EPtalk by Dr. Jayne 12/22/22

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/19/22

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/15/22

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/12/22

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/8/22

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/5/22

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/1/22

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/28/22

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/21/22

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk with Dr. Jayne 11/17/22

HLTH Recap

After leaving CHIME last week, I had just enough time to swing by my home base, run a couple of loads of laundry, and repack for a climate that was 20 to 30 degrees cooler than San Antonio. Many of the people in Las Vegas were complaining about the cold, but there wasn’t any snow like I had at home, so I was happy with the temperatures.

This was my first year attending the HLTH conference and I wasn’t sure what to expect. Registration Sunday was crowded, with lines snaking throughout the halls of the conference center. There were plenty of staffers helping people find the end of the line and it moved quickly though.

Sessions on Sunday were standing room only. It felt strange being packed together like sardines given the social distancing of the last couple of years. I was one of the few people masking during the conference, although I wasn’t able to do it as consistently as I would have liked. Still, I figured that if I can reduce the risk of being exposed by even 50%, it was worth a shot. I have a lot of reasons to not bring COVID home, including the fact that next week is Thanksgiving and I have elderly and immune compromised relatives, and also the fact that I’m scheduled for a long-awaited medical procedure and don’t want a COVID-related cancellation. In some of the conversations I had, however, I felt like I had to explain to people why I was masking, which seemed strange.

Walgreens was offering COVID and flu vaccines onsite, but I didn’t see any mention of testing. I did, however, see multiple people buying COVID test kits at the local pharmacy. Several people I spoke with wished that HLTH had encouraged people to be vaccinated and to test prior to departing for the conference. Within the first day, I received four notifications from the local COVID-tracking app letting me know that I had been exposed. Although I’m glad to get the notifications, it was disappointing to receive so many so quickly.

The exhibit hall opened on Monday. I was initially a bit underwhelmed – there wasn’t the kind of energy I’m used to when HIMSS or another big show has its opening day. This improved as the day progressed, and I think perhaps people just took longer to settle into their booths than expected.

I liked the way that HLTH handed meals, with multiple locations serving food that was included in the price of the conference. I also liked having the “grab and go” options available throughout the day, including a bagel box, sushi lunch, breakfast burritos, a protein box, and more. The only downside of the grab and go stations was the lack of beverages, so unless I had a full water bottle in my bag, I had to trek somewhere to find a drink.

The exhibit hall was set up in a hub-and-spoke configuration rather than a grid structure, although there were grids within the various spokes. While standing near the supersized maps of the hall trying to find booths, I heard many comments that people didn’t like the configuration. The center of the hub was a giant HLTH-emblazoned moon suspended from the ceiling, with a darkened space with bean bag chairs inside.

The wi-fi at the conference center went down a couple of times during the week, and the HLTH app advised attendees not to use personal hotspots as they were contributing to the problem. There’s nothing quite like spotty wi-fi at a healthcare tech conference.

I spotted these cute shoes on Monday at a panel on maternal health that featured Jaime Bland, DNP, RN from CyncHealth, Mandira Singh from PointClickCare, and Thomas Novak from the Office of Policy in the Office of the National Coordinator for Health IT. I don’t think people realize that pregnancy in the US is a risky condition. The panelists did a great job reviewing the challenges of interoperability and how to best let people know at the point of care that a patient is or has recently been pregnant. To paraphrase one of the panelists, you can’t just go around asking every woman if they’ve had a baby in the last 90 days. They discussed efforts happening to improve the situation in Nebraska, where many individuals have to travel an hour or more to receive prenatal care or to give birth.

These less-than-cute and decidedly orthopedic-yet-platform shoes were spotted at Zara, across the street in the Fashion Show Mall.

Speaking of shopping, one of the reasons I chose to stay at The Palazzo was its proximity to the meeting, as well as the fact that you can connect through the Grand Canal Shops and avoid walking through the smoky casino. One of the downsides of that path was that the folks working the cosmetic and bath products shops would stand in the doorways and hassle you as you went by. They didn’t seem to understand “no, thank you” and became increasingly aggressive as the week progressed. I have to say I’ve never made a purchase at a shop where people yelled at me from the door, and I’m not about to start.

Also spotted cutting through the shopping area was this person with a rescue-style backboard. She entered the Atomic Saloon Show theater and didn’t seem to be in a hurry, so I hope it was simply an in-service training session.

Solutions for tired feet were available at this handy vending machine at the Venetian.

Only in Las Vegas do people throw paper money in the fountain in addition to coins.

Although the food options in the exhibit hall were solid, finding dinner in the complex without a reservation was tricky. Many of the restaurants were not operating at capacity, presumably due to lack of staff. Others were packed. I successfully dodged being gifted an alcohol-filled guitar at a place where we stopped for a quick burger. On Monday, I would have enjoyed a nice glass of wine with a friend in the late evening, but we were stymied by the combination of restaurants that close at 10 p.m. and bar/lounge areas with a steep per-table minimum.

Cool things spotted on the floor:

• Caption Health offers Caption Care, which they describe as a “turnkey, end-to-end echo program” for heart failure with the ability to perform exams in the home or office setting. They offer “AI-guided ultrasound” and emphasized the ability to detect disease earlier.
• Kahun had a presence alongside a number of companies from Israel. Their digital clinical reasoning engine helps identify patient symptoms and connect them with clinical insights, including citations of peer reviewed studies upon which clinicians can rely. Some recent enhancements include the ability to order labs alongside the clinical information being provided.
• A blood drive was held Tuesday and Wednesday. Thanks to all who participated.

Hinge Health had plenty of giveaways and there was nary a rep in sight.

I spotted these reps in sperm hats several times, but couldn’t figure out which fertility company they were from.

A colleague of mine was on a panel Tuesday that was titled “Sexual Healing.” That should have been a great attention-getter, but I was disappointed to see so few people attending, especially since this is an important topic that more people should know about. It became busier as the session progressed, and most people stayed for the entire session. Sexual health can be an indicator of overall health and is impacted by many conditions, from depression to vascular disease to pelvic floor dysfunction and more. Often these conditions aren’t covered in medical school, residency programs, or physical therapy programs and it was great to hear this dynamic group trying to cut through the “shame and stigma” that they see in their patients and clients.

Carine Carmy, co-founder and CEO of Origin, noted that they are engaging patients through welcoming environments and “using wellness as a veneer for healthcare.” They are positioning their physical therapy services more like a consumer brand than a medical establishment because that’s what gets attention right now in the US. Lyndsey Harper MD, founder and CEO of Rosy Wellness, Inc. talked about their platform, which offers curated materials to help patients along their sexual health journey.

Tuesday night was party night, and I hit a couple of gatherings including one sponsored by SteadyMD (fresh off the announcement of their participation in the new Amazon Clinic telehealth offering) and Zus Health. Jonathan Bush addressed the audience towards the end of the evening, and although it was entertaining, his speech was tame compared to those he delivered at the HIStalkapaloozas of old.

From there it was off to the Ludacris performance, which was packed. I have to admit I left early, partly due to the crowd but partly due to the volume, which could literally be heard across the street at Caesar’s Palace.

After one more trip past the Bellagio fountains, it was off to bed to rest up for the early flight home.

What things did you think were the best and worst of HLTH? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/14/22

CHIME Recap

Since leaving CHIME, I’ve been dodging sketchy airline schedules, some urgent priorities at home, and snow. I finally have a few minutes to reflect on my first CHIME meeting, which overall was successful in my book.

The general conference vibe was laid back. Most of the non-vendor attendees have substantial healthcare IT experience under their belts and didn’t seem to have anything to prove, so that may have been part of it.

Sunday and Monday were the inaugural “Innovation in Clinical Informatics” sessions, which were great for learning about the challenges that other clinical informaticists are facing. A couple of thoughts stuck in my brain:

• One participant noted that they have concerns about their ability to function during a downtime event, in part because younger staff members don’t read cursive. Several people in my part of the room were unaware that schools stopped teaching cursive more than a decade ago, with the advent of the Common Core State Standards. The concern is real and should be addressed as part of downtime procedures.
• There was a lot of emphasis on asking “why” when solving informatics problems. Finding the ultimate upstream “why” can often lead to different solutions than just taking a request for change at face value. I’m a huge fan of the Five Whys tool, and if you’re not using it with your team, I would ask yourself why.
• Behavioral health was a hot topic. Several speakers noted that patients prefer to have these visits at home. Medical outcomes are better when behavioral health issues are treated, and if organizations aren’t offering adequate behavioral health services, they need to work on their strategies.
• There was good discussion about whether secure chat messages should be considered telehealth.
• UCHealth’s CT Lin presented the “Swiss cheese model of successful innovation,” explaining that all the holes have to align for projects to deliver maximum value. He used it as an admonition about the importance of clinical informatics, because clinical informaticists can often see the problem through different lenses and see how the holes need to align. They can also recommend how to make the connections and avoid pitfalls.
• Clinician burnout was a common theme, as was the importance of culture compared to strategy.

One final thing really caught my attention, and that was discussion about the need to deliver “delightful” patient experiences. Based on my recent adventures in healthcare, I’d settle for “decent” or “passable” rather than the “awful” experiences I’ve been having. That imaging result that was supposed to be released within 24 hours actually took six days to release via the patient portal, and when I returned home, I found a paper result waiting for me that had been mailed the day after the study and arrived two business days later. Something is wrong when you get your results via snail mail faster than via the patient portal.

During the conference, participants had the chance to paint a panel that will form a mural to be hung in a multi-assistance care center providing collaborative care and centralized services for individuals with special needs. The painting project was sponsored by CDW.

Tuesday was the opening keynote, with a celebration of CHIME’s 30th anniversary and an early morning champagne toast. Following awards and recognition, the guest speaker was introduced. Sophia is an “advanced humanoid” robot who was advertised as being able to wow audiences with “her superhuman intelligence and advanced ability to read faces, empathize with emotions, understand the nuances of language, and communicate with thousands of facial expressions. Unfortunately, Sophia seemed to encounter a glitch and the audience was asked to take a 15-minute break while they tried to get her back online. One can only presume that while we were out of the room, they tried turning her off and back on again. She wasn’t much better after the break, using mostly what seemed like canned segments of speech. Based on her performance, I don’t think we have to worry about robots taking over the world just yet.

The rest of the day and into Wednesday was a mix of engaging sessions, meet-ups with colleagues, and a couple of focus groups. Although generally the focus groups provided an opportunity for good discussion and learning about what other CIOs and CMIOs are facing in their organizations, one session became challenging. I couldn’t believe I was watching one participant troll another by making snarky comments about an organization’s challenges, knowing that the leader of the struggling organization was sitting right next to him. It just goes to show that it there’s a lot of variety in leadership skills. I hope that particular individual plays nicer with his colleagues at home than he did in the focus group.

The San Antonio spirit was strong as staff worked on the setup for Tuesday night’s reception and dinner.

For those of you looking for wardrobe and shoe reviews, in general the mood was subdued. Lots of jeans and blazers, but since this was my first time attending, I’m not sure if that’s usual for this conference or if it had something to do with the fact that emails were sent telling folks to bring their jeans and boots. The League of Women session had some fine shoe options including sassy espadrilles, kicky boots, strappy sandals, and “trust me, I mean business” pumps. I opted for some low-key loafers, although I did pull out the boots for the Wednesday night event.

The event was held at the Knibbe Ranch, which is about 30 minutes from the conference center. Not only were cowboy hats and western boots out in full force, but there were also several people wearing Woody costumes from “Toy Story.” As guests stepped off the buses, they had the opportunity to have a photo taken with genuine Texas longhorns. Dinner had a distinctly cowboy flair and was served from buffet lines that contained more cast iron than I’ve seen in one place in a long time (and I’ve seen a lot of cast iron). The bars were serving several Texas beers as well as the usual libations, and dessert of course included pecan pie. Attendees had the opportunity to relax with games of horseshoes and cornhole, along with a campfire.

The main event of the evening included an honest-to-goodness Texas-style rodeo, courtesy of the Lester Meier Rodeo Company of Fredericksburg, TX. In talking with some of the attendees from the UK, they’ve never seen anything quite like it. The rodeo opened with the traditional grand entry and flag processional, followed by bull riding, barrel racing, more bull riding, and of course rodeo clowns. Having spent several years in Texas and having attended a variety of professional and amateur rodeos, I have to say this was some of the wildest bull riding I’ve seen. I think only one or two contestants managed to stay on the full eight seconds, and several looked like they needed medical attention after having difficulty releasing their grips after being thrown or dismounting.

Often a rodeo will have an event called a calf scramble, where children compete to try to catch a calf with only a rope and their wits. I strongly suggest a CIO calf scramble for future rodeos, with proceeds to charity. It would definitely add a healthcare IT twist to the festivities. The rodeo concluded with a fireworks display and guests moved back to the dance hall for music, dessert, s’mores kits for the campfire, and plenty of line dancing.

I headed home Thursday morning, missing the final keynote but making it back in time to take care of some afternoon meetings, run a couple of loads of laundry, and begin packing for HLTH. It’s warmer in Las Vegas than it is at home, and I’ll have the opportunity to connect with friends I haven’t seen in years, so I’m looking forward to the bit of travel.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/10/22

I’m glad to see healthcare delivery organizations putting their proverbial feet down when it comes to patients treating staff poorly. Mass General Brigham is one of the more visible examples, as they release their patient code of conduct. The policy has zero tolerance for “words or actions that are disrespectful, racist, discriminatory, hostile, or harassing.” Patients can be asked to seek future non-emergency care elsewhere if they are found to exhibit a list of behaviors, including sexual or vulgar words or actions. Disrupting another patient’s care or experience is also on the list. Patients who violate the code will be asked to explain their point of view prior to decisions being made about future care at the institution.

Next week’s HLTH conference will include the “Patients at HLTH Impact Program,” which has been designed so that patients and patient advocates can be engaged as “equal partners in care design.” The track offers opportunities for health tech leaders to interact with patients. Since nearly every employee of every organization in the US has been a patient at some point in their lives, I’d suggest that execs don’t need to go far or to spend money on conferences to get input. One of the panels being offered is around “What do digitally-savvy, empowered consumers want?” and although that is certainly valuable, we need to not overlook the non-digitally savvy and non-empowered patients who might need our help even more than the other group. I’d like to see health tech execs troll the waiting rooms and cafeterias of any hospital in the US. They would certainly get an earful, and it would be cheaper than a trip to Las Vegas.

Addressing physician burnout is always a hot topic, so I was interested to see this piece from the American Medical Association on helping physicians reduce “pajama time” and have “more great days.” For those who might not have heard the term, pajama time refers to the time that physicians (and sometimes other clinicians) spend working outside of normal working hours. Although a lot of people think this phenomenon started when EHRs became more common, it definitely happened in the paper world. In my early days as a physician, I had a couple of colleagues who were constantly being reprimanded for taking charts home and sometimes forgetting to return them to the office. However, I was disappointed to see the suggestions made in the article. They’re not at all revolutionary:

• For medication refills, a recommendation was made to renew maintenance medications at the annual visit and to provide the maximum number of refills. This was standard of care in family medicine in the 1990s and appears several times in the literature, yet physicians still can’t incorporate it into their practices. I heard the best description of this workflow at CHIME this week, when UCHealth CMIO CT Lin referred to it as “90 by 4, don’t bother me no more” meaning that patients should receive 90-day prescriptions for their medications with four refills, enough to get them through their next annual appointment. It doesn’t apply to just primary care — anyone performing chronic care can do this and EHR preference lists or favorites make it easy.
• A physician was frustrated by having to walk to the printer to grab after visit summaries to hand to patients, so they installed printers in each exam room. Why are these not being sent through a patient portal for those who have accounts, so that they can become enduring materials accessible to the patient forever versus a piece of paper that can be lost? If the patient isn’t enrolled in a patient portal, why not have a medical assistant or checkout person print them?

I’ve spent a good portion of my professional life helping organizations address policy and procedure issues. Sometimes it’s a gap and new policies and procedures are needed, while other times there are changes needed to keep up with advances in EHR use, medical group governance, office practices, and more. Policies can be a blessing or a curse depending on what they contain, and the latter is addressed in a recent piece in JAMA Health Forum. The authors address the idea of harmful hospital policies and propose that they should be classified along with other “Never Events” such as wrong-side surgery. The authors list five particularly harmful policies:

• Aggressively pursuing payment from patients who are unable to afford their medical bills.
• Spending less on community benefits, such as public health or indigent care, than what is earned through tax breaks due to non-profit status.
• Noncompliance with federal requirements to be transparent about cost of care,
• Paying employees less than a living wage.
• Delivering racially segregated medical care by underserving surrounding communities of color.

They note that other entities, such as insurance companies and medical device makers, are also responsible for harms, but find that given the fact that the majority of hospitals exhibit at least one of the above behaviors, that hospital-associated harms should be addressed in a priority fashion. In addition to calling on hospital leaders to address them directly, they call on the Centers for Medicare and Medicaid Services to deny payments to hospitals engaged in these practices. They also call on state legislatures to require reporting in these areas and state attorneys general to investigate hospitals that are taking advantage of their non-profit status. The article is a quick read and should be mandatory for leaders of healthcare organizations.

Michigan Medicine has fallen victim to a phishing scheme that may have compromised the information of 33,000 patients. The health system learned of the attacks in August, but some patients didn’t receive the breach notification until more than two months later. At least four employees provided credentials that allowed hackers to access their email accounts. I feel for the employees who apparently disregarded their cybersecurity training, for the IT teams that had to investigate and work on the cleanup, and of course for the patients whose information was compromised by individuals who can’t follow the rules.

I feel like I’m fighting a battle on two fronts with email volume right now. At work, I’m getting multiple daily emails from HLTH which don’t always go to their designated folder since I was forced to take a recent Outlook update. In my personal email, I’m inundated with pre-Black Friday emails from retailers. I guess now that the Christmas shopping season actually begins before Halloween, it makes sense for Black Friday to begin November 1. I’d love to see the data on how various retail trends have changed over the years and see what the migration of the start dates for shopping seasons looks like. I’m sure there are big data folks in retail and marketing, so if someone has a connection to the data, maybe you can hook a girl up.

What do you think about the increasingly early start for holiday shopping? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/7/22

There has been a lot of discussion recently about practices that send patient portal questionnaires for existing patients to enter their medical histories. Certainly as a patient, I don’t want to enter information that already exists in my chart, and as a physician, I don’t want to have to reconcile a bunch of information that might already exist in the chart against patient-provided information that may or may not be accurate. Some patients are great at knowing their histories, others are less so.

Once a year, I have an appointment at a major academic center’s high-risk breast cancer program. This year, I was pleasantly surprised that for the first time, they didn’t ask me to provide information that they already had in my chart. The check-in process was quite streamlined even though three separate appointments were involved, so I was looking forward to a smooth visit.

The visit itself was great, with speedy access to an exam room, an upgraded exam gown (flannel with satin trim, if you can imagine), and a short wait for the physician. From there I went to the imaging center waiting room. Although the technician was apparently looking for me in the wrong waiting room (they have three), they ended up locating me quickly enough to get me to my imaging appointment early.

My technician was personable and efficient, making me feel like a valued patient and not like just another patient in a long line of tasks for the day. From there it was back to a different waiting room, where I received preliminary imaging results and met with another physician.

After discussing the care plan, they mentioned that a final radiology reading would be available to me via patient portal within 24 hours. They also explained that due to their current patient mix, they were asking some patients to schedule with a midlevel provider rather than the physician for their next visits. Knowing what I know about healthcare economics and physician staffing, I understood what they were trying to do in making sure the physicians have capacity to manage the patients who need active management of breast cancer and who are planning surgeries in the near term. As a patient, you put a certain level of trust in a leading academic institution to have appropriate physician oversight when you’re seeing a midlevel provider, and as a physician, I know how to advocate for myself if the need arises.

The visit hit a glitch during the checkout process, since there was no one to staff the checkout desk and everyone was being sent to the waiting room. There was quite a line since most patients needed multiple follow-up appointments for imaging, biopsies, or additional clinical appointments. I had plenty of time to read the Patient Bill of Rights they had posted on the wall, which specified that patients might see a physician assistant or a nurse practitioner as part of their visit. It also spelled out that patients have the right to see the physician if they prefer, although that might result in the rescheduling of their appointment. It’s standard stuff, and I didn’t think too much of it until the patient in front of me began to check out.

She handed over her check-out instruction sheet and began asking questions about the providers listed on the board behind the receptionist, as well as their credentials. She was asking which were breast specialists and which were other types of surgeons since it’s a mixed office. The receptionist was describing them, and when she got to the nurse practitioner, she said “Oh, she does everything,” to which the patient responded asking, “Why didn’t she go to medical school then?”

My ears perked up at that and I knew it was going to get interesting. It’s not hard to overhear things when you’re literally three feet apart, and apparently the patient had been given the same information that I had about not seeing the physician at the next visit and wasn’t aligned with the plan. She was shopping for a different surgeon rather than see someone she stated had less education. Having just read the Patient Bill of Rights, I wondered how the office would handle it. The receptionist said she would go and check with the physician.

While she was gone, the patient — with whom I had exchanged pleasantries about my cute tote bag while we were both in the imaging waiting room — turned to me and mentioned that she knew what the answer would be since the doctor had already told her she had to see the nurse practitioner. She went on to say that she was a cancer survivor and that she is scared to not see her surgeon, who knows her the best. I nodded empathetically and waited to see what would happen.

The receptionist came back and announced that she had spoken to the physician and the answer was still no – she would need to schedule as directed. Clearly that didn’t align with the posted Patient Bill of Rights, and honestly if the organization isn’t going to follow it, they need to take a good look at either modifying it or removing it from the office while they reconsider.

I was able to get my follow-ups scheduled and headed home, eager to get my final reports and try not to think about the whole situation for another six months, which is sometimes the best way to approach it as a patient. I buried myself in work the rest of the day, waiting for the familiar notification from the patient portal app that my result was available.

Unfortunately, the notification didn’t come. Nor did it come the next day, or the next, or the following one. I was busy with work and didn’t have a chance to call and wanted to also give a little benefit of the doubt since I know healthcare is in crisis. But now we’re in the weekend, and I’m relegated to wondering where there is a backup in radiology, whether my study was missed, or whether I’m going to get a callback to come back for more images. I know the system’s EHR and how it’s configured to handle release of test results to patients. Once radiology images are final, they release to the patient. The question then becomes whether something is wrong with the EHR and portal systems, or with the test itself.

Since it’s the weekend, I guess I’ll sit and wonder for a few more days, which is never a position a patient wants to be in.

Thinking about the situation as a whole, I think the practice needs to do some introspection around its messaging. In addition to the Patient Bill of Rights issue, they need to provide additional instructions on what to do if imaging results don’t come back. I’m a physician and know to track it down when Monday comes, but a lot of patients might be from the “no news is good news” generations, or don’t have patient portal access, and wouldn’t know to follow up a missing result. In the mean time, I’m off to a conference, so I will rely on my calendar to remind me to make the call.

Does your organization’s patient summary give instructions on what to do when results don’t return? Do you honor your posted Patient Bill of Rights? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/3/22

I’ve experienced an uptick in email solicitations over the last couple of weeks. It’s been fascinating to see the different content and how marketers are trying to use various strategies to get the reader’s attention.

Quite a few of them are going for the friendly-sounding approach, with short sentences and colloquial language. One of the repeat senders is further trying to build on the familiarity by mentioning the local weather and a nearby restaurant, which is fascinating but a bit odd since it’s in an adjacent town. I wonder what the algorithm looks like that says, “hey, let’s pick something close, but not creepy-stalker close” and throw that into the email. They even go so far to mention “location inferred from your company” regardless of the fact that my “company” is located hundreds of miles from the town they mentioned.

I strongly suspect that the emails are stemming from mailing lists related to the conferences I’m attending in the next couple of weeks. It’s one more way for meeting organizers to increase conference revenue, even though it’s annoying for the attendees. I don’t recall seeing any kind of “don’t sell my information” opt-out checkboxes during the registration processes for either of them, but there’s always a chance that I missed them along the way (although from past experience, it’s more likely that the conference didn’t give attendees the chance to opt out). Much like the weeks following HIMSS, I’m sure I’ll be spending quite a bit of time creating new email filters and wading through various pieces of junk email.

I do have to say that I’m a little nervous about my upcoming conference attendance, especially since flu cases are on the rise. The US has already seen more than 880,000 cases of lab-confirmed influenza, and that number doesn’t include the patients who are tested using in-office test kits at physician offices and urgent care centers or those patients who don’t present for testing. Physicians who care for children are concerned, since more than 75% of pediatric hospital beds are full. The leading viral strain at present is H3N2 influenza, which has in past years been associated with higher severity of illness for older adults and children.

Based on what I’ve seen during recent travels, I’m betting I will be one of the few people wearing a mask in crowded situations. I have to admit that I did enjoy the first HIMSS post-COVID, when a good number of people were masking, because I used to nearly always return from HIMSS with a sore throat, runny nose, and generally feeling of cruddiness consistent with a respiratory virus. Especially if you’re not going to mask, now is a great time to get a flu vaccine if you haven’t already received one. I know that lots of people are tired of thinking about contagion after the last couple of years, but the basic tenets of public health are always a good idea.

Speaking of vaccines, while some organizations have kept their vaccination requirements static, several leading universities are requiring students to receive the new bivalent COVID boosters. Schools requiring the new boosters include Harvard University, Yale University, Tufts University, Fordham University, and Wellesley College. Pushback is expected, and the comments on the article are all over the place. Uptake of the new booster has stalled in my community and my urgent care and emergency department colleagues are still exhausted, so some of us are dreading what might happen over the coming months when people move their activities inside and begin gathering for the holidays.

After a recent medical visit, I was flipping through my health system’s patient portal to see how various kinds of documents were rendering and whether there were any changes after the recent updates to requirements for release of information to patients. I found a visit from a few months ago that now had a visible visit note when it didn’t previously have one. I’m confident I would have remembered seeing a note previously based on the last line of the document: “This dictation was done with voice recognition software and may contain errors and omissions.” That’s certainly far from a vote of confidence for the treating provider. Maybe I’m old school, but I can’t imagine putting something like that on one of my notes or signing a note without proofreading and correcting it. I know that everyone in healthcare is stressed, but I’d be embarrassed to allow that in any of my patients’ charts. I had already decided to look for a new physician in this specialty and this just confirms my decision.

It’s common for researchers to create catchy names for their studies, so I was excited to see COSMOS, otherwise known as the COcoa Supplement and Multivitamin Outcomes Study. It’s a randomized clinical trial looking at cocoa extract supplement in comparison to a standard multivitamin with respect to cardiovascular risk reduction. A sub-study, COSMOS-Mind, will look at whether the cocoa extract supplement improves cognitive function and reduces the risk of dementia. Of course, I’m a big fan of chocolate (although usually in baked goods rather than in a capsule) so I’ve been keeping an eye out for the study outcomes, which finally came out this week.

The results were exactly opposite of what was expected. The multivitamin, rather than the cocoa supplement, was found to be more closely associated with improved cognitive function in older adults. The benefits were greatest in patients with a history of cardiovascular disease. Since nearly 90% of the study participants were non-Hispanic whites, the authors note that additional work is needed to confirm the findings, in particular with a more diverse patient population. Halloween passed in my neighborhood with only a small number of trick-or-treaters, so I’ve got plenty of cocoa on hand. I’m looking forward to the mood boost even if it’s not going to prevent dementia.

How was the Halloween traffic in your area? Will you be nibbling chocolates for weeks to come? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/31/22

I spent a good chunk of time this weekend preparing cranky correspondence to send to organizations that can’t seem to figure out that I don’t work for them any more or that I’m no longer a participating provider with a given payer since leaving the practice. Since I resigned from these organizations anywhere from six months to three years ago, I’m tired of dealing with the continued messages and requests for information. The off-boarding processes were variable across the different organizations, so it’s not surprising that there’s still a bit of a mess to tidy up. Still, one would think that with part-time or contractor physician positions, they would have their act more together.

Let’s take my most recent in-person employer for starters. I was a part time W-2 employee and resigned more than one calendar year ago. Apparently I didn’t get terminated properly with a couple of payers, who continue to reach out to me asking me to update my provider file with copies of my license, Drug Enforcement Agency registration, and state control substance documentation. I’ve sent multiple emails informing them of my last date of employment at the practice, and although a couple of them eventually stopped sending me reminders, there are a couple that are persistent. It’s tempting to ignore the communications, but I want to make sure all my provider files are closed out properly in the event that I join a new practice down the road. It’s always good to have definitive closure, but let’s hope it doesn’t take another 12 months to get it.

Then there’s one of my telehealth side gigs, where I only saw patients for a couple of months before determining that not only was the platform horrendous, but they could never seem to figure out how to pay me correctly. Despite having given ample notice that I was leaving and would not be seeing any patients during my notice period, they went ahead and signed me up for multiple insurance plans after I tendered my resignation. It’s likely a case of the right hand not knowing what the left hand is doing, but I’m tired of getting correspondence from various state-specific plans that can’t seem to understand I’m no longer participating in the provider group or planning to submit any claims.

This same platform continues to text me about high patient volumes despite my trying to opt out of the texts by following the included instructions. I’ve also tried sending emails to various individuals within the company with no response, which leads me to think that either those individuals have moved on or they don’t care. Since I no longer have access to the platform, I can’t look up any additional email addresses or contact information than what I have, so I’m sending my correspondence directly to the CEO and CMO of record as well as the head of the physician group, in hopes that they will respond and point me in the right direction.

There’s also another telehealth side gig, where I signed up but never saw a single patient. After watching them exhibit some unseemly behavior with colleagues, I decided not to engage with them. They followed up on my resignation letter by sending me an administrative termination of their own several weeks later, which I thought was somewhat overkill. They’re still sending me regular emails asking me to complete required training and given their track record with others I want to make sure my provider file is entirely closed out.

My favorite target of cranky correspondence is Illinois Medicaid, which is the “undead” of administrative healthcare organizations. I haven’t been a participating provider since 2014, but every now and then, some computer system somewhere goes haywire and decides that I need to update my provider records. The letters come on paper to my home, I always reply on paper because it seems to work, and I don’t hear from them again for a couple of years. I don’t want to wind up published in a directory as someone who is participating because it has the potential to lead to a lot of phone calls and wasted effort for patients who are just looking for a primary care physician and will keep working their way down the list until they find someone whose patient panel isn’t closed.

We’ll see if this batch of letters and emails is successful at tidying up loose ends or if I’ll still be dealing with them in 2023. It seems like there ought to be a better way. I know there are services out there, but the last time I looked at them, they were fairly pricey. Maybe I can find a retired medical practice manager who is looking to make a little cash on the side and enlist their help to get it done. With the number of people fleeing healthcare employment, it’s not a farfetched idea.

I also have a former employer in the tech space that can’t seem to figure out that I don’t work there even though it’s been more than four years. Not only do I get correspondence from the company proper, but also all of their vendors, including health insurance and more. They just sent me notice of the upcoming open enrollment period for health insurance and encouraged me to sign up quickly and not wait until the last minute. I wonder what would happen if I tried to register for a health plan – might be a good project for next weekend assuming an adequate number of cocktails beforehand.

Speaking of cocktails, I’m prepping to attend back-to-back conferences with CHIME and HLTH and the social event invitations have been trickling in. I almost spit my drink when talking to some colleagues about the latter, which they referred to as “the conference with no vowels.” There’s a lot of discussion about the utility of the HLTH conference and whether it’s worth the money. This will be my first year attending, so I’ll have to let you know in a couple of weeks. I’m looking forward to some warmer weather in San Antonio and Las Vegas, respectively. I’m not looking forward to being in crowded indoor spaces and potentially bringing home COVID, influenza, or some other respiratory illness, so we’ll have to see how it goes.

Any recommendations for a first-time attendee at HLTH? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/27/22

Hospitals and health systems are often sponsors and supporters of various sports teams. Although I understand the reasons and how marketing works, I’m always annoyed since deep down all that spending is fueled by patients.

One of our local surgeons, who is frankly embarrassed at his organization’s sports sponsorships and luxury suites at the local ballpark, shared this piece about a shakeup in stadium naming rights for one of the newest Major League Soccer teams. Health insurer Centene has backed out of a deal to be the naming sponsor for the newly constructed stadium in St. Louis, where the aptly named St. Louis City SC is set to play. The stadium will now be called Citypark while the team hunts for a new naming sponsor. Centene had previously inked a 15-year deal for the naming rights, but a recent statement to local media said it would be realigning partnerships to create “long-term, tangible value for local communities.”

Millions of taxpayer dollars flow through Centene every year via government programs such as Medicaid, so I’m glad they’re reassessing the use of their funds. Not to mention that recent reports indicate that their Medicare Advantage quality scores have been worse than expected, which places its 2024 revenues at risk. The organization recently announced it plans to hire a chief quality officer. I’d much rather see money spent on that role than to name a sports facility. At the same time, Centene noted that quality improvement will be “a compensation metric by which all employees’ performance will be measured this year.” I hope they set things up to truly incentivize the employees as opposed to making it a way to squeak out more cash for the shareholders.

I admit that I’m suckered in by clickbait headlines as much as the next person, so I felt compelled to click on the recent Medscape feature on “Physicians Behaving Badly: US vs. UK.” I had literally just come off a call with a colleague where we discussed various patient misadventures, including misdiagnosis, failure to receive informed consent prior to a procedure, fraudulent patient care documentation, and more. The survey looked at 2,800 physicians in the US and UK. In case anyone is curious, the US ranked higher in several unseemly behaviors, including being verbally or physically aggressive; disparaging others; using racist language; and bullying and harassment. UK physicians ranked higher in public intoxication. “Making unwanted advances” was a choice in the US survey but not in the UK version, and conversely sexist behavior was a choice in the UK but not in the US, so it was hard to compare the two.

When faced with physician misbehavior, US physicians were more likely to complain anonymously to the employer or human resources, where UK physicians were slightly more likely to do nothing. For both groups, the leading demographic for misbehavior was age 40-49, with men outnumbering women twofold. As far as how those surveyed think physicians should behave, data was almost identical for both the US and UK, with two-thirds thinking that physicians should be held to higher standards than the general public due to their role. I dislike seeing healthcare professionals behaving badly, regardless of their title, role, or geographic location. I’ve seen more training programs addressing professionalism in their curricula, so let’s hope things improve.

If primary care physicians spend more time in the EHR, does that lead to improved clinical outcomes? A study published this week in JAMA Network Open looked at this question. Researchers performed a cross-sectional study of 300 primary care providers at two large academic health centers. They found that each additional 15 minutes of daily use of EHR messaging led to improvements in glucose control for diabetic patients, improved management of hypertension, and higher breast cancer screening rates. Of course, that amount of time sounds small, but over the course of a year, 15 minutes a day adds up to an additional week and a half of work for a clinician who is more likely than not to already be burned out and stressed.

The authors noted that “these results underscore the need to create team structures, examine PCP and office workflows, and enhance EHR-based technologies and decision support tools in ways that enable high quality of care, while optimizing time spent on the EHR.” Since so much of EHR messaging work is not part of a clinician’s visit-based, revenue-generating work, they also note that “the associations we have identified between increased in-basket time and enhanced ambulatory quality of care highlight the importance of continuing to develop and expand value-based reimbursement systems that adequately reward outside-of-visit care delivery.”

They note that both academic health systems in the study have dedicated population health teams that support primary care physicians in tracking quality performance. They’re also both located in the same geographic area that has a relatively heterogeneous patient population, and as such, they may not represent the majority of primary care physicians in the US.

My favorite quote from the piece is this: “Our findings suggest that although increased EHR time, particularly after hours, has been associated with increased emotional exhaustion and burnout, it may represent a level of thoroughness, attention to detail, or patient and team communication that ultimately enhances certain outcomes. This finding is consistent with recent research reporting a trend toward better outcomes for measures of health care use for family physicians who reported some level of burnout, suggesting that the extra attention given to clinical problems and extra communication that may occur during additional time spent by PCPs may be valuable for patient outcomes.”

Primary care physicians are living in a way that most are counseled against. Time and again, we have seen their willingness disregard the phrase about “not setting yourself on fire to keep others warm.” In the US, they’re among the most hard-working of physicians with the best opportunity to intervene in chronic conditions and lifestyle issues, yet they’re at the bottom of the pay scale and often with the least support staff. The failure of policymakers to align payments in a way that will best serve patients and reduce overall costs will continue to haunt us for decades.

Do you have a primary care physician, and can you actually get a timely appointment? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/24/22

I’ve used a GPS watch to track my hikes and other travels for almost a decade. Recently, some of the features on my trusty Garmin Forerunner 25 have become erratic and had me looking for an upgrade. I’ve had it for seven years and it has served me well, but I was annoyed after the GPS went rogue a couple of times and the sleep tracker started showing the same pattern whether the watch was on my wrist or on the bathroom counter.

After extensive troubleshooting with Garmin, they couldn’t come up with a remedy and offered me a discount, but only if I stayed within the Forerunner line. I wasn’t thrilled with the options and had been casually looking at other models when a friend clued me in to a sale, spurring me to make a decision.

Wearables hold an interesting place in the hearts and minds of patients. I have plenty of friends that are obsessed with “closing the ring” on their Apple watches to the point where they are almost a servant to the technology. I’ve taken care of patients who take their daily activity tracking data seriously, to the point of messaging their physicians asking about what the slightest blip in their numbers might mean.

I’m not training for half marathons anymore, so I don’t need a lot of the training or coaching features that are out there. I wanted something with decent battery life, both as a watch and in GPS mode, as well as something that looks a little more stylish and a lot less rubbery than my current device. I settled on a watch from the Garmin Venu line.

Garmin’s packaging has become more streamlined since my last purchase. However, the setup process was considerably more complicated. Although I already had the Garmin Connect app on my phone, I couldn’t get it to pair with the watch and had to update the app. It still didn’t work, so I thought I would set up the watch manually then try the Bluetooth piece later.

Garmin is apparently confused about sex versus gender and how biological sex is more aligned with physiologic parameters than gender and only gave a choice of two genders. I picked the stereotypical pink icon with the ponytail, but hope someone at Garmin gets educated about the difference between sex and gender.

The next step was trying to set the watch via the GPS, which didn’t work. I’m assuming the GPS wasn’t working well inside my house, but since you’re supposed to have the device plugged in with the USB cable and charging while you do this, I was just following the directions. I’m not sure how many people have USB ports in their driveways.

I also ran across the menstrual tracking option on the device, which I promptly turned off. Most people don’t realize that HIPAA does not protect this kind of data when it’s being sent to an organization that is not a HIPAA-covered entity, and especially given the political climate, I have no plans to share that via a wearable.

During this process, the watch fell on the floor no less than three times due to the short USB cord that was connected to my floor-dwelling PC, coupled with the fact that it hooks perpendicularly into the back of the watch, making it unable to be placed flat on a surface.

The next step was to apply a system update to my phone, which for some reason took several hours. I tried several more times to get it to connect without any luck. Ultimately, I used Garmin Express to connect it directly to the PC, after which it forced a firmware upgrade to the watch. I was hopeful that would do the trick, but it didn’t. However, while the watch was connected to the PC, I was able to connect it to my wifi network, so at least that was something.

After disconnecting the watch, I had to take care of some household tasks and noticed that the watch wasn’t counting steps. It was counting heart rate and respirations, which I find less useful, and not doing the one task that was most important to me. After lots of fussing about with the menus, I tried a system setting to see what version the firmware was on, and it said that an update was needed. I tried to connect it back to the PC, but it wouldn’t pick up, and after plugging it in and unplugging it way too many times, it finally connected and the Garmin Express software showed that despite the recent status of “update complete,” three more updates were now needed.

Each time an update completed, I had to do a manual sync to get the next update to register, and also restart the watch. Meanwhile, Garmin Express kept telling me that the watch wasn’t connected, while the watch showed that it was.

I was asked no less than three times during the process to set up wifi and went through the entire process to have no change in the user experience. I went back to the main Garmin Express menu and was now told that I had 37 updates available even though the previous screen had said, “You’re up to date!” There is nothing worse than a confusing user interface that doesn’t tell you what’s going on or what you really need to do.

After two more unplug-and-restart cycles, the update counter disappeared and and miraculously, over 4,000 steps appeared on my watch. There’s no way they’re legitimate considering I was only wearing the watch for a couple of trips to the laundry room and back. After some digging, I figured out that somehow the steps on my old watch had been ported onto the new watch, which was definitely unexpected.

Fast forward to nearly a week worth of intermittent attempts to connect via Bluetooth. I gave up on it. I can pair the watch to someone else’s phone and pair my phone to other devices, but can’t pair the watch to my own phone. Without the Bluetooth, you lose out on several valuable features – music, alert notification for falls or incidents, and a couple of other things. I’m still able to sync the watch with my PC like I was the previous model. I hadn’t planned to allow it to display text messages or emails, so I resigned myself to being a little retro with my connectivity. I’m hypothesizing that the battery life will be much better without the connection, but I’ll know for sure in a few more days.

It’s snazzier than my previous device. I like its subtle coloring and low profile versus the chunky black model I’ve been wearing for years. For the first couple of days, the synthetic material watch band had a particular smell to it, which probably wouldn’t mean much to the average person, but to me smelled like an operating room. Although it brought back some fond memories, I was glad when it dissipated.

Overall, I’ll give this particular Garmin a solid B. It’s better than my last one, but not as great as it could be. The price was right.

What’s your favorite wearable, and how do you like (or dislike) its features? Leave a comment or email me.

Email Dr. Jayne.