Curbside Consult with Dr. Jayne 5/2/22

Today is truly a cleanup day. I’m plowing through 2,300 unread emails. Some days you just can’t make things up with the stories that are out there.

The US Department of Justice announces that a Long Island cardiologist has been charged with crimes related to a COVID-19 healthcare fraud enforcement action. He is alleged to have defrauded Medicare and Medicaid of more than $1.3 million in payments related to COVID-19 testing as he submitted claims to those payers for office visits that were not performed in conjunction with COVID-19 testing. The defendant’s practice had mobile testing sites across Long Island, and apparently some of the billed office visits occurred when the defendant wasn’t even in the state. The prosecution is part of a larger effort by the Department of Justice to crack down on those exploiting the ongoing public health emergency. Criminal charges have been filed against at least 21 defendants for COVID-related healthcare fraud and total nearly $150 million in false claims. The overall Medicare Fraud Strike Force, which was formed in 2007, has gone after more than 4,200 defendants who fraudulently billed Medicare for over $19 billion.

Just a little over a month ago, medical students across the US learned where they’d be doing their training as a result of the National Resident Matching Program. This article about a participant who didn’t match caught my eye. Travis Hughes completed both MD and PhD degrees at Harvard and had a lengthy curriculum vitae with numerous publications and four patents, yet still didn’t match into his desired field of dermatology. More than seven percent of fourth-year medical students in the US failed to match, so he wasn’t alone, although his qualifications likely make him unique. Rather than lament his situation, Hughes used the experience as the push he needed to move towards a career in healthcare technology.

I’m often contacted by people in similar situations looking for advice on moving into healthcare technology or clinical informatics. Not only do unmatched graduates reach out, but those who are in their last year of medical school and who have decided that clinical practice is not for them.

I’m supportive of people finding their bliss in medical careers that don’t involve seeing patients, but have some advice for individuals in this situation. First, just because you graduated from medical school doesn’t mean that you understand what it takes to become a board-certified practicing physician. There’s a lot that happens during the three to seven years of residency training and no amount of reading about it or having friends who are in residency is going to help you become equivalent.

Second, if you’re going to try to find solutions for practicing physicians, you need to understand what happens once you are in practice. Learn what a RVU is or how physician compensation is influenced by patient satisfaction scores and clinical quality metrics. Learn how hard it is to keep a medical practice staffed to a level that provides high quality care but runs as cheaply as corporate employers require.

Third, please don’t talk to practicing physicians like you’ve been in their shoes. Over the past two years, I’ve had many patronizing encounters with physicians who have gone the start-up route. I don’t want to hear about how you dropped out of a surgical subspecialty residency the year before graduation, yet you think you understand what it feels like to be a practicing family physician or an emergency physician dealing with COVID. Sure, you can talk about how you understand the market forces and the pressures we’re under, but you certainly haven’t been there or done that. Also don’t talk about patients like they’re numbers or widgets, because those of us who really treasure the patient/physician relationship aren’t likely to warm to that strategy. If you want to impress us, make sure we feel like you understand that those patients are someone’s mother, grandfather, sister, or child.

Finally, if you’ve decided to take a different path in your career, get some training. If you want to go into clinical informatics, maybe you should join the American Medical Informatics Association. Consider taking one of the 10×10 courses that they offer in partnership with Oregon Health & Science University. Do a fellowship in clinical informatics. Don’t post on physician-focused Facebook groups that you’ve just decided to go into informatics and ask how to get jobs with no experience and no training. Definitely don’t demand that people call you and give you career guidance because you’re too lazy to spend some time on the internet figuring out what it takes to be qualified in the field.

I do wish good luck for all those who are contemplating career changes or who did not match. Much work is ahead and it’s a difficult road. Hopefully, this advice might provide a small amount of insight for those walking it.

I’m doing a fair amount of work with various vendors and have been invited to participate in multiple vendor user group meetings for the upcoming season. While some vendors are going back to their tried-and-true pre-COVID meeting plans, others are using the opportunity to make changes to format and desired attendee profiles. There have been a few recent in-person meetings since HIMSS, and by report, the attendance has been less than previous years. Epic kicked off its XGM Expert Group Meetings last week in Wisconsin and they continue through the end of this week. The American Telemedicine Association meeting is also happening this week in Boston. I’d love to hear from attendees as far as their boots on the ground experiences as well from others who have decided not to attend conferences right now. At least one major health system that I interact with has continued to restrict business travel for the remainder of 2022. They’re not saying employees can’t travel, they’re just refusing to pay for any of it, blaming it on COVID.

Although various states, jurisdictions, and businesses have collectively decided that COVID-19 is over, it’s starting to make a return in my area. Several schools are hitting the thresholds for which students and teachers have to resume masking. I’ve got a couple of flights this week, and despite the airlines’ movement to a mask optional arrangement, I’ll be sporting a KN-95. Even though the COVID infections that most people are getting now are relatively mild, we’re starting to see much more long-term data that shows that even people with mild infections are at higher risk for cardiovascular and other complications. I’ve dodged it so far and am hoping my luck holds.

From a patient care perspective, it’s the school and sports physical season as young people get ready to go away to camps or to prepare for fall sports. Our state has instituted a special process for return to play in youth who have had COVID, and we’re finding quite a few athletes who aren’t as healthy as they thought they were before we started asking some very pointed questions.

Is COVID-19 still playing a role in your habits or travel plans? Is your employer still requiring any mitigation strategies or is everyone back to the office as usual? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/28/22

Half a dozen people sent me this article about Teladoc’s stock woes following recent statements on its outlook. Based on the comments of company leaders, it seems their customer acquisition costs are higher than anticipated. They also cited lengthy sales cycles as a barrier to growth.

Having been on both the health system side and the vendor side of the process, everyone underestimates the length of the sales cycle. My former hospital employer locked in budgets in July of the preceding year, and if you wanted to buy anything that wasn’t previously budgeted, you had to figure out how to fund it from your allocated bucket. Even if you were replacing a system with something newer and more efficient, you better not cross the red line with implementation or consulting fees. This ultimately led to a glacial experience for vendors trying to bring new solutions to the organization.

There have been some interesting articles in the telehealth literature of late. One looked at rates of antibiotic prescriptions for acute respiratory infections and compared performance by hospital-employed physicians to that of third-party contractors. There was a higher rate of antibiotic prescriptions by the contractors. Although the conclusions have received a lot of publicity, I think the results demonstrate that additional analysis is needed. The study looked at telehealth visits for health system employees and dependents between March 2018 and July 2019. The study was controlled for patient age, day of the week, and overnight visits. It only looked at 257 telemedicine encounters for acute respiratory infections.

In my experience as a telehealth provider and CMIO, the study didn’t look at some variables that can influence prescribing patterns. Number of years post-training can indicate whether the physician’s formative years occurred in the “less is better” era of antibiotics. There have been a lot of semi-retired physicians in my telehealth groups who might not be as close to current evidence as we’d like. Importance of patient satisfaction scores is another factor, and I’ve seen plenty of prescriptions issued in both the telehealth and in-person arenas by physicians who didn’t feel empowered to say no because of the potential impact on patient satisfaction scores. Method of compensation can also be an influence when physicians are paid on volume – it takes more time to explain why you’re saying no, which means lower wages for those providers versus those who are being paid a shift rate or who are compensated using other variables.

It also didn’t note whether the physicians were practicing on the same EHR system or whether the telehealth vendor had its own platform. I’ve practiced with three national telehealth vendors and none of them had the same level of clinical decision support that I’ve had in a health system or large practice EHR.

Last, it didn’t look at the presence or absence of quality metrics and reporting. In my health system-employed jobs, I’ve received a monthly quarterly metrics package that directly impacted my pocketbook as well as my understanding of my behavior. In my telehealth-only gigs, quality was only addressed robustly by one vendor and two of them didn’t deliver reports packages to me at all. None of the telehealth-only organizations offered bonuses or penalties tied to quality. I suspect that even if you had third-party physicians, if they were practicing on the same EHR and received the same quality measures reporting, compensation structure, etc. that the numbers would be similar.

It would also be interesting to look at data from the post-COVID world, when most organizations made significant leaps forward in their application of telehealth. Systems used in 2018-2019 were fairly rudimentary compared to what we have today, not to mention that physicians’ experience with telehealth visits has grown exponentially. Hopefully someone will do research to look at the impact of the rest of these factors as I suspect there is more to the story than meets the eye.

Telehealth also took a hit in this JAMA Network Open piece looking at follow-up patterns for acute conditions compared to chronic conditions. For acute problems, patients who had an initial telehealth encounter were more likely to have a follow-up encounter, including emergency department encounters and inpatient admissions. For patients with chronic problems, patients who had an initial telehealth encounter were less likely to have a follow up encounter. The authors note that there are some potential problems with uncontrolled confounding bias. They provided the example of the bias in deciding whether to deliver an encounter via telehealth or in person. They also noted the need to look at other clinically important factors, such as frequency of laboratory testing and prescribing or adjusting of medications. The study was limited to commercially insured patients and didn’t include subjects with Medicare, Medicaid, or no insurance. We know those patients often have significantly different care experiences that would be worth examining.

Thank you to all who reached out regarding my recent post on EHR downtime and medical errors. Many of you had gut-wrenching EHR downtime stories to share. I appreciate the stories but am saddened that we are all part of this club we never wanted to be a part of. Several readers noted the need to have ongoing downtime education – not just when people join the company or at the same time of year that everyone has to churn through annual HIPAA, Compliance, and Fraud / Waste / Abuse training. Others suggested practice downtime events to make sure people know when and how to declare a downtime, as well as where materials and supplies are located. Both strategies would certainly help, so thanks for bringing them front and center.

I’ve been having difficulty sleeping since the recent time change, which was confounded by multiple trips from one coast to another. I’m not into pharmaceuticals and even some popular supplements like melatonin have fallen out of favor. It’s been a rough couple of weeks, so I’m back in pastry therapy. For your consideration, I present a new take on the classic pineapple upside-down cake. With the right amount of brown sugar and butter, you really can’t go wrong.

What’s your favorite stress-relieving pastime? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/25/22

This week’s Monday Morning Update discussed an EHR outage at two of Tenet Health’s hospitals in South Florida. Apparently Tenet didn’t like the media coverage from WPTV and suggested that a story about the downtime be removed. The story covered a patient’s concern about potential medical errors during the outage, with Tenet complaining that suggesting a downtime could result in medical errors is “preposterous.” As a physician who has been in the trenches for more than two decades and who has been through enough EHR downtimes that I couldn’t begin to count, I’m speechless at the thought that downtimes aren’t problematic.

I’ve been up close and personal with a downtime-related medical error in my career, and the situation certainly would have been different had the EHR been online. It was a bit of a perfect storm-type situation. First, I was a relatively new hire still getting used to the processes at a new urgent care employer. Second, due to someone calling out sick, I had been rescheduled from my usual location to a different site, which added a baseline level of stress to the day since I was working with an unfamiliar team. Third, due to a pre-existing diagnosis, the patient I was seeing for a fever was unable to contribute to the history of the presenting problem and was combative during exam, which is tremendously stressful.

After my initial attempts at history-taking with family members and a brief exam during which I detected no emergent problems, I ordered some laboratory studies and moved on to see other patients. When I left the patient, he was pacing around the room and showed no signs of being in distress or in pain.

At some point before the tests were resulted, the EHR went down. As a new employee, I was unfamiliar with the downtime process, but knew there should be one. I asked if there was a downtime binder or how we were supposed to handle it. The clinical team lead was resistant to instituting downtime procedures, giving excuses along the lines of “the EHR usually comes back in a few minutes” and “it really makes a lot of paperwork if we try to go to downtime procedures.” Knowing that creating paperwork is the point of a downtime procedure, I pulled some paper from the printer and began writing my own SOAP notes and documenting what I could.

I remember having probably half a dozen patients on the board that I was seeing. I tried to move them through the process while begging for a paper prescription pad so I could write discharge medications and keeping a clipboard with sticky notes on it as a tracking board to help me remember what patient was in what room. Lab results were being printed from the instruments on little slips of receipt paper rather than flowing through the interface to the EHR. The results were in an unfamiliar format, with the individual tests being out of order within a panel and the reference ranges being difficult to read. Despite the downtime, the staff continued to room new patients and expected us to move forward. I was surprised by that – none of the patients were emergent, and as a walk-in urgent care center it would have been within our rights according to state regulations to stop taking new patients.

I was managing patients the best I could and providing written discharge instructions that I was typing in Microsoft Word and printing two copies so we could scan them later. For my patient who had a fever, there wasn’t anything apparent on the exam or on my review of the labs that could have been causing it, so I recommended close follow-up at home and told them what to look for. This was during the usual season for viral illnesses, and in many patients, the illnesses begin with fever but don’t always declare themselves with other symptoms for a day or more. Since the patient couldn’t describe his symptoms and the exam was difficult, I didn’t suspect anything serious.

Every one of my hand-typed discharge instructions included my best recollection of the practice’s standard disclaimer, which would have been automatically applied by the EHR had it been online. It was something along the lines of “Your examination at XYZ Health today is limited by the capabilities of this urgent care facility, which does not include advanced imaging or moderate complexity laboratory testing. If at any time you feel your condition is worsening, we recommend that you be re-evaluated at the nearest hospital Emergency Department.” I reviewed this instruction with the patient (who could not verbalize understanding) and his adult caregiver, who said she understood.

Two days later, I was called before the practice’s owner and yelled at for “letting someone walk out of here with those abnormal labs,” because by that point, the patient ended up having a significant abdominal infection that required surgical drainage. I explained that at the time I saw the patient they had no features of a serious abdominal process and reviewed the examination that I had documented on my handwritten SOAP note. I was then asked to review the documentation that had been keyed into the EHR after the downtime ended. There it was, in bright red — an abnormal lab value. I had missed it when looking at the receipt-paper printout in an unfamiliar format and with confusing reference ranges. It wasn’t a critical value, but it was abnormal enough that it might have made me think about additional potential diagnoses, even if the physical exam didn’t point me towards an abdominal cause for the fever.

In reviewing the patient’s course, he hadn’t been taken to the emergency department for more than 12 hours after I had seen him, which wasn’t a guarantee that the process requiring surgery was yet present when I evaluated him. Usually if patients have a significant infection in their abdomen, they’re not likely to be pacing around the room – they are completely still on the exam table, and you can hardly touch them. Still, I couldn’t help but second guess the factors that went into my care of the patient – the unfamiliar staff, the new location, the downtime, and the patient’s individual characteristics and presentation.

I explained to the now shouting and red-faced CEO that this wasn’t a normal visit under normal circumstances and that I didn’t have the luxury of having the abnormal lab highlighted in red in the EHR during the visit because there wasn’t an EHR during the visit. He seemed surprised to hear that. Even after he admitted that the EHR downtime was an issue and there’s to way to know if my care contributed to the problem, I agonized over the situation. Several peers reviewed the chart and had no additional suggestions, but that certainly didn’t make me feel any better.

The bottom line here is that EHR outages are difficult. They raise the potential for medical errors in a number of ways. They add stress to already overwhelmed staff. They remove safety checks that we’ve come to rely on. They increase cognitive load as clinicians look at data in unfamiliar formats. They reintroduce illegible handwriting to the environment. They also create time pressures when they end and staff is forced to key in data while they proceed forward with their usual assigned tasks.

I’m fortunate that the patient in this scenario had an uncomplicated hospital stay and there were no long-term consequences of the event, either for him or for those who cared for him. However, the long-term psychological impact on me as a physician makes me never want to encounter another EHR downtime again.

What do you think about Tenet’s comments regarding EHR downtimes? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/21/22

Telehealth company Amwell adds two new clinical programs to its platform. Payers can brand the offerings as part of their digital engagement strategies. The dermatology program offers sessions with board-certified dermatologists in an effort to alleviate delays in dermatologic consultations which can be several months in many parts of the country. The press release notes that it offers “most diagnoses returned in just 24 hours,” which makes me wonder if it’s an asynchronous offering versus a virtual visit with a dermatologist. The musculoskeletal program will help payers address challenges with physical therapy access, disrupted productivity, and downstream costs. It will provide patients with a personalized physical therapy plan, telehealth visits, digital sensors for guided exercise sessions, behavioral health support, and patient engagement services.

This article about non-fungible tokens (NFTs) caught my eye since it’s not often that you see them mentioned in the same sentence as “medical ethicists.” It raises important points about the fact that EHR data is being sold without patients being fully aware of it. How many of us actually read the documents given to us at medical appointments such as the Consent to Treat, Assignment of Benefits, and HIPAA Notice of Privacy Practices? The numbers are likely low because we just want to be treated and aren’t going to walk away regardless of what’s in there, for the most part. The last time I was at my local academic medical center, I was asked to sign a signature pad saying I had received the documents despite not having been actually offered the documents.

The premise is that a patient could own an NFT of their medical information, which could be stored in a secure database that would track access requests and approvals. The piece also points out that patients could maintain ownership of their biological specimens, from blood to tissue and even down to the cellular level. When you learn about the cell lines used in research and where they came from, there’s been tremendous injustice. (“The Immortal Life of Henrietta Lacks” is a great read if you’re curious.) Some ethics professionals disagree, saying that ownership of such data is shared between patients and the physicians and health systems who are involved in their care. The article notes that there needs to be a balance between privacy and public health along with greater understanding of why patients might not want to share their data.

There are also sustainability concerns around the creation of NFTs and maintaining the blockchains used to track them, as well as the risks of data making it outside of the public ledger or it moving to the black market. One researcher points out that “you can’t de-identify something with a genome,” reminding us of the uniqueness of each and every one of us. I would settle for greater attention to how patients are informed of the ways in which their information is used, and protections for those who want to opt-out of having their data become part of anonymized data sets that lead to profits for others. I’m not sure what the other potential answers are here, but will be interested to see how things evolve over the coming years.

With as much time as I’ve spent recently with marketing and branding exercises, I was surprised to learn that “debranding” is also a thing. Upon further review, it’s an extension of branding, but with a focus on simplicity and cleaner design. Examples include removing complicated color gradients or shadows in order to make logos cleaner. Increased use of mobile devices is a driving factor, as is a drive towards a more professional appearance. It’s fun to look at certain brands and see how their presentation has changed over time, especially in the consumer space.

A recent KLAS publication looked at the causes of clinician turnover. Although nurses are most likely to leave in the next year, other types of clinicians are close behind. EHR and IT tools are cited as a major cause, along with burnout, chaotic work environment, lack of personal control over workload, and more. I recently joined an online physician forum for EHR issues and have been shocked that the majority of questions are actually operational and management questions rather than technology issues, but physicians are turning to technology hacks to try to fix deeper issues.

I feel like I’m yelling into the void every time I say something along the lines of, “This is an operational issue requiring a policy and procedure to keep your practice staff from dumping on you, not something that needs another macro or preference or configuration in your EHR.” One physician confided in me that her two partners have left because the practice, owned by a large health system, is so chaotic and mismanaged. Rather than hiring a locum tenens physician until they can fix the problem and find permanent hires, the employer expects her to manage a panel of over 10,000 patients by herself with only a front desk staffer and two medical assistants. This is in a semi-rural area, and I’ve seen the complexity of her case mix. She’s to the point where she’s ready to resign if she doesn’t get some help, and the health system doesn’t seem to care. From a couple of decades in practice management and healthcare operations, I’d bet on the fact that better EHR templates and macros to respond to patient portal messages are not the answer. Shame on the health system for letting it get to this point and especially for thinking this is an acceptable solution.

When people are under stress, they turn to different diversions – often during the workday. If my Facebook feed is any reflection, there are many people are into playing the New York Times Wordle game. There have been plenty of imitators as well as specialty games. If you’re looking for some brain-stretching timewasters, I offer for your consideration:

• Worldle – geography themed.
• Wordosis – medical themed.
• Morsle – Morse code recognition.

Ever gotten the Wordle on the first try? How fast can you transcribe Morse code? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/18/22

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/14/22

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/11/22

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/7/22

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/4/22

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/31/22

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/28/22

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/24/22

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/10/22

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/7/22

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/3/22

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/28/22

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/24/22

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.