest to my house. There were also no appointments available after 6 p.m. at the 10 closest locations. If we really want people to be vaccinated, we ought to make it convenient.

I also tried Walgreens, just for fairness if I was going to go the retail pharmacy route. Walgreens also had an updated system where I could quickly document my eligibility for a third dose or a booster dose depending on which criteria applied. Walgreens had an excellent assortment of evening appointments, but interestingly, none during the day – 5:45 p.m. was the earliest available slot. The site also offered the opportunity to add multiple other vaccines to the appointment including those for flu, shingles, pneumococcus, and Tdap. It was looking like the best option so far.

Glancing up at the vaccine card that’s stuck on the bulletin board behind my desk, I was reminded to think about the hospital where I received my initial COVID vaccines. There weren’t any opportunities to schedule vaccines of any kind within MyChart, only office visits, video visits, or telephone checkups. Visiting the health system’s website, it did appear that they were offering third dose appointments, but through a completely separate scheduling system depending on your state. After a few quick questions, it was on to the scheduling menu which had dozens of open slots but only on Mondays, Wednesdays, and Fridays, which might make it difficult for some patients depending on their work schedules. At the moment, my schedule is pretty flexible, so I scheduled for later this week. At the point where I needed to confirm the appointment that I selected, it offered me the opportunity to log into MyChart so that the appointment would be put on my record.

In hindsight, that seems like the best option regardless of convenience, because then all three doses will be from the same entity and I can download them all on a single record. Interestingly, the hospital in question hasn’t been very proactive about scheduling booster dose clinics for its employees and staff physicians, so it feels a little strange to be in the first wave of boosters when I’m not as exposed as others at the moment, especially considering how it was last December when the same health system was vaccinating its attorneys and marketing people but wouldn’t share doses with frontline urgent care physicians actively seeing dozens of COVID-positive patients each day. It just goes to illustrate how topsy-turvy and often without direction our healthcare system has become since this all started.

At a hospital where I have a pending application to be on the medical staff, they haven’t even started scheduling influenza vaccine clinics for employees despite typically starting them in September. Even though it’s not contraindicated to receive both vaccines on the same day, many people prefer not to receive two if they don’t absolutely have to. I’m hopeful that we have enough people masking and still modifying their activities that we have a flu season that is as mild as last year’s, but I’m not going to hold my breath.

I’ve got my talking points ready for any clients who reach out asking for assistance with scheduling of booster doses and have started putting some thoughts together on best practices for vaccine clinics in the event that the Pfizer vaccine is approved for children under age 12 next month. Parents in our community are clamoring for it as a way to avoid quarantines for their children as well as it being a way to try to restore some level of normalcy to childhood. I’m hoping that schools offer in-building vaccine clinics to make it easy for parents and caregivers, but given the politics around vaccines in some communities, that might be easier said than done.

How is your institution handling COVID-19 booster shots? Are you running recall campaigns, making a plan, or just trying to figure out how you’re going to address it? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/23/21

Hospitals in my city are in lockstep as far as requiring COVID-19 vaccinations for employees, with compliance upwards of 98% for most facilities. Employees who aren’t compliant and don’t qualify for a religious exemption are finding that there isn’t anywhere to work unless they want to relocate or leave healthcare, so difficult choices are being made. In that context, I was interested to read about the approach being taken by Conway Regional Health System in Arkansas.

The system asks that those employees claiming a religious exemption attest that they understand that the same fetal cell lines they object to being used during development of the vaccine were also used in the development of commonly accepted medications such as Benadryl, Sudafed, and Tylenol. They go further in asking employees to confirm that their “sincerely held religious belief” prevents them from taking those medications as well. Many of my physician colleagues and I have had ongoing conversations about the fact that so many of the world’s major (and often fractious) religious groups have found common ground on recognizing COVID-19 vaccines as permissible and often encouraged. If only they could find common ground on other topics as well. Kudos to the system’s leadership for making sure its employees understand the science behind their exemption requests and what it might mean for non-vaccine products.

I left my most recent in-person clinical employer for a variety of reasons, including such factors as inadequate personal protective equipment, hellacious hours, short staffing, and cultural issues. Regarding the latter, we had reached a point where the mentality of “the customer is always right” had come to interfere with patient care by creating an environment where physician judgment was being questioned, and where leadership was turning a blind eye to clinicians who were prescribing non-evidence-based therapies like hydroxychloroquine and ivermectin for COVID prevention. A recent MSN article brought back some negative memories. The headline “Entitled consumers have terrorized service and retail workers throughout the pandemic” also applies to healthcare.

In checking with my former colleagues, patients are still throwing fits that they can’t be accommodated quickly for pre-travel testing due to the extremely high demand for testing. Patients register at 6 a.m. and often aren’t able to be seen until 2 or 3 p.m., so they take their anger out on the staff when they arrive. Never mind the fact that my county has free drive-through testing at the county health department, where test turn-around time is about 4 hours – patients don’t want to drive to what they perceive as “the wrong side of the tracks” for testing for a variety of preconceived notions. When you do the math, it would be more efficient even with the crosstown drive, and it’s certainly cheaper since my former employer is requiring a full physician visit (and urgent care co-pay) even for testing. However, the perception of convenience or quality or service is everything, apparently.

The practice is still fighting the most basic of battles, including patients who refuse to wear their masks properly despite being in a healthcare facility where known COVID-19 positive patients are present, and clinicians aren’t permitted to refuse to see patients who refuse to mask up. Patients who haven’t planned adequate turnaround time for their pre-travel PCR testing are permitted to complain to leadership, who will allow them to take their specimen swabs and personally drive them to the lab vendor for expedited service. This adds extra steps for the already overburdened staff. The organization still has approximately 20% of its locations closed due to lack of staffing and has even started its own emergency medical technician training program in an effort to bolster reserves. However, they seem unwilling to look at evolving the practice culture as a way of improving staff retention and satisfaction.

Unfortunately, many healthcare organizations will continue to confront these types of scenarios (and others which may be even more challenging) as the pandemic continues to rage. Healthcare has changed so much in the last 18 months; I can’t even imagine what it might look like if we ever make it out the other side of this. The reality is that we are one vaccine-resistant variant away from going back to square zero, and it feels like clinical teams are constantly waiting for the other shoe to drop.

The IT arm of Ascension plans to outsource an additional 330 technology jobs in the next few months, according to a Missouri state filing. The organization had already planned to lay off over 600 workers during the bottom half of the year. It’s hard to understand the true economic impact of these cuts because Ascension had transitioned earlier this year to allowing all employees to work remotely, which makes it more challenging to understand where the impacted positions are based. Functions being outsourced include application support, end user engineering, network services, and telecom. I always enjoy looking at primary source materials and, in this case, nearly 30% of the text of the document was redacted, so I will have to use my imagination to conjure up what I might have missed.

Today ONC awarded more than $73 million in Public Health Informatics & Technology Workforce Development Program funding to 10 college and university consortia. The funding comes from the American Rescue Plan and is targeted to providing training in public health informatics and technology for over 4,000 individuals. Organizations receiving funds include Historically Black Colleges and Universities, Hispanic Serving Institutions, Asian American and Native American Pacific Islander-Serving Institutions, and other higher education organizations. I’m pleased to see the diversity of recipients as we move forward addressing social determinants of health, as there are many underrepresented demographics in the public health workforce.

The funds will help provide support for curriculum development, recruiting, training, paid internships, and career placement assistance for those seeking positions in public health organizations. Having come up through the informatics ranks in a large hospital system, I didn’t have a lot of exposure to public health informatics. As I studied for my clinical informatics board certification, I found it to be one of the more interesting domains of the subspecialty. I’m excited to see it receiving more focus and hope that the funding helps attract some of the best and brightest to the discipline.

News of the weird: The State Medical Board of Ohio has given a two-year renewal to a physician who claims that vaccines cause people to become magnetic. The board has the opportunity to discipline a physician for false statements by a vote of at least half its members, yet it has failed to act in this case. The article goes on to mention that another notorious physician, this one of ivermectin fame, has his license coming due October 1. He has openly admitted to clinical wrongdoing, and it will be a travesty if the board continues to allow him to practice.

One of the reasons that state licensing boards are fighting against national licensure is their claimed need to police their own physicians. I’d recommend that if they’re going to continue to make that claim, that perhaps they start stepping up surveillance of those spreading dangerous misinformation.

Do you think state medical boards are living up to their responsibilities for physician discipline? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/20/21

I was recently invited to join a physician forum centered on EHR optimization. It sounded like a great opportunity to share what I know about getting the most out of your EHR and to help colleagues who might not have access to clinical informaticists.

I decided to familiarize myself with the group by going through old posts and was surprised at how many physicians had posted questions that didn’t receive any responses. I felt bad for those docs, sending their questions into the wind without anyone answering. I wish I would have been there for many of them because it would have been easy to point people in the right direction at the time. Here are some of the main themes that we as tech enablers should be aware of:

First, despite what we might think at times, physicians often want to learn more about what they can do with their EHRs and want to be better users. However, they might not understand the resources that are available to them, even if they are free or included in the cost of their system. There were a number of highly specific questions about a particular EHR, such as “How do I document XYZ procedure in my EHR?” Those were the types of questions that most frequently went unanswered by the forum. In my experience as an EHR champion, they would have been easy questions to answer had the physician contacted the EHR vendor’s help desk or online help mechanisms.

I’ve done consulting work for several of the vendors mentioned and they all have robust help desks and client support structures, and one has a lot of searchable hands-on videos that would have answered the questions. I can only guess that the physician didn’t know how to contact the vendor. Perhaps they are an employed physician and their organization’s internal help desk didn’t give them the assistance they needed, or maybe they’re part of a group where a managing partner or office manager tightly controls the information. I felt bad for them though, wondering if they ever found answers to their documentation questions.

Second, many of the physicians showed a high level of interest in ideas that went way beyond EHR optimization. One hot topic on the forum was that of bias in artificial intelligence. The discussion also covered ways that physicians could advocate to their institutions to try to minimize bias in their systems. Of course, this topic is likely much more relevant to those at academic medical centers rather than small primary care practices, but it certainly got a lot of conversation. Physicians care deeply about whether technical systems could be harming their patients and want to know more about predictive rules or algorithms that they might be presented with.

Third, the physicians were vocal about how vendors, including EHR and third-party vendors, might be using their patients’ data for profit. There was a near-universal lack of enthusiasm for cloud-based patient data being sold, whether it was for research or not. One particularly spirited discussion revolved around an EHR vendor who was alleged to have sold patient data to a nutrition and supplement vendor. Whether it’s explicitly allowed in a vendor contract or not, the physicians had negative feelings about anyone profiting off of their patients. There was particular opposition to the supplement vendor since supplements are not regulated by the US Food and Drug Administration. It’s also a $40 billion industry that causes a lot of confusion for patients and may require physicians to spend significant time on counseling and education, so I can see why they felt this way.

Overall, it looks like an interesting opportunity to be able to contribute, so I am looking forward to the next round of posts and seeing if I can be of assistance. Hopefully their moderators will be more flexible than those of a group I tried to participate in last year – I was kicked out of the group for “self-promotion” for mentioning that I worked for a chatbot vendor while answering a question about chatbots. Never mind the fact that I never mentioned the name of the company I was working for and didn’t try to solicit business, or that I was simply trying to establish credibility and provide transparency before giving a very specific answer to a question. It’s always interesting to see how these groups police themselves, so we’ll have to see how the new one runs.

Other than my foray into the physician forum, I spent most of the weekend heads-down on a big client project. They’re getting ready to go live with some new content this week and didn’t finish building it until Thursday afternoon. They had hired me to do their user acceptance testing so their crunch time became my crunch for the weekend.

Typically, I encourage organizations like theirs to have their actual end users participate in user acceptance testing, because only their end users know what their daily workflows look like. We all know that users are creative, and depending on the number of workarounds in a given system, they might not follow the prescribed workflows all the time if at all. I’m more than capable of testing the new content against the organization’s published best practice workflows, but even if everything passes my review, there is still a risk that they might have broken a workflow that they didn’t even know was in use.

“Document, document, document” is my middle name these days, so if things do go awry, I will have plenty of backup for the fact that I warned them that their plan was not ideal. So far, nearly everything I’ve tested has met the specifications although I’ve found some issues with the training materials and documentation that need to be addressed before go-live. They’re going to have the virtual equivalent of a fat stack of markups waiting for them when they arrive Monday morning, so I hope they had a restful weekend. I’m sure they’ll be throwing it back over the fence to me shortly thereafter, so I’m going to spend Monday resting up myself.

When’s the last time you had to work on a crunch time project? What’s your beverage of choice for all-nighters? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/16/21

This was a rough week on a number of fronts, and I had to resort to some pastry therapy. I wasn’t sure what to think about sopapilla cheesecake initially, but it made my house smell amazing. I’m a big fan of butter, but I think it’s actually possible this recipe had too much, if that could even be a thing. Now to wait for three hours for it to chill, and then I’ll be able to give the final verdict.

The best thing about the week was hearing from my friends at the Office of the National Coordinator for Health Information Technology, in response to my earlier post covering topics such as information blocking, the 21st Century Cures Act, and patients’ access to their notes. They brought up some really good points in response to the post and I wanted to share them, since there are some good clarifications as well as links to resources, FAQs, and more.

Hi Dr. Jayne,

Your August 23 post was shared with ONC and we want to share some information that we hope will be helpful to your readers. Some general resources that might be helpful to your readers are:

• General resource page
• FAQs
• Recorded webinars
• September 14 provider-focused webinar

Regarding some of the specific issues raised in your post:

Re: Open Notes

• The ONC Cures Act Rule does not specifically point to “Open Notes,” which is a branded industry initiative.
• However, the rule does require availability of electronic health information (EHI), which includes notes. From April 5, 2021 through October 5, 2022, the definition of EHI is limited to eight note types, but it expands to include more notes thereafter.

Re: Types of notes

• As noted above, eight specific types of notes are included in the EHI definition through October 5, 2022, and more notes are required thereafter.
• During the current period of the more narrow EHI definition, note types are determined by the content and function of the notes, not by the names assigned by any particular organization or vendor.

Re: Health care providers subject to the rule

• The regulations apply to an array of health care providers, including hospitals and ambulatory physicians (as well as health information networks/exchanges and developers of ONC-certified health IT).
• We have a resource that providers may find helpful in assessing whether the regulations apply to them (Health Care Provider Fact Sheet).

Re: Exception for harm

• There is indeed a Preventing Harm Exception
• However, it does require an individualized determination of risk of harm and a reasonable belief that the exception is needed to substantially reduce an individual patient’s risk of harm or, as applicable, another individual’s risk of harm

Re: EHR certification

• The regulations apply to all health care providers included in the health care provider definition under the rule, regardless of whether they are using ONC-certified EHR technology.

Re: Scope of medical record

• The regulations focus on EHI, the scope of which is initially more narrow, as described above.
• EHI is the electronic portion of health information that would be included in the Designated Record Set (DRS). The DRS is defined by HIPAA regulations and includes any information in the record used to make decisions about individuals.

Finally, we’re making every effort to help the industry with this transition. Let us know how we can help!

Thanks!

ONC

I appreciate their input and the open lines of communication. It’s always good to know that the powers that be are reading and are willing to help us better understand the work that we’re all trying to do together.

I got a chuckle out of a headline in an email that talked about Epic looking to grow its Twitter presence after noticing that its customers use the platform “quite a lot.” The Wisconsin State Journal reports that Epic has created a Twitter account for its new website, epicshare.org, which is designed for client organizations to share ideas and receive information from the vendor. The site also features a “Hey Judy” page that shares “Thoughts and Stories from Judy.” So far, @EpicShares has 215 followers, yours truly included. It will be interested to see how the software giant fares on Twitter since this is its first foray into that social media space.

I was curious about a quote from Leela Vaughn, Epic senior executive, regarding patient use the site. Vaughn noted that “Anybody can be reading these and showing them to their doctor” and that the site was written in a way where they “really worked hard on getting rid of the jargon” so that it could be useful “to people who aren’t super tech savvy.” Physicians already have to worry enough about patients who take the “ask your doctor” advice seriously for every TV commercial they see for a new drug – I can’t imagine what physicians will think when their patients come in and begin quoting things that they read on an EHR vendor website. For one, the vast majority of physicians are not attuned to what Epic is doing as a company – they’re just trying to keep their heads down and see patients, while surviving the pandemic. I’d be curious to see what others think about this approach.

Mr. H previously mentioned the MyMountSinai app, designed to offer patients additional features that aren’t available in their Epic MyChart mobile app. One of the features that is included is the ability to upload COVID-19 vaccine cards. It would be interesting to know if the app allows the data from those vaccine cards to populate the patient’s medical record and function in the same way that vaccine data would function had the vaccines been natively documented in the health system’s record. I have multiple physicians on different instances of MyChart and it still surprises me that they don’t recognize each other’s data. For example, one system continually prompts me for vaccines and services that are documented in the other record, even though I know they have the capability to recognize those care elements behind the scenes. That’s the kind of information blocking we need to get rid of at the patient level, and doing so would make things easier for both patients and providers. The app also includes the ability to schedule visits with new providers and wayfinding assistance for some of its facilities.

Sobering statistics: 1 in 500 people in the US have died of COVID-19. As of Tuesday, more than 663,000 people have been lost to the disease. I remember the early days of the pandemic when we hoped that interventions might cap the deaths at 60,000 or 70,000 and how horrified we were at those numbers. Now we’re exceeding that by a factor of 10 and plenty of people don’t bat an eye. Every one of those casualties was something to someone – a mother, father, sibling, grandparent, friend, or neighbor. As a physician, I’m tired of hearing from people that this is no big deal, or that people didn’t really die “from” COVID-19 they just died “with” it, etc. Frankly, your healthcare teams no longer want to hear it. It’s exhausting and it just needs to stop.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/13/21

As a family physician at heart, I’m always looking for ways to help my clients meet their patients where they are, whether it’s through designing communications strategies, enabling patient-centered care platforms, or delivering more effective and culturally competent care. I was interested to see an article in the Journal of the American Medical Association that looked at whether emoji could improve communication between patients and their care teams. The initial thinking is that using emoji might help patients communicate symptoms and concerns.

On initially launching into the article, I was concerned about a potential of the approach. People don’t always have a common frame of reference for what emoji are supposed to depict. I recall one older family member who thought for quite some time that a certain brown and somewhat pointy emoji was a chocolate kiss rather than something more scatological in nature. Upon further reading, the authors suggest that various medical disciplines should have their own unique sets of icons as well as using healthcare-specific emoji. The idea is that using icons can make communication more accessible for children with developing language skills, people who speak languages other than English, and patients with communication challenges.

The authors propose using emoji as part of a method of point-and-tap communication that could be used quickly, as well as to augment hospital discharge instructions that patients and families often find confusing. They see emoji as powerful because they are standardized, universal, and familiar even though some users might have a bit of a learning curve as I noted previously. I was surprised by some of the data in the article, including an estimate that five billion emoji are used each day on Facebook and Facebook Messenger alone. Curation of emoji is managed by the nonprofit Unicode Consortium and there are over 3,500 emoji in the Unicode Standard.

The article went through a history of some of the existing emoji that could be considered useful in medicine, including the basic body parts such as ear, hand, leg, and foot. Additional “medical” emoji didn’t come into play until 2015 and those included the syringe and pill, followed a year later by male and female health workers. I used the opportunity to put my new phone through its paces and was only able to find the latter two by searching for “health” and the little stethoscopes around their necks are so microscopically tiny that I admit I had to use reading glasses to see them.

In 2017, Apple collaborated with the American Council of the Blind, the Cerebral Palsy Foundation, and the National Association of the Deaf to add various emoji, including the mechanical arm and leg (which I have on my new phone) and the hearing aid and white cane (which I do not). Several others were introduced in 2019 including the stethoscope, blood drop, bone, tooth, and microbe. The authors worked in conjunction with the United Kingdom’s National Health Service to introduce the anatomical heart and lung emoji, which I have as well.

Several other emoji are under consideration and are pictured in the article, including: intestines, leg cast, stomach, spine, liver/gallbladder, kidneys, pack of pills, bag of blood ready for transfusion, IV fluids, CT scanner, EKG tracing, crutches, a weekly pill dispenser, and one I couldn’t identify. I had overlooked the description for the graphic and it turns out that the one I couldn’t identify was supposed to be a scale, and the one I thought was a coronavirus was actually supposed to be a white blood cell. Maybe those emoji aren’t as standardized and familiar as the authors think they might be.

The authors hope to advocate for a “more comprehensive and cohesive set of emoji” but are also researching how the healthcare community could better leverage an expanded set of medical emoji. There’s certainly precedent for using icon-based systems like the Wong-Baker FACES Pain Rating Scale for helping patients quantify the intensity of pain they’re experiencing. The authors note, though, that many visual analog scales like the Wong-Baker scale are trademarked, but emoji are open source.

The last proposed benefit that the authors specifically call out is that related to advancing telemedicine. They propose that using emoji to describe symptoms via online messages can be helpful. As a practicing telemedicine physician, I’d have to say the devil would be in the details as far as how much information you could obtain via emoji and whether it would make it more challenging than eliciting the information during a focused interview. They note that there are challenges with using emoji, including patients without access to technology, those who are not facile users, and overall low health literacy that would preclude the use of anatomical emoji.

Speaking of anatomy, the article taught me something I didn’t know. Emoji skin tones are based on the Fitzpatrick pigmentary phototype skin classification system, which reflects how much melanin is present in different skin, how sensitive it is to UV light, and the relative risk of skin cancer.

The authors conclude by calling on the healthcare community to “take the lead by formalizing a unified perspective on emoji relevant to the field, including important gaps and solutions.” Given the pressures faced by healthcare providers right now, I’m not sure that evolving a representative set of emoji is at the top of anyone’s priority list, but it’s certainly something to think about in the context of overall communication with patients, caregivers, and colleagues.

We’ve come a long way as communications have evolved from voice pagers to numeric ones and then from alphanumeric pagers to emoji. I think I can safely predict that the ways in which we communicate will continue to evolve over the next several decades. As they do, I hope they become more efficient and reliable as well as having improved abilities to convey information. Maybe a few years from now, instead of lamenting the performance of our voice-to-text, we’ll be talking about using voice-to-emoji or maybe even some modalities we haven’t thought of.

What do you think about expanding the use of emoji in the delivery of healthcare? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/9/21

Lots of chatter in the healthcare community about the percentage of workers having “breakthrough” infections despite being fully vaccinated. Various investigations are looking at causes, including waning immunity, the increased transmissibility of the delta variant, and more.

It still boggles the mind that a year and a half in, we have not come to consensus on the fact that all healthcare workers need to be wearing high-level personal protective equipment. None of the hospitals in my area are providing adequate N95 respirators for their healthcare workers, the vast majority of whom are expected to see all patients wearing a surgical mask. The reality in our community is that a good number of people walking into healthcare facilities are indeed COVID-19 positive, so those on the front lines really need better protection. I was in an outpatient office today and staffers were wearing cloth masks and not even surgical masks – it is hard to believe that anyone thinks that’s appropriate in a healthcare setting. At times, it seems like embracing the new normal is instead a race to the bottom.

I booked my HIMSS22 hotel reservations today, despite the HIMSS website being completely confused as to what year we’re talking about. The HIMSS rate for my hotel of choice was $60 per night less than the rate on the hotel’s website, and with the post-COVID-19, less-draconian HIMSS cancellation policy, booking it through OnPeak was a no-brainer. The only reason I thought about booking my hotel was the fact that I received an email asking for HIMSS22 proposals. 

I’m glad I got in at a reasonable room rate, although I wish there were more hotels closer to the convention center. I don’t mind getting my cardio in on the way to the conference, but my feet are definitely tired at the end of the day. Back to the call for proposals – they are due by September 20 and can be submitted for general education Sessions, preconference symposia, and preconference forums. Interested applicants can visit the HIMSS website, but don’t be thrown off by the ongoing presence of the HIMSS21 logo.

For those of you responsible for maintenance of the back end of EHR, practice management, and revenue cycle systems, the American Medical Association this week released its Current Procedural Terminology code updates for 2022. There are over 405 changes this time, around including nearly 250 new codes, 60 deletions, and nearly 100 revised codes. There are updates to vaccine codes and additions for remote patient monitoring and care management for patients with chronic conditions. Organizations need to look at the list of changes and determine how it impacts their physicians, coders, and other personnel. It’s not as simple as updating the codes in the tables of the IT systems – often changes are needed to workflows and education for end users is definitely a good idea. The changes take effect January 1, 2022.

Teladoc health announces open nominations for the She Powers Health awards, which are designed to “shine a light on diversity and inclusion initiatives across the healthcare industry that address the disparity of women in executive and board positions.” The third annual awards reception will occur at the HLTH 2021 conference. There are two awards, with the first being the Individual Award, which recognizes someone “who has not only made a significant impact on peoples’ health, but who also has recognized, empowered, and championed women and the important role they plan in enhancing care and transforming the healthcare industry.” The second award is the Rising Star Award, targeted at a member of the under-30 crowd “who has made an impact on peoples’ health, empowers women in the workplace, and is a champion for diversity and change, while still early in their career.” Nominations close September 17, 2021.

Jenn tipped me off on a recent job posting. The Centers for Medicare & Medicaid Services has posted for a chief experience officer. The chief experience officer is expected to work with CMS stakeholders to improve customer experience delivery and to develop and implement strategies for CMS to use as part of its routine development process. Additional responsibilities include promoting continuous change and developing a voice of the employee program to promote retention, recruitment, engagement, and productivity. The salary range is commensurate with government employment, so I suspect the position will attract those who are truly motivated to serve as opposed to those who seek C-level titles for other reasons. If you are interested, apply quickly, as Friday is the closing date for applicants to submit their materials.

Speaking of job postings, I’m working with a client right now who picked the wrong team for a project and now is trying to clean up the mess. It’s a case study in the need to really understand the skill sets you need for your team to be successful and to make sure that everyone has the minimum skills needed to move the project forward. Just because a physician is “interested in technology” doesn’t necessarily mean they’re suited for a role on a technical team. You can be the most brilliant clinician in the world, but if you can’t figure out how to work with Confluence and Jira, it’s going to be difficult to keep up on an agile team.

Despite training, they are struggling, and I’m almost to the point of recommending that we hire the equivalent of a scribe to assist them with their daily tasks. Paying for an intern or assistant would be cheaper than burning hours at a physician rate, for sure. On the other hand, they mastered biochemistry and passed their board exams, so I’m cautiously optimistic.

One of my other projects this week has been shopping for a new phone. My trusty Motorola is being rendered obsolete by upgrades to my carrier’s network, so despite the fact that it meets all my needs and doesn’t give me any trouble, I have to retire it. Several of my friends are trying to get me to cross over to the land of the iPhone, but I’ve been happy with Android ever since giving up my beloved Blackberry, so I think I’ll stay put on platform. I’ve heard the changeover to the phone I selected is easy and straightforward, so wish me luck as I’ll be working through it this weekend.

What’s the best or worst thing about upgrading your phone? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/2/21

The American Medical Informatics Association is putting out a call for submissions for its 2022 Clinical Informatics Conference, scheduled for Houston in May. The CIC conference is known for being clinically focused, with lots of practical presentations about clinical informatics. Included focus areas are informatics-driven value-based healthcare; usability, efficiency, and user experience; clinical decision support and analytics; organizational challenges; emerging technology and technical infrastructure; and leadership, advocacy, and policy.

I’ve never attended, and while Houston isn’t one of my favorite cities, it might be on my list if we make it through this winter without crazy COVID and flu peaks. I can certainly appreciate any learning about organizational challenges since I seem to be having a number of them with my clients lately. Potential presenters have until November 30 to submit.

With all the stresses on healthcare organizations, mental health is at the forefront of many discussions. I was interested to read about Nike closing its corporate offices for a week to allow employees to take a break. While corporate office employees are receiving a week of paid vacation, retail employees didn’t get the same consideration. I would propose that the customer-facing retail employees probably need some bolstering of their mental health as well. If sick patients aren’t willing to mask and distance at their physician’s request, I can’t imagine being a retail employee who has to engage with people who don’t want to practice social distancing or wear masks. I’d be more impressed if they gave all employees extra time off, not just those in the corporate office.

Healthcare providers behaving badly: New York area hospital workers have been purchasing fake COVID-19 vaccination cards for $200 each. The Manhattan District Attorney’s Office announced the filing of charges against a New Jersey woman for the cards and against a New York medical worker who would enter the person’s data into the New York state immunization registry for an additional $250. The co-conspirator is alleged to have entered fraudulent immunization records on at least 10 individuals. Those purchasing the fake vaccination records were also charged, and include workers at hospitals, medical and nursing schools, nursing homes, and other critical environments. The fraudulent documents were sold through Instagram accounts and prosecutors call on social media platforms to assist in the crackdown. The idea that someone would enter fraudulent data into the state registry is so offensive – I hope the penalties are severe.

For those of us who deal with search algorithms and learning systems on a regular basis, the report that the Amazon algorithm was directing users to ivermectin, and other COVID-19 misinformation sites is also offensive. CNBC reports that not only are user reviews listing false claims, but that since the autocomplete functionality on Amazon’s search field are driven by customer activity, searches that start with “IV” are bringing up ivermectin products due to high search volumes. Amazon is supposed to be blocking those autocomplete entries to help mitigate the issue. Users searching for “ivermectin for humans” and “ivermectin covid” should also receive a warning that the FDA has not approved ivermectin to treat or prevent COVID-19.

Several of my clients have added informational banners and callouts in their patient-facing platforms and websites, letting patients and potential patients know that the group will not prescribe ivermectin off label. It’s largely an attempt to avoid angry situations in the office which have been happening with increasing frequency, as well as to lower the volume of calls that patients are making in the hopes they get them.

One physician reported to me that an angry parent called wanting to interview her as a potential pediatrician for their child, but they had already called 20 pediatricians and didn’t want to see anyone who was going to try to recommend a COVID vaccine or who wouldn’t prescribe ivermectin or hydroxychloroquine. Since my client is squarely in the camp of evidence-based medicine, her practice opted to add banners to the website and informational posts on social media so that they could hopefully avoid other calls. I guess the fact that every pediatrician the parent had talked to had the same opinion had no sway on his thinking. When I asked my client about this, she noted that the caller told her she must be in the pockets of big pharma since she was a vaccine proponent and that he would keep calling around.

I’ve known a lot of front-line pediatricians and I can tell you that not a single one seems to be in the pockets of big pharma or any other financial influencer. When you stroll through the physician parking area at the hospital, you can pretty much predict that the well-loved Honda Accords and Toyota Camrys belong to the pediatricians, family physicians, or geriatricians. Primary care physicians tend to do what they do because they genuinely care for patients and want to see people lead longer healthier lives and are willing to make a lot less money than their colleagues to do so. Many of them have worked consistently through the pandemic with less-than-ideal personal protective equipment and have taken huge financial hits, so to accuse them of being compromised by some facet of industry is laughable.

Speaking of laughable, I receive a lot of emails asking me to look at new products or check out websites in the hopes that I’ll promote them. I would highly recommend that you spell-check and grammar-check all copy that you plan to put on your website, and then have at least two people other than the author read it to find anything that the computer missed. One recent request led to multiple errors in the first paragraph of copy on the website. As a physician, once I see that, I’m done. If you don’t have the attention to detail to make sure your copy reads well, I’m not about to consider using you as my patient engagement solution because I can’t trust that you won’t send nonsense to my patients.

Big hugs to my colleagues who are trying to get their practices back up and running after being hit by the recent hurricane and storms. Many can’t even practice remotely or via telehealth due to infrastructure issues and the level of helplessness that some of them feel is agonizing after everything they’ve been through in the last year and a half. Here’s to a speedy restoration and recovery effort.

Has your organization had to cope with storm damage or other recent natural disasters? How are things going from an IT standpoint? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/30/21

During the past couple of weeks, I have spent some quality time doing decidedly low-tech things. I know I’m going to be starting a big project soon and plan to be heads-down for many months, so I’ve been trying to get as much adventure on the calendar as I can.

Camping is one of my low-tech pastimes and sometimes it’s just good to get away from the hustle and bustle, although I did enjoy having the option of firing up the hotspot and getting a little work done while I was away. I can’t say I enjoyed the ridiculous humidity or the high number of spiders that wanted to join me in my tent, but overall, it was a good couple of days away.

I also had the opportunity to take an 80-year trip back in time. The Union Pacific “Big Boy” 4014 locomotive has been touring the US, delighting tens of thousands of fans as it carves a figure eight covering Wyoming, Nebraska, Kansas, Oklahoma, Texas, Louisiana, Arkansas, Missouri, and Colorado. Having spent a good chunk of my career in healthcare IT, I’m a fan of complex systems. However, you haven’t seen a complex operation until you’ve seen what it takes to run an 80-year-old steam locomotive in the modern world. The Big Boy class of steam locomotives was the largest ever built, and they were originally used to haul freight over the Wasatch mountains. At the time, supporting infrastructure along the route would have included water tanks to keep the boiler full as well as maintenance facilities that could handle such a beast.

Needless to say, nothing like that exists in the US any more, so the train is accompanied by fuel trucks that can supply the recycled oil it runs on after being converted from coal. It also runs with multiple water cars to supply the 100 gallons it goes through each mile as well as a customized tool car that contains nearly everything it takes to keep it running. The train stops every couple of hours for maintenance and lubrication and is accompanied by a “helper” diesel engine to supply dynamic braking so that the antique doesn’t wear out its own brake shoes, since they have to be changed from below and nowhere on the tour has a roundhouse that can support a 1.2-million-pound locomotive. Stopping every couple of hours also allows people all over the US to come out and see it.

Just looking at all the piping, valves, gaskets, and hardware on the locomotive reminds me of the most complex and ancient IT systems I’ve worked with – those where any number of points of failure can bring the system to its knees and there are only a handful of people with the knowledge and skills to keep them running. During the stop I visited, I was able to see the Union Pacific “pit crew” in action getting the Big Boy ready to move out. In addition to replacing a gasket and refilling the water cars, they also performed some “percussive maintenance” on a couple of parts. and I think we can all sympathize with systems that we want to hit with a hammer at times, although the Union Pacific Steam Team gets to do it for real.

Seeing the Big Boy’s crew in action was also a great study in team dynamics. They clearly have made it to the performing stage of team development and were working in 100-degree heat with complete focus and dedication. The head of the team was spotted stabilizing a ladder for another crew member, which reminded me of some of the hospital administrators that I most enjoyed working with, those who weren’t afraid to roll up their sleeves and get to work when things got tough.

In between tasks, they were being peppered with questions from the crowd, which they always answered with a smile. Since they’re essentially rock stars of the railroading world, they were also being asked to autograph all kinds of memorabilia. Watching them interact with the children in attendance, many of whom were dressed like the crew, was priceless. One of the highlights was watching the team’s leader stand on the roof of the cab and capture video of the crowd. Seeing thousands of people come out to admire your work has to be a pretty big rush, I’d imagine.

I was also happy to learn about some of the problem solving that had to happen during the locomotive’s restoration. Much like our work in healthcare (and especially in healthcare IT) if the team didn’t have what they needed to get the job done, they had to figure out how to create it. Where they might be fabricating replacements for 80-year-old parts (as well as the tools to service them) we’re often creating solutions to problems that at times feel like they’re being randomly thrown in our direction. Since patient care is at stake, we don’t have the option of not solving them, so we have to get creative and sometimes cobble things together to get the job done. Those of us supporting legacy systems have to learn how to do things we never thought would be on our plate, and it was a good reminder that every day is a new adventure.

As dark as some of my healthcare days have been over the past year and a half, seeing the crowd at the display event gave me a lot of hope. The Big Boy brought out people of all ages, from newborns in carriers to a woman who was 99 years old, as well as different social, economic, and cultural groups. Despite a mix of masked and unmasked attendees at the outdoor event (although masks were required for those entering the actual railcars) and despite the heat and the fairly crowded conditions, I didn’t hear a single negative word about anything. People were so intent on just experiencing the wonder of the situation that everything else was secondary. When people were inadvertently jostled or bumped, apologies were given from both sides, which is seemingly rare in these days. Union Pacific kept the crowd well supplied with ice water and places to rest in the shade and provided golf carts for those who needed assistance. There was no jockeying for places to take pictures, everyone waited their turn, and it was just a pleasant time to experience a taste of the past. Best of all it was free, so kudos to Union Pacific for an outstanding public relations event that gave a lot of people great joy.

I’ll definitely go into this week with a new appreciation of the concept of hard work, as well as a boost in my mood based on my encounter with the Big Boy and all of its fans. Here’s to better times where everyone can rally around something that unites us and puts a smile on all our faces.

Have you ever heard a steam whistle that rings right through to your soul? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/26/21

The big news of the week was the official FDA approval of the Pfizer COVID-19 vaccine, which in turn triggered a rush of corporations to mandate employee vaccinations. Those companies that want to offer alternatives will require regular testing in lieu of a vaccine. Others, such as Delta Airlines, will charge unvaccinated people a premium on their health insurance and will block them from receiving pay-protection funds if they become infected with COVID-19.

As a physician, I appreciate the Delta Airlines strategy since it’s trying to tie cause and effect. The reality is that unvaccinated people who contract COVID-19 have a much higher risk of hospitalization and higher odds of costing their employers money and hitting people in the pocketbook might be much more effective for some than current vaccination strategies.

Once a drug has formal FDA approval, that opens to door for clinicians to consider so-called off-label prescribing, where they recommend use of the drug outside of the official approval. Off-label prescribing is common with a number of medications. For example, while we were having a shortage of antibiotic ear drops last year, physicians substituted the same drug in an eye drop formulation, which is widely considered to be safe and effective.

The official FDA approval for the Pfizer vaccine was only for patients aged 16 and older. Those 12 to 15 are still covered under an Emergency Use Authorization. Still, in the early hours following approval, several sources in my area made a play to administer vaccine doses to 10- and 11-year-olds. A quick clarification from the FDA as well as the American Academy of Pediatrics made it clear that this shouldn’t be happening, and that prescribers need to wait for additional approvals in younger age groups. Part of the delay in younger patients involves evaluating the dosing, but given the relative size of some larger 11-year-olds compared to smaller 12- and 13-year-olds, the risk of harm in those few children who received “unauthorized” doses is likely to be small.

Regarding the potential for upcoming booster shots, a couple of my neighbors were discussing the idea of trying to jump the gun on a third dose. One of them heard that a local pharmacy was throwing away doses that were expiring, so went and presented herself like she was there to receive her first dose. My other neighbor was incredulous that someone would be able to do that, “because don’t they have a national database of who has received what kind of vaccine?” She was shocked to learn that immunization registries are a patchwork across the states, and that they’re often not bidirectional or fully interoperable with hospitals and health systems, let alone other states.

I had a similar conversation with a neighborhood mom after the local school district requested copies of vaccination cards for students so that they would have them on hand in the event of an exposure. She didn’t understand why the schools “just can’t get them from the pediatricians’ offices.” Lots of members of the general public assume healthcare technology is a lot farther along than it is. I look forward to the day we can really exchange data like we need to in order to better enable quality care.

Many of those organizations requiring vaccination are healthcare delivery organizations, who have a vested interest in not only keeping their workers healthy, but in helping reduce transmission between staff and patients. A recent Kaiser Family Foundation brief concluded that over the last two months, COVID-19 hospitalizations of unvaccinated patients has cost the health system $2.3 billion. For hospitals running on razor thin margins, there is likely to be a certain amount of uncompensated care that will never be recouped. Other costs will be absorbed by taxpayer-funded programs (Medicare, Medicaid) or passed on to workers or businesses. In other words, we’re all going to be paying for this debacle for a long time.

For those of us on the vendor side of the healthcare IT industry, this means hospitals will continue to be strapped for cash for the foreseeable future, reducing available funds for technology projects including upgrades and new solutions. In addition to funding challenges, hospitals and health systems are also focused on trying to recruit and retain staff while keeping overloaded clinical divisions working. They’re certainly not going to be as eager to hear from technology vendors as they might have been a couple of years ago unless they’ve identified something particular that needs resolution and can’t wait. I’ve watched many companies turnover their entire sales teams over the last year due to low sales, but it seems inevitable that organizations will be pinching pennies for months to come.

The Medical Group Management Association has announced that its October Medical Practice Excellence: Leaders Conference in San Diego will require full COVID-19 vaccination for all attendees, suppliers, speakers, and exhibitors. Attendees will have to interact with plenty of other personnel – hotel staff, transportation workers, and those at dining establishments as well as members of the public who aren’t attending the conference, so the conference won’t be able to create a complete bubble. As for masks, MGMA says “masks are strongly recommended for attendees.” but it appears the organization is holding off on announcing a mask mandate pending changing conditions.

The Healthcare Financial Management Association’s Annual Conference slated for Minneapolis in November will also be vaccination-required for those attending onsite. Unlike HIMSS, registrants are able to cancel penalty-free or they can switch to the digital version of the conference if they do not want to comply with the vaccination mandate. In addition to attendees, vaccination is required for speakers, exhibitors, volunteers, staff, and backstage crew.

In speaking with some of my vendor contacts, everyone is already in the thick of their HIMSS22 planning. It will be interesting to see what the winter conference season looks like, starting with the Consumer Electronics Show kicking off in January. I’m planning to attend digitally this year as I did last time and looking forward to seeing innovative new technologies as well as things that are just quirky.

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/23/21

Part of the fun of being a consulting CMIO is working with a variety of clients that have needs across the clinical informatics spectrum. Sometimes I work with smaller organizations that need informatics leadership but don’t have the funding for a full-time position or qualified physicians willing to fill the role even in a part-time capacity. Other times I might be augmenting a large health system going through a transition, supporting a specific element of their informatics needs such as absorbing legacy systems they acquired through practice purchases or consolidating ancillary systems. There are always challenges and sometimes I run into areas where I’m not fully expert in the subject matter, but a big piece of being a good consultant is knowing when (and where) to get help when you need it.

Less fun in the arena of the consulting CMIO is when a client hires you for your expertise, and then proceeds to either ignore it, or worse yet, acts like you don’t know what you’re talking about. I was going round and round with a client last month who insists that the information blocking rule of the 21st Century Cures Act (which some of the analysts continue to refer to as the “Cares Act” despite corrections) does not apply to them. There are a number of outstanding resources that help organizations understand the requirements and how to implement them, and I’ve provided checklists, infographics, and even the relevant pages of the Federal Register in an attempt to get them on board.

In short, Open Notes requires that healthcare providers offer patients access to much of the health information in the electronic medical record without delay. Failure to provide the required access constitutes information blocking.

I had a meeting with one of the newly hired operations VPs a while back, when I again tried to talk the client into accepting their need to comply. The conversation I had was fairly comical:

Me: We need to talk about Open Notes again. You’re not in compliance, and this places the organization at risk. Additionally, it’s not good for patient satisfaction, as your competitors are all releasing their documents. We really need to figure out how to move this forward.

VP: My interpretation is that it only applies to health systems and we’re just a physician group.

Me: Actually, this applies to all healthcare providers. Since the organization is a physician group, it needs to comply.

VP: We think our patient will be harmed by this. Isn’t there an exception for harms?

Me: There are specific criteria for a “preventing harm” exception, but given the fact that the majority of visits performed in the organization are routine medical visits, it would be impossible to claim that across the board. [slides copy of FAQ document from a reputable organization across the table]

VP: This list of documents doesn’t apply to us. We don’t generate any of these documents.

Me: Let’s see – consultation notes, history and physical, lab reports, procedure notes, progress notes – there aren’t any of those in the EHR?

VP: No, we have encounter notes.

Me: It doesn’t matter what you call them, basically all of your encounter notes are consultation notes, history and physical notes, procedure notes, or progress notes.

VP: Our EHR isn’t certified, so we don’t have to do it.

Me: Actually, that doesn’t matter. The ONC FAQ page specifically says that it applies to healthcare providers “regardless of whether any of the health IT the provider uses is certified under the ONC Health IT Certification Program” or not. And we really should talk about that EHR …

This went on for a good 20 minutes, as the VP — who is half my age and has less than two years’ experience on the provider side of healthcare — tried to convince me that I didn’t know what I was talking about. The organization has been through several such VPs in the short time that I’ve been working with them. 

As all the VPs do, he said he would “have to take it to legal,” who always refuses to do anything. It’s the ultimate brush off since “legal” really means “our outside counsel since we can’t keep anyone on staff” and no one ever takes responsibility for a decision. The physician CEO of the group perceives himself to be too busy running the group and dealing with disgruntled physicians to get involved in escalating this with the legal team, dumping it back to me “because this is why we hired you.”

It’s disheartening to have to work with people like this when you’ve been hired to do a job that you’re good at and have a proven track record of helping other organizations achieve what you’re trying to accomplish. Not to mention, as a patient who has uncovered some pretty significant misses in my own medical record through the magic of patient-facing notes, I’m a believer in the power of the tool regardless of the regulatory requirements around it.

This particular VP is the same one who tried to convince me that certain data elements in the patient chart — including blood pressure records that the patient brought to the office and the physician signed, dated, and had scanned into the chart — aren’t technically part of the legal medical record, despite the fact that the physician used them to support the Medical Decision-Making component of an office visit and referred to them in his dictation.

Fortunately, I use a standard contract that lets me terminate clients like this with relatively short notice, so I opened the escape hatch a couple of weeks ago. I’m wrapping up some final transition items this weekend and am looking forward to moving on. I’m not fond of putting my professional credibility on the line for organizations like this.

I find the CEO’s attitude particularly unsettling and I understand why he might be dealing a number of disgruntled physicians if they are having to interact with people like the operations VP. I’ve built some good relationships with several of the physicians and I’m sure they’ll keep me posted on what happens with this over time.

Is your organization on board with Open Notes, or are you holding out? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/19/21

HIMSS sent out its HIMSS Digital survey this week in an attempt to gather attendee feedback. The questions were predictable around whether the conference met expectations, whether the content was unique or valuable, if it was thought-provoking, and whether attendees can use what they learned in their organizations. Some of the areas they asked about I hadn’t heard of or seen promoted on any of the Digital communications, so I hope someone got something out of them.

I also received the “Important HIMSS21 Health & Safety” Update email, notifying attendees of several attendees who tested positive either on the way out of town or upon arriving home. If there really were only three cases that would be outstanding, but I suspect there might be quite a few mildly symptomatic or asymptomatic people out there. Judging from the people I’m seeing for testing (thanks to a touring musical act who shall remain nameless but did require testing or vaccination to attend the show) there are quite a few asymptomatic positives out there. My community’s transmission rate is rather high at the moment, so I’m not at all suspicious that they are false-positive results.

Desk jockeys, take heart: a new study in the American Journal of Physiology Endocrinology and Metabolism looks at the concept of “interrupted sitting” as a way to help mitigate negative impacts of sedentary work. Although the study was small with only 16 adults, it showed promising results. For 10 hours daily, participants were prompted to get up every 30 minutes. The active group had fewer extreme blood sugar values, suggesting that even small amounts of intermittent activity can be beneficial. I’ve been working on a big EHR build lately and often feel like I’m strapped to my desk, so I’m making it a point to try to get up regularly even if it’s just to walk to the kitchen to put more ice in my water glass or to drop a journal in my recycle bin.

I have to say that I’m really enjoying working on the build project. It’s different from what I usually do, and I am working with an outstanding team who gets it as far as understanding what clinicians want and need from their EHR. Several of them have clinical roots, so it’s not surprising that they know what needs to get done. Unfortunately, it’s a short-term gig and all good things will eventually come to an end, but it will have been fun while it lasted.

On the flip side, I established a micro practice earlier this year after leaving my urgent care job. It’s a way to have a place to hang my shingle so I don’t run afoul of the regulatory and licensure folks in my state. It’s also a way to experiment with new technologies and see how they play out in actual patient care. I’m test driving an EHR right now that can only be described as atrocious. It reminds me of some of the first systems I used in the late 90s, which were a cross between FileMaker Pro and an electronic prescription pad. For what I’m doing, I don’t need a certified system, but I certainly miss things like CPOE and clinical decision support that I think the majority of clinicians take for granted.

Two journal articles caught my eye this week. The first, in the Journal of the American Board of Family Medicine, reinforced the idea that perhaps breakfast is the most important meal of the day after all. Researchers analyzed existing mortality data from the NHANES 1999-2002 data sets, looking at overall mortality, cardiovascular mortality, and fiber intake. Nearly 83% were identified as breakfast eaters, and on the whole, they were older, had lower body mass index, and ate more calories and fiber daily than non-breakfast eaters. The study certainly doesn’t show causation, but the association of breakfast eating (especially when individuals consume more than 25g of fiber daily) with lower mortality rates seems solid.

The second article, also found in the Journal of the American Board of Family Medicine, looked at the practice of incorporating patient narratives in the medical record. It caught my eye because it took place in the Netherlands. One of my outdoorsy gal pals hails from that part of the world and is always sharing stories about how life is different in her home country. According to the article, the Netherlands is the home of the world’s oldest practice-based research network and contains over 300,000 patient-years of data gathered from 2.2 million encounters documented between 2005 and 2019. During the registration process, the practices gathered contextual information such as country of birth, level of education, family history, and trauma history and added it to the EHR.

Looking at data from early in the COVID-19 pandemic, they analyzed patient-reported reasons for encounters and found that episodes of pneumonia most often started with a complaint of cough. When documentation showed both cough and fever, the incidence of pneumonia was even higher. Cough with concomitant pulmonary disease was also a strong predictor of pneumonia, as was low socioeconomic status. Throughout my journey in the EHR world, people frequently minimize the need to have structured data in chief complaint and history of present illness fields. This just goes to show that maybe that data might be usefully mined after all.

I’m pool-sitting this week and have definitely enjoyed some quality time in a lounge chair in between long stretches of conference calls. I haven’t yet been bold enough to take a call from the pool deck, but looking at what’s on the agenda for the rest of the week, I just might. Any noises that might make it onto calls can’t be worse than what I’ve been hearing lately, as my remote colleagues seem to have become increasingly more casual. One co-worker has had a toddler on almost every call for the last few months, which makes me wonder how much work he’s getting done unless he’s cramming it all in while his son is asleep.

Do you think remote workers have become more casual during the pandemic? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/16/21

Earlier this week, a friend shared a Health Affairs blog piece looking at the future of innovation at the Centers for Medicare and Medicaid Services. The blog is co-authored by Chiquita Brooks-LaSure, MPP, incoming administrator of the Centers for Medicare and Medicaid Services.

It starts by explaining the creation of the Center for Medicare and Medicaid Innovation, also known as the Innovation Center, as part of the 2010 Affordable Care Act. The primary role of the Center is to create movement towards a healthcare system in the US that revolves around value-based care, the core of which is reducing spending while delivering high quality care. The forces behind the creation of the Center tell a hard truth – that healthcare in the US is expensive and doesn’t always deliver high quality outcomes.

I enjoyed the summary of what has happened over the last several years. For some of us who live this day to day, you kind of lose the forest for the trees. I didn’t realize that there have been more than 50 alternative payment models launched. I can probably only think of a couple off the top of my head, so it would have been interesting to see a list of all of them. The authors describe having “taken stock of lessons learned” as they begin to map out value-based care plans for the next decade.

Looking at the past so we don’t continue to repeat our mistakes is already a good thing. I hope they looked beyond clinical and cost outcomes to also see what the impacts (positive or negative) have been on clinicians. It’s important to understand whether programs that achieve the stated goals promote a stable physician workforce or whether they become just another factor that drives good people to reduce their schedules or to leave medicine altogether.

They note that six models have created a statistically significant savings for Medicare and US taxpayers:

1. ACO Investment Model
2. Home Health Value-Based Purchasing Model
3. Medicare Care Choices Model
4. Maryland All-Payer Model
5. Pioneer ACO Model
6. Repetitive, Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport Model

I had only heard of two of these and only had more than a passing familiarity with one, so am interested to learn about the rest of them.

The authors “explicitly acknowledge health equity as a central goal for this vision.” We’ve known about the challenges for medically underserved populations and areas for many decades now and I’m eager to hear how they plan to improve care delivery in those communities. They note six key takeaways from the lessons of history:

1. “The Innovation Center should make equity a centerpiece of every model.” This means going beyond Medicare and those organizations that have had the resources to participate and drawing in Medicaid, rural, and safety net providers.
2. “Offering too many models is overly complex, particularly when models overlap.” Apparently, there are 28 models running concurrently, which can create conflicting incentives as well as making it difficult for participants to figure out drivers and outcomes. They will focus on offering fewer models going forward.
3. “The Innovation Center needs to re-evaluate how it designs financial incentives in its models to ensure meaningful provider participation.” For most of the Meaningful Use period, my practice simply opted out. The burden to providers was far more than the penalty, so we took the penalty and moved forward. The authors admit that there have been challenges in testing some of the models because providers don’t join or opt out when they think they will lose money.
4. “Providers find it challenging to accept downside risk if they do not have the tools to enable and empower changes in care delivery.” One future goal is to have manageable levels of risk for providers as well as providing supports needed to help providers take on more risk.
5. “Challenges in setting financial benchmarks have undermined our models’ effectiveness.” They are looking at ways to modify the current risk adjustment methodology and to make sure that models aren’t leading to overpayment. I know that my colleagues will likely be excited about the former, but not so much the latter.
6. “Innovation Center models can define success as encouraging lasting transformation and a broader array of quality investments, rather than focusing solely on each individual model’s cost and quality improvements.” They plan to scale practices that work in models by adding them to other models, to Medicare, and to Medicaid.

They go on to say that “in order to deliver on the promise of putting people at the center of their care, we need a health system that meets people where they are, keeps people healthy and independent, and coordinates care seamlessly and holistically across settings.” That statement sounded suspiciously like everything I was taught in my family medicine residency training, and I remembered how enthusiastic and idealistic I was when I graduated. Those feelings were quickly beaten out of me as I grappled with the world of prior authorizations, difficulty getting my employer to allow me to spend what I needed to hire high-quality office staff, and the crush of trying to coordinate it all while seeing 30 patients a day.

I paused for a few minutes to reflect on that before I read the rest of the blog because I wanted to see what the Innovation Center was going to propose to counter the forces that drove me out of traditional primary care.

They have identified five strategic objectives:

1. “Drive Accountable Care.” They hope to reduce fragmentation by rewarding coordinated and team-based care the delivers high-quality outcomes. Accountable Care Organizations are a central part of this plan.
2. ”Advance Health Equity.” Elimination of health disparities is a key goal, with one action being the active engagement of providers who have not historically participated in value-based care incentive programs. Another action is ensuring that application processes and eligibility criteria include organizations that care for disadvantaged populations. Partnership with Medicaid will be a key activity.
3. “Support Innovation.” They propose delivering tools that help close care gaps, including addressing mental health and social determinants of health. These tools may include access to real-time data to support providers, flexibility in rules, and looking at targeted approaches to impact specific populations.
4. “Address Affordability.” The goal is to not only lower spending for Medicare and Medicaid, but also to lower patients’ out of pocket costs. This may mean waiving cost-sharing for certain services, controlling drug prices, or reducing low-value care that is wasteful.
5. “Partner to Achieve System Transformation.” I love me some clinical transformation, but know that the devil will be in the details for this one. CMS knows that it needs partnership with not only Medicare and Medicaid but with patients, providers, payers, and community-based organizations. The people problem is often one of the most difficult to solve, so I wish them well.

It will certainly be interesting to see what the next decade brings, especially with the ongoing challenges from a global pandemic that shows no signs of stopping, a completely burned-out clinical workforce, and tip of the spear care delivery organizations that are stressed to the max. Many healthcare organizations are not ready to take on one more thing, especially when it puts more strain on the system. I’d be interested to see if readers have any insight or thoughts to offer.

Who’s ready for the next evolution of value-based care? Leave a comment or email me.

Email Dr. Jayne.

Dr. Jayne Goes to HIMSS Digital – Thursday

Thursday is functionally the last day of HIMSS for many attendees, as they’re worn out from cocktail parties and walking the exhibit hall. By this point, I would typically be packing my suitcase and dropping it at the bell desk so I could pick it up on the way to the airport for my late evening flight. Historically I do an Exhibit Hall Crawl with one of my long-time HIMSS friends, as we see who is left standing at the end of the week and who has headed out early. This time I’ve been receiving photos of the mostly empty exhibit hall from people on the ground.

I decided to attend the “Encouraging Science of Happiness” keynote featuring Rainn Wilson, since it was one of the few in-person sessions that was to be live-streamed. Logging into HIMSS digital, there was no information on the session, but I remembered hearing it was going to be streamed through the Accelerate platform. After way too many clicks, I was able to access the session, which was to start at 8:30 a.m. Ten minutes into it, I was still watching people wander in and find seats, with no update from HIMSS about any delays other than a single instance where a voice said something about “Changemakers, take your seats, the program is about to start.” It’s not like they had a crush of people they had to fit into the room.

Things finally got going at 8:42, but instead of showing video of speaker Reid Oakes, we were treated to a static image, and then the slide deck moved onto the HIMSS Stage 7 award recipients. They finally cut to a speaker view, but then the same thing happened when the keynote speakers came out – we got the slide deck, but we never got to see the actual speakers again until nearly the end. I guess HIMSS couldn’t figure out how to do a split screen?

Still, it was a good presentation, and talked about some of the challenges of current times – specifically the challenge of loneliness (which several nations including Japan and the UK have appointed governmental ministers to address) which according to the speakers has the same negative health effects of smoking a pack of cigarettes each day. Despite being one of the most connected generations, 18- to 24-year-olds (even pre-COVID) report higher levels of loneliness than senior citizens. One of the main points of the speech was the idea that intentionally choosing joy is an act of rebellion – going against the status quo. There was a part where the audience wrote notes to people who had positively influenced them and some of them read their notes aloud. It would have been nice to see those interactions rather than just a static slide.

Great Tweet from Jan Oldenburg @janoldenburg yesterday, pondering how we will identify the potential impact of COVID-19 spread from HIMSS21. Everyone will be going back to their homes and their day-to-day lives, not necessarily knowing where or when they might have come into contact with someone who was positive. This makes determining if and when to test somewhat problematic, since CDC recommends that even if you’re vaccinated, as all HIMSS21 attendees are, that you test on day 3-5 if you’re exposed. Since HIMSS keeps touting its Accelerate platform and the meeting app, having a COVID-19 tool as part of it would have been cool – even my alma mater has one for its on-campus students.

Although I can’t provide medical advice since I don’t want to run afoul of any laws, I can tell you what my own plan was going to be for post-HIMSS symptom surveillance: stay mostly in one part of the house, avoid the rest of my household, and have a test four days after coming off the plane. If negative, it’s highly likely that the virus has been dodged.

From everyone who has corresponded with me, it sounded like the in-person conference still had value even though there were some 100% unstaffed booths today. People generally liked being able to conduct their business without having to navigate crowds and without having to rush from meeting to meeting, since some of the meetings had canceled. Vendor-side reps felt the conversations were high value and less rushed. We’ll have to see what things look like a few short months from now, when we (hopefully) gather in Orlando. Time to hit the end-of-summer sale rack for what will become my sassy spring sandals.

Will you be attending HIMSS22? Leave a comment or email me.

Email Dr. Jayne.

Dr. Jayne Goes to HIMSS Digital – Wednesday

I rolled out of bed for an early morning client call, which I would have had to do had I been in person in Las Vegas, but it was at 7 a.m. rather than 5 a.m. so I was grateful. Rather than a $33 room service coffee such as the one Mr. H mentioned yesterday, I opted for a Diet Coke with my morning bagel.

Once clients were done for the day, I got ready to tune in to HIMSS, only to have the neighbor’s lawn care service join the party. I’m used to it by this point and was ready with a headset, but it just illustrates the contrast between HIMSS in-person and HIMSS Digital.

I had a little bit of frustration with the programming this morning as I logged into what was supposed to be a keynote session. Instead of getting a typical intro for a keynote speech, we started out with 10 minutes of banter between the hosts. They were again pushing the Leaderboard Challenge and the participation prizes, this time sweetening it with not only a Starbucks gift card, a HIMSS membership, and a paid registration for HIMSS22, but an Alex Rodriguez autographed baseball. The host was giddy with excitement when talking about it. Personally, I’d rather have a Farzad Mostashari autographed bow tie, but that’s just me.

When the keynote speaker, Arianna Huffington, finally arrived, the presentation was more like an interview than a keynote. I guess I’ve become too accustomed to actual keynote speeches where the speaker is up on a stage, or if virtual is delivering prepared remarks, rather than having what feels like an impromptu conversation. The discussion went on for about 20 minutes and covered some good points, then it was back to the hosts and the “HIMSS Community Wall.” Host Chris tried to amp up the audience with an enthusiastic “Hey healthcare changemakers, temperature check time!” and honestly I didn’t even know what to say to that.

The next segment was “Global Burnout: Can Digital Transformation Be the Cause and the Cure?” The speakers had some good points about burnout in general among clinicians, and it warmed my heart when the speaker from Stanford talked about how important it is to have clinical informatics physicians involved in major technology projects. Overall, the consensus was that all of us are suffering with some degree of burnout and I certainly agree. One panelist talked about how when her institution implemented an EHR, she swapped her 20% clinical work for 20% teaching because the work required to learn the EHR wasn’t worth it. Another panelist who is a subspecialist discussed being re-tasked to the emergency department during COVID and how glad she is to be back doing colonoscopies.

They talked about how delivering telehealth causes a different kind of exhaustion than in-person care – where people are not getting up from their desks, not taking restroom breaks, not eating or drinking, and having to provide technical support for patients when the physicians themselves weren’t equipped to do so. She noted that for the people who think telehealth is easier, thinking about it in that way is a mistake.

They also discussed what their institutions were doing to prevent burnout. One panelist noted that her organization has a team that calls patients pre-visit and does the technical check-ins to remove that burden from providers. Her organization also pushed a program called “Home for Dinner” which encouraged workflows to allow providers to finish their office days quicker and get home to their families. They used EHR data and personal observations to create individual learning plans to help providers. Inbox optimization and creation of refill protocols were also part of the initiative. Of those who completed the program, 85% of physicians recommended that their peers participate, so now they have a waiting list. I wish more organizations would take this approach, but of course training is just another budget line item that often gets overlooked yet leads to provider dissatisfaction.

The final part of the session was about preparing future clinicians for the digital workforce. The moderator’s feed was having issues with the video not lining up with the audio, which was distracting. There was good conversation about the need for 1:1 mentoring for clinicians who want to work in tech, identifying skills gaps and trying to develop existing workers. Other comments included the need to set up designated training programs to ensure clinicians are ready to embrace digital health.

Vendor notes: Podium sent an invite at 9 a.m. for their event at Topgolf tonight. It came to an email address that isn’t registered for HIMSS so I’m not sure how I got on the list or why the invites went out so late, but good try!

Presenter tips from the HIMSS Digital trenches:

• If you’re using a ring light, do a brief video of yourself and make sure your ring light is not reflecting in the lenses of your spectacles. You’ll thank me later when you don’t release a timeless recording of yourself with weird circles over your eyes and your audience will thank you for not providing that as a distraction.
• Test your audio and do a brief recording of yourself and see how you sound. Not all devices have good microphones and sometimes people using Bluetooth headsets experience feedback or weird static sounds compared to using a wired microphone. Understanding microphone gain is important to make sure you’re not too quiet and that you don’t have to yell to have your volume at the same level as other presenters.

Today’s reader shoe pic is great – I love the tassels. I got a kick out of Microsoft Word suggestion that they were sandals, however. Perhaps the folks at Microsoft need a shoe advisor? I’m available.

Dr. Jayne Goes to HIMSS Digital – Tuesday

No line at the coffee bar (a.k.a. my kitchen counter) again this morning, and my bagel was included as “complimentary” given the list of things I picked up on my Costco run last week. I could order delivery for every meal this week and still come out ahead compared to what I’d pay in Las Vegas, so I’m not complaining.

I had some frustrations with the HIMSS Digital platform today. First, when you add a session to your calendar in the platform, there’s not an option to add it to your Outlook or other calendar. Instead, you have to open the session, then click the “Add to calendar” button. At least for Outlook, rather than opening an appointment with my native Outlook client, it tried to send me into Office 365. Not sure why they can’t make their tech work like every other calendar interaction that consumers encounter, but after all it is HIMSS.

I also had the usual HIMSS frustrations around there being no sessions I cared about at a particular time but then having a couple that I was interested in that occurred on top of each other. That would likely be the same in-person, except for Digital you can opt to stream the recording a couple of hours later. One of the conflicting sessions revolved around the cultural aspects of digital healthcare transformation and the other was about capturing structured and unstructured telehealth data to determine whether telehealth is truly delivering return on investment. I ultimately opted for the cross-cultural session and was rewarded with a pop-up thunderstorm with lots of lightning and an unstable internet connection, so it was kind of a wash. I’ll have to try to pick up those two recordings tomorrow.

We’re all used to big press releases at HIMSS but the only thing I saw today was the announcement that CVS Health has launched its Aetna Virtual Primary Care program in partnership with Teladoc Health. The offering is available for self-funded employers and includes both remote and in-person care. It includes coordinated care between a designated virtual care physician and a consistent team of specialists, which differs from some of the other virtual primary care offerings out there that don’t include the specialist piece. Other features include unlimited communications with a virtual nurse care team including support for navigation to in-person services and a zero-dollar copay for primary care services. We’ll have to see what the uptake looks like over the coming months. According to my friends at Statista, 67% of US workers are covered by self-funded plans, so it’s quite a market.

I can’t be there for the exhibit hall happy hour, but made sure to have a cocktail in hand for my afternoon sessions which were largely on-demand. I did receive my first reader shoe pic today, and I think this attendee is fully embracing casual mode. Two of my usual HIMSS BFFs and Exhibit Hall Crawl pals sent me some pictures of after-hours social activities, so at least I can live vicariously. I miss you all, and especially all of your fabulous shoes.

What’s your take on HIMSS21 in-person or digital? Or are you glad you’re not part of it at all and just going on about your day? Leave a comment or email me.