Curbside Consult with Dr. Jayne 11/8/21

The highlight of my weekend was attending a graduation party for one of my favorite former co-workers. I worked with her in the urgent care trenches for half a decade, through Flumageddon, COVID-19, the deaths of three co-workers, and a host of other calamities.

Of all the people I’ve worked with clinically, she’s one of the handful I would walk through fire for. Three years ago, she decided to go to nursing school and completed her bachelor of science in nursing degree while continuing to work part time. She’s one of the hardest working people I know. I had the privilege of working my last urgent care shift with her, so I was glad she invited me to come celebrate her achievement.

It was a mini reunion of former colleagues, 80% of whom have left our former urgent care employer. It seems like everyone is thriving since they left. Since I was kind of the “mom” of the practice sometimes, hearing their stories brought me joy. Several are in graduate school and others have moved to other healthcare settings, but all of them are still involved helping patients.

It was also fun meeting the graduate’s parents and brothers, and now I understand where she gets her sassiness. Sometimes we don’t get to see people bring their dreams to life, but I’m excited for her in her new role as a nurse in the emergency department of the city’s premier Level One trauma facility. Hopefully we’ll be able to catch up again down the road. It will be interesting to hear stories from a new graduate’s point of view.

The rest of the weekend was spent playing catchup – working on some personal projects and catching up on work I needed to finish after being out for a training class most of the week. For one of my new projects, I need to have a particular EHR certification that I’ve never done before, and it was quite the adventure. Since most vendors are still offering remote training, I decided to take advantage of that option. Not that I mind traveling, but it’s always better to be able to sleep in your own bed. I was pleased that the training had been adapted to remote learners, including having multiple trainers available to cover real-time questions while the main presenter continued presenting the content. That let people catch up while the rest of the class moved ahead. As someone who has taken countless in-person classes, I enjoyed that approach much better than when a single class member holds everyone up with questions since it’s much harder to hand someone off to a co-trainer in a live environment.

Of course, there were some technical glitches for attendees, with people intermittently losing audio or having glitchy video, but that’s to be expected even at this point where most of us have adapted to nearly 100% remote work and virtual meetings. There were also some people with multiple monitors who were having issues with popups they couldn’t see because they would open on a different monitor, and that seemed to be a little trickier for the remote training team to try to troubleshoot. Overall, I thought they did a nice job with plenty of breaks for people stretch and just get away from their desks, and also a full hour for lunch which I haven’t had before even in an in-person class. It was nice to be able to grab something to eat, check email, and walk around a little bit before settling in for another half day of classes.

Fortunately, I’ve worked with this part of the EHR before,so while I’ve never been certified, so the content wasn’t overwhelming. I imagine that if you were new to EHRs in general, such as an IT person who hadn’t done much clinical work but was diving in, the pace might have been a bit brisk. There are plenty of new terms to learn in healthcare (particularly in the wild and wacky world of US healthcare) so the learning curve on those items would have been steep. Most of the attendees were able to get through some clinical workflows though and had a good understanding of how their end users will be using the system. It’s always a good thing when clinical people can see what IT folks have to work with, and vice versa, in order to have a high functioning team.

I’m taking another class this week and it’s a much deeper dive into the underpinnings of the EHR, which I’m very excited about. I never met a database table I didn’t like and am looking forwarding to learning things I may not have known about the underlying structure. As a CMIO, I’m often at the 10,000-foot level, but it’s always good to understand the complexities of the system when I’m asking my team to consider using new features or attempting to customize around a native workflow. I’ve got a topnotch team of seasoned veterans, so I’m not worried about their skills, although I’ve had people working for me on previous engagements who tried to snow me on how hard it would be to do customizations or to modify workflows. I remember one upgrade when my team was acting like they’d have to do hundreds of hours of work to make changes to provider workflow templates, and when we did a work breakdown and estimation exercise, it turned out to be less than one person-week of work.

I also spent some time doing my quarterly Maintenance of Certification questions for both my primary and secondary board certifications. They use completely different methodologies and delivery systems for their questions, and I’m wondering why the different boards can’t get together and come up with a best-of-the-breed solution. One board allows five minutes per question, and you have to do 25 questions per quarter, where the other allows 10 minutes per question with 12 questions per quarter. Fortunately, they’re both open-book and open-internet, with the main limitation being that you can’t engage other people to help you or share the questions with others. I’m not close enough to retirement to consider dropping either certification, so I get to stay on the certification hamster wheel for many years to come.

Did you have a productive weekend, or were you just able to enjoy some down time? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/4/21

I was at my local academic medical center for a meeting a couple of weeks ago and noticed that they have new policies in place regarding wearing scrubs outside the hospital. Apparently they’ve selected a new and distinctive color for the scrubs that are worn to the operating rooms, and if you’re caught trying to wear them out of the building, you’re subject to disciplinary action and possible termination. They already have scrub “vending machines” that prohibit you from taking scrubs home since they’re linked to your ID badge and you’re limited on how many sets can be issued to you. Wearing scrubs from the outside world into the operating suite isn’t ideal, so it makes sense not to let them go to the outside world in the first place.

Still, they don’t have any restrictions on what shoes can be worn in or out of the hospital, which given some recent news, might be a good idea. Shoe soles were swabbed for the presence of C. difficile bacteria, which is the most common healthcare-associated infection in the US. The results were presented at the Infectious Disease Week 2021 annual meeting and showed that shoe soles had a high rate of contamination and were similar to floor samples taken in either private homes or healthcare facilities. The researchers propose that when patients who are at risk for getting C. difficile infection are placed on high-risk antibiotics, that they may need additional education about cleaning floors and removing shoes before entering the home. Sometimes public health informatics isn’t considered sexy, but if you’ve ever encountered a patient with C. difficile diarrhea, you would likely support any research that would help reduce its presence in the world.

The AHIMA Foundation recently released a study on the “Understanding, Access and Use of Health Information in America.” In short, more than three-quarters of patients in the US don’t leave their physician’s office on a positive note. The study notes disconnects between the information that physicians think they are sharing and what patients understand. The findings are similar among caregivers who share concerns about their loved ones’ ability to process information they’ve been presented.

One of the data points I found most interesting was that more than 20% of patients don’t feel comfortable asking their physician certain questions. That points to the difficulty in building patient-physician trust and open communication. I was reading this in the context of a recent conversation with a medical school professor, who noted that at times his trainees were so uncomfortable with certain topics in class forums where patients were present that they asked if they could present their questions to the patients anonymously.

Other interesting tidbits:

• Seventeen percent of patients report not having an opportunity to ask questions at all during a visit.
• Ninety percent of patients search for health information on the internet, and 80% are confident that information is credible.
• More than half of patients report that they rarely access their medical records to review health information.

The latter bullet point indicates that we have a long way to go as far as the patient side of the information blocking equation is concerned. I certainly don’t see any public health organizations that have the resources to educate patients on the benefits of interacting with their own records, and although hospitals and health systems are promoting the use of patient portals as a convenience, I don’t see a lot of campaigns around how important it is to actually review your records. I’ve found multiple errors in my own charts (one of which was potentially life-altering), so I always review my after-visit summaries, but then again, I’m a physician who is also a data junkie which is a status shared by a relatively small number of patients.

Administrative simplification is a hot topic among my friends who are part of the revenue cycle side of healthcare informatics. The US spends a ridiculous amount of money on healthcare administration and a recent editorial in the Journal of the American Medical Association notes that administrative simplification has the potential to remove a quarter-trillion dollars from our healthcare expenditures in the near future. In 2019, $950 billion was spent on administrative functions within the US healthcare system, despite efforts to introduce technology as a way to streamline functions. In our non-system system, administrative staff outnumber physicians and nurses 2:1 with more than a million administrative roles being added in the last two decades.

The authors propose that 28% of annual administrative spending could be cut without impacts to quality or access. Many of the targeted areas are not healthcare related: general administration, human resources, non-clinical TI, sales, marketing, and finance. The second largest group of targets is financial, including revenue cycle management, prior authorization, and claims processing. Further down the list are the actual healthcare interventions, such as convincing payers they should standardize processes and clinical requirements for prior authorization. The authors propose that for many of the changes, financial incentives would be needed to overcome organizational inertia.

I’ve been in some recent training classes with international physicians, and it’s been interesting to hear their questions about phenomena that are particular to the US health system. In many countries, there’s no concept of different billing codes for different types of visits. In some countries, primary care physicians are mandatory, and in others, the concept doesn’t exist. I’ve enjoyed learning first-hand what things might look like in another part of the world and I hope that some day we could reach the levels of commitment to public health and universal coverage that I’ve been hearing about. In the mean time, we’ll have to keep playing Whac-A-Mole with crisis after crisis in the US healthcare system and see if it can recover before it breaks.

If you’re part of a payer/provider organization, I’d be interested to hear what administrative simplification looks like from your perspective. Is the grass already greener on your side of the street, or are you smiling like the Mona Lisa because there are secrets you can’t talk about? Let’s hear some ideas for how to solve these issues and free up money for other worthy projects. Have ideas? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/1/21

Halloween is my favorite holiday, and I hated that COVID-19 pretty much killed it last year. This year, I decided to make a driveway treat station, keeping a table between the trick-or-treaters and me, and making sure to sanitize before lobbing candy into pillowcases and plastic pumpkins. (No kids’ hands in the bucket, thank you very much!)

I had a little less than half of the visitors I have in a “normal” year, but was glad to see people getting out. Lots of adults were in costume and running around with their youngsters, and more than one mom commented on my gallon of industrial hand sanitizer. What can I say? Old emergency department habits die hard.

I’ve been knee-deep in telehealth projects the last couple of weeks, so I’m always on the lookout for good articles or information. I thought this NPR article was interesting. It presents all the reasons why patients like telehealth, such as not having to leave home, not having to wait at a medical office, etc. However, it also presents data from a recent poll that found that 60% of patients would prefer to see their provider in person. This may be a sign that the pendulum is swinging towards traditional in-person office visits. As a physician, I agree that certain conditions are better handled in person, such as a new orthopedic injury, rashes, or abnormal moles. Patients who are nervous about telehealth or who have technology challenges are better served in person as well.

Still, I take issue with one of the quotes in the article, where a concierge physician mentions limitations during telehealth visits where “You may be missing that opportunity to be talking with the doctor who’s going to say, ‘Hey, by the way, I see you haven’t had your mammogram or you haven’t had your pap [smear].’” I would argue that’s not necessarily a limitation of the telehealth modality, but rather an issue of the patient and physician taking time to focus on preventive measures or reviewing potential gaps in care, which should be easy to accomplish regardless of the way the visit occurs. There’s not anything particular about a telehealth visit that should interfere with a physician accomplishing that discussion. Failing to review preventive milestones seems to me more like a bedside manner issue than an in-person versus telehealth issue.

The article wanders into the premise that maybe telehealth is only for when in-person visits aren’t available, such as in rural communities or where there are shortages of specialists. I disagree. What I’ve seen as a telehealth physician is that many patients prefer not having to interrupt their lives to participate in the frustrating operational exercise of interacting with a medical office. Especially with the overall labor shortage and people leaving healthcare in droves, the frustration factor of interacting with short-staffed offices is at an all-time high. Where offices may be adding greater access through telehealth, they may not be spending time fixing broken processes or making the patient experience smoother.

I had one of those frustrating interactions this week that made me want to tear my hair out. As a person who has had a couple dozen skin biopsies, I know when I see something unusual that needs to be checked out. Due to a busy schedule, I hadn’t been able to call my dermatologist’s office, but ended up checking in MyChart to see if they were doing online scheduling. It looked like they were, and I was excited, but when I hit the button to search for open appointments it told me that someone would be contacting me from the office. Two days later, in the midst of another busy day, I received a MyChart appointment reminder, for an appointment that was two hours from the current time. Since I can’t drop everything and run to an appointment, I canceled it online then immediately called the office to reschedule.

Due to staffing issues, the office has transitioned its scheduling to the medical school’s central scheduling line, and a fairly unprofessional phone staffer told me “I have no clue how you got that appointment, because your doctor is booking way out at the end of February.” I was treated like I was making the whole thing up. He told me that he would have to send a message to the office to “see what they want to do with you” and that someone would call in 48 to 72 hours. I didn’t bother to tell him that 48 to 72 hours would be Saturday or Sunday since I honestly didn’t think he would care. While on the call, I received a MyChart message from a nurse offering me the now-canceled appointment, and I responded that I had canceled the visit already and needed at least a little lead time for an appointment.

Several hours later, I received two hang-up calls from the office followed by a third that actually connected. This was a scheduler who was responding to the central scheduling message and was unaware of the previously offered appointment. I explained the whole timeline to her and that I didn’t think this was an urgent issue, but I didn’t want it to wait four months given my history. She was able to find a “work in” appointment at the end of November. Had I not been a physician who understood the potential seriousness of what was seeing and had the wherewithal to advocate for myself, I probably would have given up by this point. Had I been a worker who couldn’t take random calls from my physician’s office, the phone tag probably would have gone on for days.

It’s within this context and with this type of underlying frustration that people are experiencing telehealth. I’m sure it has an impact on their perceptions of how much better it might seem than having to go to the office, sit in a waiting room, wait some more in an exam room, and be ignored while people tend to phone calls at the check-out desk. Of course some offices manage this better than others, but the point is that patients are ready for a change and anything that is not the status quo is going to be welcome.

The bottom line is that we need to work to make all health interactions more streamlined, more valuable, and more patient and family friendly. While we are making things more convenient with telehealth, we also need to make them more convenient when patients choose or require in-person visits. Let’s optimize all those systems we paid big money for. Let patients update their histories and check in online before the visit rather than handing them the proverbial clipboard at the office and requiring them to write down information they’ve provided a dozen times before. Let’s figure out how to allow patients to self-schedule while simultaneously solving practice capacity issues so it doesn’t take a third of a year for a patient to be able to have a new problem evaluated.

Telehealth is part of the solution, but it’s not the only answer to the many problems we’re facing. Let’s challenge ourselves to try to find one way each month to make things better for our patients. Who’s with me?

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/28/21

The big news in the public health informatics space last week was the transition of pandemic data tracking to the Centers for Disease Control and Prevention. The organization owned tracking prior to a shift by the previous administration, and now the HHS Protect platform will fall under the oversight of the CDC. It’s been a couple of years of ups and downs for the agency, with a constant need to evolve its guidance based on data that has been at times difficult to obtain and manage. One would hope that the pandemic would allow for greater visibility into the public health space, and better tools for managing communicable diseases. However, given the fragmentation in our society these days, my hope is tempered by the reality of the situation.

The Journal of the American Medical Informatics Association published an interesting article looking at whether templates are beneficial for creating EHR clinical notes. The authors looked at 2.5 million outpatient visits across 52 specialties and found that templates were used to create clinical documentation 89% of the time. Their findings included a significant presence of individualized templates — over the two years of the study, 83% of templates were used by only one clinician. There were over 100,000 unique templates in the system, which could cause issues during system updates as well as when policy changes might require changes to thousands of templates at a time. They also note that individualization may lead to providers using templates that are outdated.

I found the breakdown of templates and their contents to be interesting. More than 46% of templates included placeholders for manual text entry, where nearly 43% contained only static text. Data links were present in 38% of templates, with 21% having lists for selecting text. Of the 1,000 most used templates, the authors identified five main template types — full-note templates, attestation / signatures, short phrases, datapoints / panels, and screenings / procedures. Not surprisingly, full-note templates were the most commonly used templates, used in nearly 65% of visits. Of the more than 23,000 full-note templates, barely 20% were used by more than one person. The specialty breakdown was also interesting, with pediatricians (particularly residents) more likely to use a departmental template.

The authors note that health systems would benefit from governance, managing templates with standards for naming, documentation, and appropriate use. The study concludes that there need to be standards for templates if organizations want to improve quality. I’ve always worked in organizations that had significant structure around the creation of custom templates, sometimes to their detriment. Thinking about a system with over 100,000 unique templates, I understand even more why it’s beneficial to have some rigor around customization. Especially when templates are being used to support patient care, it’s important to have a discussion around whether there really is a need for each member of a department to have a unique template or whether there can be consensus to create standardized templates that support evidence-based care as well as help with efficient documentation.

Many technology vendors are still having virtual user conferences, not willing to risk significant expenditures on events that can be impacted by pandemic uncertainties. Some healthcare organizations are still not allowing travel outside the local area or the state and others have slashed conference budgets. A friend of mine who works on the vendor side was excited to attend an in-person conference, sponsoring several refreshment breaks as well as staffing a booth in their exhibit hall. Unfortunately, between the time of signing the exhibitor contract and the actual conference, the organizers elected to offer a virtual track but failed to notify exhibitors. In-person attendance was only two-thirds of what had been promised, which definitely changes the return on investment. I understand offering a virtual track, but that’s no excuse for not notifying vendors and sponsors, especially when there isn’t any opportunity provided for them to reach virtual attendees.

The US Food and Drug Administration recently gave marketing clearance to Cognetivity Neurosciences for its CognICA integrated cognitive assessment tool that allows for the early detection of dementia. The artificial intelligence-powered test is performed on an iPad and is said to allow for detection of early cognitive impairment without cultural or educational bias. The platform can be used for large-scale self-administered testing and integrates with electronic health records. The test previously received European regulatory approval as a medical device and is in use by primary and specialist clinics in the UK National Health Service.

My former clinical employer is still suffering from significant staffing shortages, resulting in temporary closings of some locations and limitations on patient volumes at others. They’ve gone so far as to start their own emergency medical technician training program to try to grow their own staff, but that will take months to bear fruit. The reality is that it will take months if not years to build the healthcare labor market to where it needs to be, not only to recover from the pandemic, but to prepare for the aging of the US population. In order to assist, the US plans to spend $100 million through the National Health Service Corps to help address the problem. The program is targeted to match primary care physicians with communities that need them, providing loan repayments and scholarship funds in exchange for a term of service in an area with a shortage of health professionals. States have until April to apply for grants, which could be as high as $1 million annually.

I’ve written in the past about the evolution of clinician communications, and a recent JAMIA piece caught my eye with its title, “It’s like sending a message in a bottle.” The article looks at the consequences of one-way communication technologies in hospitals and how clinical workflows are impacted by workarounds. The study looked at four US hospitals during 2017 and involved researchers spending two weeks shadowing clinicians, conducting interviews, observing, and holding focus groups. They coded their observations to identify preliminary themes as they looked at the primary communication technologies of pagers and telephones. They concluded that many of the workarounds involved the one-way nature of communication, varying access to different technology types, and mismatches between available technology and workflow needs. I’m sure no one who has ever worked in a hospital would disagree. I would be eager to hear reader thoughts on the best vendor solutions for two-way communication.

Got a sexy communication solution that you want to share with the world? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/25/21

I always enjoy reading other physicians’ blogs and “A Country Doctor Writes” doesn’t disappoint. When your tagline is “notes from a doctor with a laptop, a house call bag, and a fountain pen,” how can you go wrong? A recent piece titled “American Primary Care is a Big Waste of Time (When…)” had some really good points. He mentions that using scribes in medicine is “almost medieval” and draws a parallel to how books were copied prior to the invention of the printing press. Where other fields are focused on scaling and automation, US primary care is still “doing things one patient at a time.”

I don’t disagree, but I think it’s important to note that there are a number of cultural factors behind how we do things in addition to the technical ones. It’s still difficult at times to get patients to participate in group visits or group classes regarding their health issues, and the pandemic didn’t make that any easier. Our consumer-driven culture and the need to obsessively groom our patient satisfaction scores don’t always support our efforts to streamline care or create consistent workflow processes. Team-based care can certainly help, although some organizations are better at it than others. One of the first things he notes as a time saver is something I’ve been begging physicians to do for years – creating standing orders for health maintenance or preventive measures and letting appropriate support staff enable those activities.

His next point is something I hadn’t thought about in such a clear context, that physicians are “forced to act as if we only see our patients once – ever, instead of over several visits year in and year out. We can’t see you quickly for your sore throat or UTI, because a visit without the required screenings hurts our quality ratings.” This became much more of an issue with the transition to EHR and the Meaningful Use incentive programs, where physicians were tasked with capturing a tremendous amount of information when the patient presented for their first visit of the calendar year. He points to asynchronous interactions via email, events, and other modalities as potential solutions, although he notes that some physicians are still reluctant to embrace these methods because they’re still paid primarily based on direct patient interactions.

I’d like to see greater flexibility by healthcare organizations to accept data flowing into their EHR from other sources. As I’ve mentioned in previous posts, I still work with health systems that don’t recognize other hospitals’ data for the purpose of satisfying gaps in care, even though it’s available on the system and visible to the patient and providers. EHR technology now supports this, but for some reason, administrators have chosen not to turn it on at one of my sites of care, so there’s always some confusion at the beginning of a visit.

He notes that unless physicians in the traditional US primary care model can adapt, patients will move away to concierge medicine, direct primary care, retail clinics, and other care environments. Some practices are definitely better than others at adapting to new models of care and harnessing the payments available when they participate. Some of my colleagues have refined their practices to the point where their quality scores are so outstanding that they can command additional bonuses beyond what anyone else in the region receives because they’ve embraced new models. Others are electing to retire early, and some are just reacting to changes in the marketplace rather than trying to proactively evolve their practices.

This theme isn’t limited to the musings of a country doctor, however. The Harvard Business Review dove into the topic recently with an eye-catching headline that “The US Health Care System Isn’t Built for Primary Care.” Citing this spring’s report from the National Academies of Sciences, Engineering, and Medicine, they note the conclusion that “primary care is the only medical discipline where a greater supply produces improvements in population health, longer lives, and greater health equity.” The author notes that “current efforts to wring ‘value’ from primary care by focusing on diagnostic algorithms and quality metrics reveal fundamental misunderstandings of primary care’s purpose. The attempts to apply processes and technology designed for subspecialty care to the delivery of primary care have proven insufficient to support the complex work of the primary care team.”

The article poses that unlike other specialties, “the heart of primary care’s success remains a unique relationship between physicians and patients built on trust.” Although I’d like to agree, and a decade ago I might have, there has been a substantial erosion of that trust over the last two decades. When patients had to start changing primary care physicians when their employers went with cheaper insurance plans each year, those relationships became less valuable. The evolution from patient to consumer and customer further eroded the relationship, and new generations who never experienced the ”old-time family doctor” visit didn’t understand its value as they prioritized convenience and speed given their busy lives. The pandemic has put that shifting trust into focus, where some patients are more likely to believe things they read on social media than to trust the advice of their primary care physician.

The section headed by “Primary Care Doctors Are Not Subspecialists” was particularly thought-provoking. Where procedural subspecialists are more likely to be served by checklists, templates, and process-driven approaches, primary care has to be more dynamic. Often the outcomes of primary care are achieved over a period of years rather than months, which makes it more challenging to understand the cost/benefit equation. Money that is spent by commercial insurers during a patient’s employed years might not lead to savings until disease is prevented or caught early, at a time when the patient might be covered by another payer or even by Medicare.

The author lists three places to focus on reinventing primary care, and they’re all things that plenty of others have been saying.

First, we need to reform the payment model since the US spends 50% less on primary care than any other developed nation. Future payment models must support multidisciplinary primary care, and according to the author, “should include predictable cash flow up front, in recognition of primary care as a common good in society.” We’ve tried to do that in the past with capitated payments with varying degrees of success, and although there are organizations that have figured out how to do this well, others seem to want to reinvent the wheel rather than learning from experience.

Second, the author notes a need to fix EHR technology, to create systems that are “clinical first” and are integrated across all facets of healthcare. Now that we’re over the initial implementation hurdles, it’s time for healthcare organizations to optimize what they have and to push their vendors to deliver additional capabilities and efficiencies.

Third, the author proposes that we change medical education. Many practicing physicians were trained in “big hospitals that glamorize subspecialty and inpatient care.” As someone whose medical school didn’t even have a department of family medicine, I know what that’s like. Hearing comments like “you’re too smart to do primary care” isn’t going to encourage the best and brightest to gravitate to the field (although more people in my class went into family medicine than general surgery, which was a blow to the surgical egos at my institution but gives me some hope).

Technology is at the intersection of many of these concepts and will need to keep pace with other changes as the healthcare environment evolves. EHR and other clinical systems vendors have been varyingly successful at this, with some systems moving towards greater integration in a logical fashion but others growing by acquisition and bolt-on solutions, which adds to the feeling of fragmented care. There’s plenty of discussion about “disruption” and “innovation,” but some days it just feels like we’re nibbling around the edges of the problem. A couple of organizations are poised to make some significant change, and I’m eager to see what they come up with.

Not everyone is going to need subspecialty care in their lifetime, but all of us are consumers of primary care services. Do we know the answers but just need to implement them, or are there solutions we’re still not talking about? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/21/21

There has been lots of chatter with my IT friends around the Windows 11 rollout. Most of the large organizations I’ve worked with over the years would rather risk letting their operating systems become so dated that they’re almost not supported rather than consider being on the cutting edge of a new release. I worked with several people who I thought would need to have Windows XP pried out of their cold dead hands, but somehow everyone survived their upgrades. From a consumer standpoint, several of my physician friends have run the “compatibility check” from Windows and are concerned that they may not be able to support the new release, but it’s usually due to requirements that they can meet but that aren’t enabled.

Apple is preparing to move AirPods into the medical device space. Temperature and posture sensors are on the horizon, as well as the ability to use them to augment hearing. Using them to check temperature in the ear isn’t a tremendous leap, but I’m less convinced about the posture sensor’s proposed slouch-detecting capabilities. AirPods Pro already have the “conversation boost” functionality, but it’s not clear whether they’re going to expand on this or offer something else for hearing loss. Having been part of plenty of dinner table conversations where dead hearing aid batteries have been a factor, I’m not sure how that’s going to play for Apple either.

As technology becomes smaller and has the potential to bring new diagnostic modalities to the bedside, it becomes more important to evaluate whether they’re really better than the status quo. There are some big discussions going on regarding whether robotic-assisted surgeries really deliver better outcomes than non-assisted procedures, and I’ve seen some pretty heated debates on the matter in the physician lounge. I enjoyed reading this article in JAMA Internal Medicine regarding so-called point-of-care ultrasound (POCUS). The headline sums it up: “Visually Satisfying Medicine or Evidence-Based Medicine?” Over the last several years, primary care journals have had plenty of editorials and discussions about the technology. It’s pretty slick, whether you’re using a dedicated device or something that hooks into your phone. But it requires training to interpret the images and seems to be best used by people who have the opportunity to use it frequently, rather than by individuals who might use it sporadically. The authors note that although “it has become the standard of care for most common bedside procedures” that “its use for diagnostic purposes is not as firmly grounded in evidence demonstrating net benefit on patient outcomes.”

They point out some key challenges for POCUS – that its use is somewhat informal and that images may not be accessible for later review. There is also a lack of clinical trials that have looked at key clinical outcomes such as length of stay or complications from a missed diagnosis. The variability between users is also a concern. They authors call for additional studies as well as the ability to capture images for later review. This may be a field where artificial intelligence might come into play to help with those retrospective reviews, flagging studies with concerning findings for immediate review as well as creating a quality assurance model for overall use. I always enjoy a scholarly article that has a little flair, and the description of POCUS use as “viscerally satisfying” is on track both for accuracy and in making my inner reader smile.

I had virtual drinks with a friend who works in the accountable care organization space and asked her what she thought about this piece regarding the transition to eCQM reporting. She agreed that the process is painful and shared some of her own experiences with the process. CMS is apparently listening and has pushed back the timeline for the transition, but it sounds like some of the EHR vendors might not be as on top of things as they need to be for ACO leaders to feel comfortable. It’s important to remember that ACOs might be dealing with data from dozens of disparate EHR platforms and making sure that the measure specifications are consistent is a significant challenge.

The article calls out a key challenge of electronic quality reporting, that users have to enter the data in the fields where the reports are looking for the reports to work. If there is a lot of dictation or speech recognition documentation being performed at the expense of discrete data entry, numbers aren’t going to look very good. Early in my consulting career, I worked with a number of health systems on their Meaningful Use efforts and it’s more difficult to change end user behavior than you might expect. My more successful clients baked discrete data entry into their physician compensation programs, which as you might expect led to a rapid transition.

JD Power released the results of its 2021 US Telehealth Satisfaction Study. Of the 4,600 patients surveyed, Teladoc was ranked number one for the time period from June 2020 to July 2021. The survey ranked providers based on customer satisfaction, consultation, enrollment, and billing / payment categories. Some interesting tidbits: although telehealth usage was consistent across generations, the highest use was among Generation Y (born 1977 to 1994) and the “Pre-Boomers” born before 1946. Top reasons for use include convenience, timeliness of care, and safety. Top concerns noted include difficulty accessing care and inconsistent service, which given the pandemic and its impact, I’m not surprised. Rounding out the top five, in order: Teladoc, MDLive, MyTelemedicine, Doctor on Demand, and LiveHealth.

Researchers at Stanford and UNC are looking at a wearable medical device that can deliver vaccines. The hope is that it will make it easier to distribute vaccines in underserved areas, but I’m sure there are plenty of people that will still see it as a product of a vast conspiracy. The 3D-printed vaccine patch works without the traditional injection and is said to also work more effectively than current delivery techniques. Using microneedles, the vaccine is delivered intradermally (into skin) rather than into muscle, creating a significant immune response. Part of the magic is that the 3D printing method allows creation of microneedles of controlled geometries which are difficult to manufacture via other means, which leads to greater retention of the vaccine within the skin. I’m a huge fan of prevention, so I can’t wait to see what they come up with next.

Fall is here in my world, with daily temperatures swinging 50 degrees during the course of a 24-hour period. I’m heading south for a little bit of sunshine before I have to deal with freezing temperatures and the potential of increasing COVID-19 transmission as people move their activities indoors. It will be good to get a little break because my latest project has me spinning in circles, but in a good way.

What are you doing to prepare for fall and ultimately winter? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/18/21

I was feeling a bit bummed this weekend, as I couldn’t attend the HLTH conference due to a previous commitment. I do a little dabbling in amateur radio and had been asked by a local radio club to be a station operator for the World Scout Organization’s “Jamboree on the Air” event. It’s held the same weekend in October every year and is a chance for young people around the world to talk to each other via radio (an internet component was added in 1995). There is always a big contingent from Germany on the air and it’s fun to try to have your scouts reach someone from every state as well as reaching international scouts. Women are typically a small percentage of any amateur radio gathering and I think it’s important for girls to have role models in tech hobbies, so I packed my gear and headed out.

Usually there is a lot of time for chitchat as you’re assembling antennas, staking them out, running cable, and figuring out how things are going to work when you’re trying to operate from a location you’ve never been. My team for the event included a search and rescue specialist, a retired Navy signal operator, an Eagle Scout, and a retired electrical engineer. Whenever people find out I’m a physician, they always ask where I practice, which can be tricky to explain based on what I do. When I mentioned that I’m only practicing virtually right now, the electrical engineer’s ears perked up. It turns out he’s got a little broader experience than electrical engineering. After receiving his degree in the 1960s, he started doing work in the then relatively new arena of biomedical engineering, specializing in the design of technology for the practice of nuclear medicine, but also in expanding the use of computers in healthcare.

Based on that, I figured I could go a little further and tell him that I spend the majority of my time working with electronic health records and emerging technologies such as chatbots, artificial intelligence, etc. and he was very interested. He asked if I had ever heard of “a guy named Larry Weed” and I said of course. Apparently my new radio friend had done some collaboration with him on his problem-knowledge coupler software in the 1980s and had some great firsthand stories about how that technology was received by physicians (not as well as it might have been) and how it evolved. It’s always interesting to learn from people who worked with the founders of our specialty and what they were like not only as innovators but as people. Had I gone to the HLTH conference, I certainly would have missed out on my own healthcare IT oral history project.

The day ended up being a lot of fun and hopefully we were able to get some young people interested in the art of radio. They enjoyed hearing how amateur radio operators can help in natural disasters and other emergencies, and they really loved learning how to craft Morse Code messages using some vintage code keys. Fortunately, conditions were such that they were able to chat with scouts on the radio from coast to coast, but the parents’ eyes were widest when they saw our teenage radio operator having a live Morse Code conversation with someone 2,000 miles away.

Online, they connected with scouts from Iceland, Taiwan, Finland, Japan, Cyprus, the UK, Serbia, and more. One of the highlights of the day was a radio “fox hunt” where the scouts had to use a directional antenna to find a hidden transmitter more than a quarter of a mile away, especially since the reward for successfully finding the fox involved chocolate chip cookies.

In addition to learning about Dr. Weed and his efforts, I picked up a couple of other tidbits along the way. The best radio tip was how to make an easily assembled and effective antenna mast out of a fiberglass paint roller extension pole, and needless to say I have since added one to my collection. We’ll have to see if the Homeowners Association has anything to say when I test it on my front lawn.

Back to HLTH, I’ve been getting some reports from the field, and it sounds like there is some good networking going on. Telehealth seems to be a hot topic, along with remote patient monitoring. I haven’t heard any grumbling about HLTH’s health and safety protocols, which involve not only proof of COVID-19 vaccination, but also a negative test within 72 hours of picking up your attendee badge at the conference. For those unable to get a test at an approved provider, onsite testing is available. Reading through the documentation on the HLTH website, the conference is picking up the tab for the onsite pre-event testing. It notes that optional testing will be available at no cost for anyone who wants to test throughout the event.

In the details, however, it specifies that attendees must have active US health insurance coverage “to receive free onsite services,” which tells me they’re not actually free — there just isn’t a patient payment required. We’ll all be paying for those “free” COVID tests that everyone is getting so they can attend events through higher insurance premiums and increased cost-sharing to the patient. As of this weekend, one of my local sports teams is requiring proof of vaccination or a timely negative test prior to attending events, and local urgent cares are already feeling the pressure.

Tuesday night is the HLTH Foundation Gala, and I hope people will share reports about the evening as well as photos of any sassy shoes or bedazzled masks they may encounter. I’m sure a lot of people have missed being able to dress up and go to events like these, so I’m betting at least one person will go all-out. At $250 per ticket, I hope the dinner is good and the entertainment is engaging. If not, the cocktails will certainly help. Maybe I’ll bust out some high heels and a martini glass and attend in spirit from my living room.

Are you at HLTH, and what’s your take on the event? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/14/21

As my readers know, I’m a big fan of prevention. I went this week for my regular dental visit and was interested to see a wireless headset sitting on a charger on the dental hygienist’s counter where she usually charts. She mentioned that they had installed a new system that would allow her to dictate her findings as she was performing my preliminary examination, so my informatics senses were tingling.

Looking closer as she was getting ready, I noticed that an Echo Dot had also been added to the exam room, so I figured it was part of the new solution. Unfortunately, the system failed to respond to the wake word after several tries. Since patient care was the priority and not troubleshooting the technology, she said she was going to go “old school” and key in the data manually as they had done in the past. It was disappointing not to be able to see their new toy in action, but I have to give them full credit in doing what was better for the patient (and likely for their schedule). As always, I scheduled my six-month follow up before I left, so hopefully the system will be better behaved in April.

Digital transformation has certainly impacted care delivery organizations, but it is also impacting those that support clinicians. The American Academy of Family Physicians announced last week that they are no longer requiring a certain number of live Continuing Medical Education (CME) hours for physicians to maintain membership. In the past, physicians had to report 25 hours of live CME every three years. Reductions in the availability of live meetings due to the COVID-19 pandemic impacted the ability of physicians to claim these credits, leading initially to the AAFP granting extensions on the time needed to obtain the hours.

However, AAFP also realized that the definition of “live” has become more fluid in the digital world. Rather than deal with the complexity of defining whether “live” means “in person” versus “virtual” versus “livestream” or something else, they’re eliminating the category altogether in the name of allowing active members “to pick the learning formats that best suit their needs and preferences.” Active members will still need to report 150 hours of CME every three years and half must have the AAFP Prescribed credit designation, so we’re not entirely to the point where we have total flexibility in how we obtain our CME. The response in the comments section was overwhelmingly positive, so kudos to AAFP for helping make physicians’ lives at least a tiny bit less complicated.

Speaking of blurred lines between in-person interactions and other modalities, I enjoyed learning more about what Cleveland Clinic is doing at its Indian River Hospital in Florida. As part of a new program, patients are being “seen” by mental health providers during emergency department visits, an approach that not only reduces the time for patients to receive services, but is improving quality. Psychiatric consultations are being seen in less than an hour versus the 24 hours that could occur previously. Often, treating psychiatric concerns in the emergency setting can be a challenge, and in my area, we recently opened a dedicated psychiatric emergency department to better serve patients in a more welcome environment. From the day it opened, though, it’s been at capacity, so maybe augmentation with telehealth resources – either there or within traditional emergency departments – is something to think about.

JAMIA Open published an article last week looking at an AI-based system that can flag medication errors in the EHR by looking at clinician ordering behavior in context. Researchers looked at pharmacy orders over a two-week period in a major metropolitan hospital system. The goal was to identify orders requiring pharmacist intervention then to further refine it within a given clinical context. Contextual data included specialty, clinician type (attending, resident, midlevel provider), day of the week, time of day, and the therapeutic class of the medication. The data used was from two weeks in July 2017, which somewhat limits the study – July is when new interns start and residents typically advance, resulting in changing responsibilities. The authors note this, and also that the small sample wouldn’t account for seasonal variations. Still, it’s important work, and developing effective systems to help reduce medication errors is a good thing.

I’m prepping tonight for a community presentation about COVID-19 vaccines, as a local volunteer organization tries to push its vaccination rate beyond 90%. I expect quite a few questions about third doses versus boosters as well as the usual questions about vaccines in general. I’m on a couple of groups’ COVID advisory panels, so I have to keep up with a steady stream of news along with being able to play my own little version of “MythBusters” every time I do a public forum. Today provided some interesting material about long COVID, which now has been officially defined by the World Health Organization. The clinical case definition of “Post COVID-19 Condition” as it is called includes lingering fatigue, shortness of breath, and cognitive dysfunction (also referred to as “brain fog”). Symptoms may continue for months after the initial COVID infection and are often severe enough to prevent patients from completing daily activities. Additionally, other explanations for the symptoms must be excluded before a patient is considered to have the condition.

In parallel, the US Centers for Disease Control and Prevention formally added an ICD-19 code for long COVID: U09.9 Post COVID-19 Condition, Unspecified. Additional guidance from the US Department of Health and Human Services explains that the condition can be considered a disability under the Americans with Disabilities Act. For those who think that COVID-19 infection is not a big deal, I hope we can look back in a few decades and it’s actually true. In the short term, however, I have significant concerns about the overall cost of COVID care to our health system and ultimately to the global economy. Seems like the $20 vaccine is looking like more of a bargain every day compared to the potential of hospitalization, disability, and death.

CMS announced that the Quality Payment Program website will no longer support Internet Explorer 11 after October 13, 2021. I was shocked by the fact that approximately 2% of users access the site through IE 11. If you’re still using it, you’re missing out on the features offered by other browsers, so hopefully those users will like what life is like on the other side of the fence.

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/11/21

Early in my informatics career, I worked on a health information exchange project. It was during the early days of HIEs, and many of the challenges were legal and operational as opposed to technical. We had to wade through the minefield of consent, debating opt-in versus opt-out models within the confines of the laws of multiple states. We also had to address access issues, decide when break-the-glass functionality could be used, and create policies and procedures around auditing access to the data and ensuring appropriate use. Only once those thorny issues were settled could we begin to define the clinical data sharing model and determine what information would be shared from what sources.

We then had to work through the technical issues. We had to decide whether we wanted ambulatory office visits to automatically query the HIE versus whether providers would have a manual trigger to prompt data sharing. We had to address hosting issues as well, along with the pure limitations of the product we had, since we had purchased our solution from a company whose strategy was still evolving. There were dozens of interfaces to evaluate and integrate, and we had to create a solution that would provide immediate value while not breaking the bank, buying ourselves time to bring up the rest of the data feeds. The big draw for our solution was its ability to allow providers to incorporate discrete data from the HIE into their charts so that they could use it instantly within the context of the patient encounter.

We didn’t necessarily see them coming, but many issues we faced though turned out to be political in nature. Unknown to us, the CIO of the health system with which our physician group was affiliated had his own HIE plans, and they didn’t involve us. He had secured funding for his own HIE and had crafted a strategy without any input from the thousands of ambulatory physicians who were clamoring to be connected. His solution was more of a viewable repository that was document based rather than enabling the exchange of discrete data. The last thing our physicians wanted was to have to sift through textual information and then perform data entry tasks in order to incorporate that information in their own records, so you can guess whose solution was more popular.

Needless to say, he spent a lot of his time trying to kill off our project. Not only would our HIE concept provide more value, but we were planning to deploy it for a fraction of the cost of what he had planned. He also wasn’t terribly fond of having to work with physician informaticists, let alone one who was relatively young and decidedly sassy.

Since we were technically independent despite the affiliation, we pressed ahead and implemented quickly, helping physicians from day one. Our most valued feature was assisting in reconciling medication lists from different sources and identifying patients who might be seeking controlled substances from multiple physicians. Other solid features involved supplying data for problem and diagnosis lists as well as laboratory and biometric data.

Although I moved on before our little HIE reached maturity, I still regard it as one of the best projects I ever worked on, and also the most educational for me as a clinical informaticist. I learned more about discrete data, interfaces, and interoperability in those months than I probably did in the first five years of my career. In the early days of data normalization, I also learned that laboratory directors don’t like it when outsiders find problems with their data, and if you’re going to question senior physicians who are twice your age, you had better come ready with plenty of facts and examples because it’s going to be difficult to convince them that their system isn’t perfect.

Since then, I’ve kept my eye out for interesting HIE stories and have enjoyed seeing how exchanges have evolved over time. Although many of the technology issues have stabilized, there are a host of challenges that are both operational and financial. A Brookings Institution blog post caught my attention last week. It reviewed some of the digital transformation that has occurred as a result of the COVID-19 pandemic, including increased adoption of telehealth and the rise of healthcare technology startups and retail healthcare.

The authors note that the transformation is also impacting the health information exchange world, raising questions about how HIEs fit into the larger healthcare ecosystem. Where traditional HIEs typically involve data exchange among physicians and hospitals, there is a growing need to incorporate data from a multitude of other sources. Since many of the newer players, including retail clinics, involve large national organizations, there is motivation for them to maintain their own medical records without necessarily having to integrate with traditional provider or hospital organizations.

Additionally, given functionality required by federal incentive programs, patients now have a greater ability to view, download, and transmit their own health information. The authors note that new features such as Apple’s iOS Health Records functionality allow patients to communicate more directly with their physicians. However Epic, was not included in the Apple implementation. They summarize, “Not only can these companies choose which HIEs to work with, but they disrupt the original purpose of HIEs, which was to centralize medical care for improved efficacy of patient care.” This means that HIEs may need to play a new role in the marketplace, and the authors list strategies for HIEs to try to remain relevant:

• Diversify network members and data types to stay relevant.
• Include knowledge discovery in their focus.
• Work horizontally and vertically to meet patients and providers where they are.

These are certainly important points. HIEs are going to need to widen their user base and make sure they stay current in understanding the needs of their constituents. HIE use cases have gone far beyond catching patients who are seeking duplicate prescriptions (most states have prescription drug monitoring programs for that now) to providing opportunities for analysis of broad aggregations of patient data that could provide valuable information for public health as opposed to being merely push/pull platforms. In the third point, the authors propose that HIEs consider mergers and acquisitions to expand in similar service lines, such as collaborating with HIEs in neighboring states, where vertical integration would allow them to better integrate with their current data suppliers and consumers or add stakeholders such retail healthcare providers.

The authors also note that further HIE growth may be limited by other factors. These include concerns over patient privacy and worries about increased regulation.

For the latter, there are concerns that charging a fee for data exchange might be construed as information blocking, so there are plenty of issues to resolve there. I’d also mention that they need to worry about cyberattacks and maintaining adequate financial resources to ensure solvency.

In our current environment, they also need to be wary of becoming embroiled in political controversies. For clinicians, sharing vaccine information through HIEs has been a tremendous benefit and allows us to have complete records on pediatric patients and avoid giving duplicate immunizations. In our polarized political climate, I wouldn’t be surprised to see certain states try to make it illegal for healthcare organizations to share COVID-19 vaccination data.

HIEs have always had tremendous potential, but the road to success has been a rocky one and there have been quite a few failures along the way. I’m hopeful that the current generation of HIE leaders understands the challenges and that those leaders are getting creative about ways to ensure longevity and a bright future.

What role do you see for HIEs in the coming years? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/7/21

In telehealth news, California’s governor recently signed a bill (SB 306, the STD Coverage and Care Act) which requires health plans to cover at-home test kits for HIV and sexually transmitted infections (STIs). The state has had recent increases in STIs, and the bill is aimed to help reduce those numbers. Patients can self-collect samples for many STIs. Studies have shown that self-collection (even in the physician office) increases rates of adherence for recommended testing. Coverage is required for health care contracts that are issued, amended, renewed, or delivered after January 1, 2022.

If I was working at a telehealth vendor that didn’t already offer a business line that addressed this kind of testing, I’d be spinning it up right away. There are some nuances to managing these types of tests (including being able to report results to local public health authorities) but the COVID pandemic accelerated automation of these functions so that they’re much less onerous. Developers have about three months to get their functionality in gear, so it’s ready-set-go for anyone with clients in California.

The National Institutes of Health announced that its All of Us Research Program will make more COVID-19 data available for researchers. This could allow better exploration of the long COVID symptoms that some patients experience as well as help identify factors that might identify which otherwise healthy patients will do poorly if they become infected. The expanded dataset now includes data on over 300,000 patients, with nearly 80% of them representing groups that are typically underrepresented in medical research.

Having access to such a robust dataset is going to be key to ensure artificial intelligence technologies don’t have bias from the data used to train the models. A testimonial from researcher Sally Baxter, MD, MSc explains the limitations of using a single-site dataset from her own institution versus the improved performance after using the All of Us data for training the model.

In the “healthcare folks behaving badly” category, a pharmacist in Puerto Rico enters a guilty plea after administering COVID vaccine to children who did not meet the age minimum approved by the FDA. In addition to improperly vaccinating children aged 7 to 11, the pharmacist billed Medicaid for the services. Additionally, since the vaccines were part of stock provided by the US government, not only were the administrations clinically inappropriate but also “unauthorized and unlawful.” The vaccinations were identified by the Puerto Rico Department of Health, which suspended the pharmacy’s participation in COVID-19 vaccination efforts. Only a couple of dozen patients were involved, but since the dosing for that age group hasn’t yet been approved, it’s not clear what they were given and if they received the full adult dose or something else. I hope all the children involved are doing well and didn’t experience any complications from the situation.

The COVID-19 pandemic has placed a tremendous burden on provider organizations, many of whom tapped the US government’s $178 billion 2020 Congressional Provider Relief Fund. STAT news has created a database showing how much funding physicians and healthcare organizations received. Not surprisingly, large health systems and those in major metropolitan areas received large pieces of the pie. Altogether, there were 412, 591 payments, with 90% of them being below $192K. The median payment was $12,530.

Looking at the data from my state, it’s difficult to see how much some of the large health systems received since some of them are listed separately and have a number of hospitals, clinics, and affiliated entities. I found it interesting that my former urgent care employer received more funding than many of the smaller hospitals in the state, but I wasn’t surprised given the volume of care they deliver and the acuity of patients, as well as the number of employees. What I did find surprising was the number of optometry practices that received several million dollars each. Also, at the bottom of the list, there were over 200 practices that received less than $100, which I’m sure didn’t even cover the money spent filling out the application. A couple of dozen practices were between $1 and $20. I found the fact that they issued checks for $1 to be bizarre since it probably cost many times that amount to create the check and will cost the practice more than that to cash it when you figure in staff salary and the potential for bank transaction fees.

It’s always interesting to use the various available databases to see what kinds of payments physicians and other healthcare providers are receiving. One of the more well-known data sources is the Open Payments database, which gathers numbers on payments made by drug, medical device, and other companies to physicians and other covered recipients. If a pharmaceutical rep buys a physician lunch and it’s over a certain amount, it’s reportable. CMS recently released adjustments to the reporting threshold for the 2022 Program Year, based on the Consumer Price Index. In case you’re curious, anything less than $11.64 doesn’t need to be reported unless the total annual value of payments to a covered recipient exceeds $116.35. I searched for myself in the Open Payments database, which goes back to 2014. I had exactly one payment for some consulting work that I did as a clinical informaticist, looking at specs for a new diagnostic testing apparatus. I’m not sure it should have been subject to Open Payments, but I’m not about to argue it.

I’m nearly back to normal after the side effects of my recent COVID-19 booster, with only some aggravating itchy sensations remaining at the injection site. Several readers weighed in on my request for good shows to watch while recuperating. There seems to be a general theme to some of the options, with many of them being on location in the UK. Fortunately, I was able to reserve a couple of the recommendations at my local library, so I’ll be able to stay well entertained as soon as they’re ready for pickup. In the mean time, I’m venturing into the great outdoors this weekend. I’m about to start a very big project that will take up most of my time for the foreseeable future, so I’m looking forward to kicking back around the campfire and enjoying some delicacies cooked in cast iron. There’s more to fall than pumpkin spice, y’all.

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Curbside Consult with Dr. Jayne 10/4/21

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/30/21

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 9/27/21

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/23/21

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/20/21

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

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

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

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

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

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

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

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

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

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

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

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EPtalk by Dr. Jayne 9/16/21

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

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

Hi Dr. Jayne,

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

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

Regarding some of the specific issues raised in your post:

Re: Open Notes

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

Re: Types of notes

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

Re: Health care providers subject to the rule

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

Re: Exception for harm

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

Re: EHR certification

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

Re: Scope of medical record

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

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

Thanks!

ONC

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

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

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

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

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

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Curbside Consult with Dr. Jayne 9/13/21

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.