EPtalk by Dr. Jayne 8/26/21

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/23/21

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

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

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

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

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

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

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

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

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

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

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

VP: No, we have encounter notes.

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/19/21

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/16/21

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

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

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

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

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

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

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

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

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

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

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

They have identified five strategic objectives:

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

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

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

Email Dr. Jayne.

Dr. Jayne Goes to HIMSS Digital – Thursday

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Dr. Jayne Goes to HIMSS Digital – Wednesday

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

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

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

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

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

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

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

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

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

Presenter tips from the HIMSS Digital trenches:

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

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

Dr. Jayne Goes to HIMSS Digital – Tuesday

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

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

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

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

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

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

Dr. Jayne Goes to HIMSS Digital – Monday

I decided to take full advantage of the HIMSS experience and slept in a little this morning, pretending I was on Pacific time to justify some extra lounging. I’ve asked my household to do some random door-slamming to simulate the hotel experience, but they were fairly quiet and there was no dinging of elevators or rattling of ice machines either. In honor of the “reduced attendee headcount” experience, they allowed me ready access to the coffee rather than having to stand in a queue, and fortunately my morning brew was complimentary with my already-paid room.

My registration experience was confined to having to log into the HIMSS Digital app since I hadn’t used it in 72 hours on my desktop PC. Once again it asked me for a validation code that it said would be delivered to my phone but never was, although it did finally arrive via email. I picked out of a couple of on-demand sessions for my morning education, but I had a bit of a client fire to put out, so I’ll have to make it to those later.

The lunch hour was rounded out with a meeting that was supposed to happen in person in Las Vegas but ended up being via phone since we both elected not to go to HIMSS. I definitely enjoyed being able to meet with her with a sandwich on my desk versus trying to fight to get a restaurant reservation as you usually do at HIMSS.

Finally, the main event arrived, the opening session, titled “The Year That Shook the World,” including Hal Wolf’s opening speech that was followed by the keynote with Patrick Dempsey. The first eight minutes of the session included some banter by the hosts about how great Digital HIMSS is and how many safety precautions they’re taking on the set, as well as some comments about attendee door prizes including a free HIMSS membership and a Starbucks gift card.

To be honest, I was a little tuned out because I don’t do well with silly banter, and the portion of the speech by Hal Wolf felt like a buzzword salad. He covered the rise of telehealth, the need to transform current care models to one focused on value-based care, and the instability of healthcare organizations’ financial positions. I can only hear about the intersection of people, process, and technology so many times, so it was a struggle not to multitask.

HIMSS also pushed its Accelerate platform that I can only describe as a cross between LinkedIn, Facebook, and other social media platforms that HIMSS thinks is “exciting” and “incredible” but most of us think is pretty “meh.” The hosts talked about how excited they were about the platform and how “I felt like it was built just for me.” More inane banter ensued, with attempts to also engage people on social media and intermittent check-ins with their social media wall display that they have on the set.

The “Visionary Keynote” from Patrick Dempsey was an approximately two-minute “tribute” wishing us a good conference and thanking healthcare providers for our service. He’s apparently onsite for a movie in Ireland and gave a salute with his teacup. The presentation segued back to more banter between the hosts and encouragement to “break social media” using the #HIMSS21 hashtag. To be honest, 28 minutes into the presentation, they pretty much lost me. I tried to get into the panel on “Lessons Learned and Forward Strategies for Virtual Care,” but it was basically a summary of what I’ve lived for the last year and a half as well as the projects I’m currently working on. I didn’t get a lot out of it, but felt like if you weren’t knee deep in virtual care, you might have found it more engaging.

Moving into the next segment on “Getting AI Right and Guaranteeing Equity,” I had to cringe when the host couldn’t pronounce John Halamka’s name correctly. I do love Dr. Halamka’s ability to talk about complex topics in a way to make it understandable. He gave a great example why you can’t create an AI model using EKGs in thousands of Scandinavian Lutherans and expect it to work properly in Spain. He likened using the nutrition label on foods to needing a label on our AI algorithms to show the economics, ethnicities, etc. that went into creating the algorithm. Definitely one of the more engaging segments of the afternoon.

I received a couple of vendor emails inviting me to booths at HIMSS21 if I would have been there. Cisco was one of them and also offered a complimentary code for HIMSS Digital, so I would have been pretty aggravated if I paid for it rather than attending as part of my rollover registration from 2020.

Readers at the live conference have been keeping me posted on lines at check-in, reporting growing lines throughout the day. One hotel had 30 people in line at 10:30 a.m., with only three employees working the front desk. One reader reported elevators with six-plus unrelated people in them and only 50% masking. I can’t help but imagine that the frontline healthcare providers who decided to attend are losing their minds when confronted with those scenarios.

Other boots on the ground reports include that the food at the opening reception was “actually pretty good” but that there were no performers in show girl costumes this time around. I also heard that the subterranean area of the expo center is no more, and that the new exhibit hall layout “redefines social distance” with a 100-plus degree heat and half a day’s worth of steps to get there. Kudos to my intrepid correspondent for braving the melting sun to keep me posted.

I’m still waiting for shoe and fancy mask pictures, so please send them my way!

Email Dr. Jayne.

Dr. Jayne Goes to HIMSS Digital – Sunday

As I prepared for what would have been my departure for Las Vegas, my inbox was filling with notes from vendors that they were cancelling their in-person presence at HIMSS21. Although this represents a financial loss for those vendors, it also makes a statement that they’ve considered that public health implications might be more important than exhibiting, so I salute them.

Other meetings scheduled for later in the year are beginning to cancel outright. The American Academy of Family Physicians announced Thursday that it’s postponing its annual Congress of Delegates meeting that was scheduled for Kansas City in September, citing “local spread of the delta variant of SARS-CoV-2” along with the fact that “AAFP cannot control the vaccination status of other guests and staff at the planned meeting site.” Travel restrictions from employers and academic institutions were also cited.

Also Thursday the Urgent Care Association canceled its 2021 Annual Convention slated for New Orleans in October. They noted that “In the past two weeks… COVID volumes in urgent care centers have doubled, tripled, and quadrupled.” They also mention that projections from the Louisiana Department of Health aren’t looking good for any improvement by October. I was supposed to attend conferences in September, October, and November, but none of them are looking promising at this point.

Also in my inbox was a confirmation from a hotel reservation that I canceled back in February, when I upgraded to a different hotel. I tried to cancel it online but it told me I would have a cancellation penalty to the credit card on file, so I called the hotel. They only showed the reservation that was previously cancelled and couldn’t find the “ghost” reservation even by searching my name as well as the confirmation code. We’ll have to see if any charges ensue. I called The Palazzo to cancel my actual reservation and after a 45-minute hold was able to do so. The agent kept telling me I’d see a refund on my card despite the published cancellation policy that would forfeit my first night’s already-charged guarantee, so I’m not holding my breath for a credit.

I had been looking forward to seeing the FDB CDS Analytics solution from First Databank, who has elected not to exhibit. They still plan to launch the product as scheduled. It aims to help organizations monitor and customize clinical decision support (CDS). Understanding how users are handling (or ignoring) alerts is key to patient safety, as is finding the right balance of alerts that won’t overwhelm but will prevent the most serious harms. Most organizations don’t know if their CDS is effective, and the solution is designed to track CDS impact over time. It’s available in the Epic App Orchard and I’ll definitely be reaching out to FDB for a demo.

I finally spent some quality time looking at the HIMSS Digital schedule and making my plan for the week, which was pretty easy since most of my time was open. There is a mix of real-time and on-demand sessions, and even the real-time ones will be available on demand a couple of hours after their conclusion. That’s good for me, because I’m pretty sure I’m going to miss the Patrick Dempsey portion of the opening keynote due to a last-minute meeting request. As in all things consulting, the billable takes precedence over the entertaining. I also identified which sessions are available for continuing ed so I can log the appropriate hours, so I felt pretty prepared for the week.

Shoe pictures have started arriving from my most dedicated readers, including these adorable snow globe slides from Kate Spade. They’re still available in my size, if anyone is curious. I’d like them even better if there was a resin model of a coronavirus particle in the heel, so I could fantasize about crushing it every time I take a step.

What are the best shoes you’ve seen at HIMSS21? How was the registration and badge pick-up process? Since I have to live vicariously this time around, leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/5/21

A federal judge denies Elizabeth Holmes’ request to suppress patient complaints and Theranos testing results as evidence during her trial. Attorneys argued that the failure to preserve the laboratory information system database should allow the exclusion. Theranos is accused of decommissioning the database and giving investigators an invalid copy. Jury selection begins August 31 for what is sure to be an entertaining trial.

I see a lot of error messages, but this was one of my favorites. Not even a cookie, just a crumb.

The US Department of Health and Human Services announces the availability of $103 million in funding from the American Rescue Plan to reduce burnout and improve mental health among healthcare workers. The funding will be available over a three-year period and is targeted to consider the needs of rural and medically underserved communities. It plans to “help health care organizations establish a culture of wellness among the health and public safety workforce and will support training efforts that build resiliency for those at the beginning of their health careers.”

I take issue with the whole idea of needing to “build resilience” among healthcare workers. We are plenty resilient to begin with, but the systems that surround us have failed patients and have failed us. Telling us we need to be more resilient is not the answer – that’s a “blame the victim” strategy implying we’re somehow not “enough” for the situations we are in. Let’s fund efforts to reduce abuses in healthcare, improve caregiver-to-patient ratios, reduce or eliminate nonsense regulations and requirements that make it harder to do our jobs, and adequately fund public health and health literacy efforts in the US. Those types of transformation will really put a smile on our resilient little faces.

Feel-good story of the week: A WWII vet celebrates her 100th birthday with a helicopter tour around a ship named after her late husband. Ima Black was part of the Women Accepted for Volunteer Emergency Service (WAVES) program during World War II and for 50 years was married to Delbert D. Black, who after surviving Pearl Harbor went on to become the highest-ranking enlisted sailor in the Navy. The Navy named a destroyer after him and a Florida helicopter crew flew her not only around the ship, but showed her downtown Jacksonville to boot.

Less than feel-good story of the week: The Journal of the American Medical Association publishes an op ed piece regarding “The Increasing Role of Physician Practices as Bill Collectors: Destined for Failure.” Shifting of costs from insurance companies to “patient responsible” balances has led physicians to manage a growing share of the payment portfolio. Patients are responsible for deductibles, co-pays, and co-insurance, all of which can be confusing, not only from a healthcare literacy perspective, but from a financial literacy perspective as well. Physicians struggle with collecting these amounts due, which drives a spiral where they request higher reimbursements, which increases charges, and the cycle starts again.

I made the difficult decision this week to cancel my trip to HIMSS21. Clark County, NV is being hit hard, with 89% of ICU beds in use. Although I’m vaccinated and at low risk for complications of COVID, my analysis had the risks outweighing the benefits. I’ve been seeing a significant number of breakthrough COVID cases in fully vaccinated (and otherwise healthy) individuals, and it’s not clear whether it’s the remoteness of the vaccine versus the properties of the now-prevalent delta variant that is responsible. One of my favorite people was just diagnosed today and I hope he recovers quickly. It doesn’t seem prudent as a healthcare provider to potentially take myself offline for patient care by attending a large event regardless of the mitigation strategies. Not to mention that masking in airports and on planes is far less than universal.

The county’s hospitalization numbers mean that the Las Vegas area is not equipped to respond to any kind of mass casualty event like it has unfortunately seen in the past. I would be pretty angry if a convention rolled into my similarly sized metropolitan area right now regardless of the economic benefit. My own personal ROI was also a factor – my client meetings have been canceled and I suspect even those exhibitors that are still attending will send skeleton crews, so it wouldn’t be productive from a business standpoint. At this point I can reuse my airfare (thanks Southwest!) while attending digitally and am only out my first nights’ hotel charge. I guess I’m also out of pocket for the sassy shoes I purchased for the Mothers in Medicine Fund reception that was wisely canceled due to public health concerns. I’ll wear them around the house Tuesday night and think about the hard-working healthcare moms the Fund is trying to assist.

I went ahead and tried to queue up my HIMSS Digital account, which requires that you submit your name and email address to receive a validation code by text and email. I never got the text and the code in the email didn’t work, so I had to go through the process again. Second time was a charm, although I was annoyed by the process and moved on to other things. I’ll have to spend some quality time with the agenda tomorrow, deciding on my sessions and dropping the Patrick Dempsey keynote onto my schedule. It still won’t be the same as seeing everyone at HIMSS, so I’m looking forward to hopefully a more “normal” HIMSS22.

On the positive side, since I won’t be out of town, I will be here for our local school board meeting where I plan to go toe-to-toe with anti-vaccination and anti-masking advocates. Our hospital admissions rates look just like they did last October so I’m supportive of anything we can do to try to crush this surge. The hospital teams are completely burned out and there are no travel nurses or reinforcements on the horizon. It’s going to be a bumpy end to the summer, for sure.

For those of you attending HIMSS21 in person, I wish you a safe and uneventful conference. Hopefully everything will be low key and you’ll be able to accomplish what you set out to do by attending. Please feel free to keep us apprised of any cute shoes you see, wild booth promotions, or general HIMSS shenanigans. We’re counting on you!

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/2/21

Like most of us, it’s been a long time since I’ve attended an in-person conference. Often, the sessions aren’t terribly memorable, and once I get home, I rarely consult my notes.

One of the exceptions was a presentation I attended at the American Medical Informatics Association Annual Symposium some years ago, where the topic covered patient portal use among children and adolescents. I remember the speakers talking about how their institution did the difficult work of defining what elements could be shared, which should be shared, and how to best set up various age and proxy restrictions for the best outcome.

Fast forward, and now we’re dealing with not only the limitations of patient privacy and EHR capabilities, but the impact of interoperability and information blocking rules. JAMA Pediatrics had a good viewpoint article about this last week. Working with patients who are minors can be challenging, especially as they move through the adolescent years and become candidates for certain healthcare services that can be kept confidential to some degree, such as pregnancy, sexual health, mental health, and related care. It’s always been a fine line that we’ve had to walk, because although we can restrict that information in the medical records, parents and guardians may still receive the bills and insurance correspondence.

For those who might not be in the data-sharing trenches, the article provides a nice overview of what HIPAA and HITECH have required as far as making records available. It also summarizes the 21st Century Cures Act and information blocking rules. As far as information blocking goes, there is a subset of situations where information blocking might be allowable, including technical infeasibility, preventing harm, and privacy. Those caring for minors might need to use one of these exceptions to protect patient confidentiality, especially considering that states have differing requirements as far as protecting restricted categories of information such as mental / sexual health services and contraception.

Clinicians have to understand those state rules and what parents might be able to see, and they also need to fully understand what features their EHRs might provide to help them with this daunting task. Some EHRs I’ve worked with allow users to mark specific data elements as “sensitive” and block release; others require the user to create separate encounter notes where an entire visit’s documentation is blocked from release. Less-savvy users might not understand these nuances, leading to negative consequences for patients, not to mention increased liability for themselves and their institutions.

The article also notes that the flow of data must also protect information provided by caregivers who might have a need to keep certain history elements from the patient, such as adoption status, genetic diseases, or other pieces of family history that a patient might not be mature enough to absorb. Another tricky area noted by the authors is the maternal data that is contained in a newborn’s EHR chart. This information often includes sensitive testing (HIV, hepatitis, sexually transmitted infections) as well as information on maternal drug and alcohol use, intimate partner violence screening, and more. Disclosing the mother’s protected health information to other caregivers can be a problem if not handled carefully.

The article mentions benefits of information sharing and jogged my mind on some of those aspects from the AMIA presentation. When I was in a traditional family medicine practice, we often spent the majority of the 17-year-old well visit discussing “Healthcare Adulting 101” so patients could understand their health information and how to best access it as they headed to college or otherwise into adulthood. With the rise of patient portals, adolescent patients may be able to schedule their own visits, request refills, and more. Education is needed so they understand the difference between urgent messages, non-urgent needs, and the best ways to navigate our often-chaotic healthcare system.

For adolescents with complex medical histories who have the ability to participate in self-management programs, having access to their information can be valuable and can help them get the best outcomes. Patients can partner with their parents for co-management, but organizations must be careful that common policies (such as reducing parental access to the chart during the teenage years) do not inadvertently hamper successful family dynamics. It’s quite a tightrope that that care teams walk at times and I thought the article was a good reminder for the rest of us. Unfortunately, since it appeared in a pediatric-specific journal, I’m not sure how much external visibility it will get.

The piece paired nicely with another article that I ran across, this one about using artificial intelligence systems to sort through electronic health records. The study looked at the amount of time that clinicians spent reviewing clinical data during patient visits and whether an AI system could help organization patient information prior to review. The study was small, with only 12 gastroenterologists participating. Each participant received two clinical records, one in the standard format and one that had been optimized via AI. They were then required to search the record to try to answer more than 20 clinical questions. The AI-optimized records allowed physicians to answer the clinical questions faster with equivalent accuracy. Nearly all the physicians stated they preferred the optimized records to the standard.

Even though the study was small and really needs to be redone with a larger number of physicians across multiple specialties and with multiple samples per physician, it got me thinking. What if you could use AI optimization to tackle the pediatric data- sharing problem? What if AI could be used to augment clinician efforts to seek out and appropriately tag or restrict sensitive information? Could AI-enabled tools run in the background while physicians are documenting and alert them to state laws about the information they’re adding to the chart, and do so right at the point of documentation? What if our systems could actually allow us to work smarter and could help make it easier to do the right thing the majority of the time? I think that’s the goal that most of us have in clinical informatics, although it’s often difficult to deliver those advantages to our users.

For those of you in the pediatric informatics trenches, how well are the tools available to you doing? Are they making it easier to manage information sharing or more difficult? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/29/21

As I get ready for HIMSS, people always ask me what’s on my must-see list for the year. The Medicomp booth is always at the top because the people are friendly, the product is solid, and they always have the good carpet for giving your feet a break. I enjoyed their two-story booth in the past because it provided an interesting view of the HIMSS spectacle.

Notwithstanding the physical space, Medicomp has a couple of cool things to talk about this year. The first item is the new Holy Name EHR, built using Medicomp solutions and brought live in their emergency department in the middle of a pandemic. Having spent way too much time in the ED trenches, I’m eager to see what they came up with in their custom solution compared to the off-the-shelf products.

The second Medicomp item I want to learn more about is the plan for partnership with CPSI to integrate the Quippe Clinical Data Engine into the CPSI platforms. I’ve been a big fan of Quippe for a long time since it has the power to help the EHR surface important information at the point of care. One of my favorite features is its ability to tag different clinical findings across time, so physicians can easily see where a symptom appeared previously. CPSI is used in many community hospitals and integrating Quippe will add some bells and whistles that will help build on quality initiatives and make documentation more efficient. While academic centers and large integrated delivery networks get a lot of attention, community hospitals enjoy having nice toys, too. Hopefully the integration will go quickly and get some cool tools into the clinicians’ hands.

Social media is everywhere, and I always enjoy having new emojis to enhance my communications. The new @VaccineEmoji is gaining traction and will provide a welcome alternative to the much maligned bloody syringe. The new emoji is modeled on a Rosie the Riveter-esque arm with a bandage strategically located over the deltoid muscle. Designers hope it will help in public health messaging, although the emoji is still awaiting approval by web text organizations. The director-general of the World Health Organization even supported it on World Emoji Day, which I didn’t know until recently was a thing.

I participated in a telehealth roundtable this week and one of the hot topics was medical licensure for telehealth physicians. Those who practice telehealth exclusively often have a dozen or more licenses, which can be burdensome and costly to maintain. Some states participate in the Interstate Medical Licensure Compact, and while it streamlines the licensure process somewhat those licensed in participating states, physicians still have to obtain individual licenses. Telehealth advocates are lobbying for relief, including licensure reciprocity or potentially a federal-level license that would allow people to practice in any state.

I live on a state border. Back in the day, I could care for my technically out-of-state patients over the phone without concern. Now, however, that is considered telemedicine, and my choices were to either get another license or stop caring for those patients over phone and video. The license process was a pain, especially the part where they wanted me to submit my high school transcript – a data point which makes absolutely no sense for determining whether a physician is worthy of licensure. One would think the medical degree, board certification certificate, etc. would be enough. Still, I had a good laugh with my high school’s registrar who promised to find my transcript on microfiche. One approach being championed by the Alliance for Connected Health includes a Medical Excellence Zone, which would be a group of states that recognize each other’s licenses as long as the physician doesn’t create a physical office in the other states.

In addition to being an annoyance for border dwellers like me, it is also a barrier to very specialized or renowned physicians who want to provide second opinion services to patients without the inconvenience of travel or distance. A federal licensure approach would likely benefit these physicians most, although many states will resist. The precedent is there for physicians credentialed by the Department of Veterans’ Affairs for telehealth. I learned from another panelist about the Sports Medicine Licensure Clarity Act of 2018, which apparently allows team physicians to care for their athletes in any state where the athlete or team is playing, as long as they hold a valid license in at least one state. If it’s good enough for professional athletes, shouldn’t it be good enough for the rest of us?

Recent Illinois legislation HB 3308 establishes payment parity for numerous telehealth services through 2027. Audio-only telehealth and asynchronous telehealth services were expanded as well. The bill also prevents payers from requiring an in-person visit before telehealth services can be delivered and keeps them from requiring patients to provide a reason for requesting telehealth. It also protects patients who request in-person care by preventing payers from requiring virtual visits and protects providers by preventing insurers from mandating delivery of telehealth services.

Breakthrough COVID-19 is real, y’all, and it hit close to home as one of my fully-vaccinated family members added an undesirable diagnosis to his problem list. It’s heartbreaking to see people who did such a good job avoiding infection now being impacted, but the transmissibility of the delta variant is definitely in play in my community, as is the abject lack of masking. My former employer is seeing record-breaking numbers of patients, a sizable percentage of whom are unvaccinated and test positive, although the vaccinated positive patients are becoming more numerous.

Looking for testing options, both Walgreens and CVS were booked for days and he didn’t want to be exposed to other illnesses at urgent care, so I was able to get him scheduled at the local county health clinic. Drive-through appointments were abundant and I was able to go online at midnight to book an 8:30 a.m. appointment. The only negative of the county health process was the lack of practical medical advice provided to the patient – his only follow up was a link to his lab result that simply said “detected.” Not every patient is going to readily understand that it means positive or what to do next. Fortunately, I was able to provide isolation and self-care advice, so we’re hoping for a speedy recovery.

HIMSS21 will be requiring masks as well as vaccines, and I truly hope it doesn’t turn into a super spreader event. I’m waiting for my academic colleagues to get hit with travel bans again, so my planned catch-up opportunities may be dwindling.

What are your HIMSS21 plans? Is it time to throw in the towel? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/26/21

I learned a valuable lesson in procrastination today, as I delayed writing until after I had an unfortunate encounter with a cheese knife. It was a classic blunder because I was in a hurry, and now I get to figure out how to type with fewer digits because I forgot how much finger lacerations hurt. It’s a good thing I’m not seeing patients in person right now because proper hand hygiene would certainly be a challenge. Public service announcement: don’t cut toward yourself, folks.

I should be practicing music in preparation for a recording that’s due soon, but that’s not going to happen. In the meantime, I’m recuperating by catching up on my journal articles and some light Netflix watching, which I almost never get to do. One of the first articles to catch my eye is timely given the state of burnout among my healthcare colleagues. It deals with the evaluation of resident physicians as to their level of “grit” and its association with wellness outcomes. The personality trait of grit is defined as “perseverance and passion for long-term goals.” Grit has been associated with conscientious behavior and higher levels of hope. In healthcare, those with higher grit scores have been associated with lower burnout scores.

The article looks specifically at the association of grit scores in surgical residents with burnout, thoughts of leaving the program, and thoughts of suicide. Researchers tested residents following the 2018 American Board of Surgery In-Training Examination. Where previous studies looked at data for residents in a single institution, this approach allowed them to look at nearly all clinically active surgical residents. Although the scores varied between programs, they found that residents with higher grit scores were less likely to have burnout, thoughts of quitting, or thoughts of suicide. It also confirmed that residents overall continue to have unacceptable levels of burnout, suicidal thoughts, and thoughts about leaving their training programs.

Fast-forward a couple of years and we have a situation where physicians and other healthcare providers around the world have been pushed to the brink. Many of them are working hours that are similar to what they worked in residency or their training programs, except now they’re responsible for these larger patient loads and sicker patients rather than being in training. It’s a heavy burden to bear and this week I saw four more of my colleagues resign from medicine. Mentally it seems worse, I think, because the patients are often in the situations that they are in by choice – by refusal to vaccinate, wear a mask, or practice social distancing. It’s hard to manage the cognitive dissonance around putting yourself at risk caring for others who didn’t take basic precautions.

As a clinical informaticist, I’ve learned to tread lightly around physicians and other care team members who are stressed. It’s important to know what else has been going on in their days before figuring out the best approach to training them or working with them in meetings. For example, did the OB/GYN on the committee just come out of a disastrous delivery, and that’s why they are disengaged or sound angry? Was it a difficult day in clinic? Lately, it seems like all the practicing physicians with whom I work are stressed every single day, which makes it hard to take projects forward when you need their input. I’m seeing many more canceled and rescheduled meetings and lots of schedule juggling. I’m having to think of entirely different ways to work with some of my end users while they struggle to balance all of the different pressures that they are under.

Lately it seems like they never get a break. The younger clinicians seem particularly stressed because school is starting soon. Most of them have planned for their children to attend in-person school, and the thought that our local COVID case numbers might change that is pushing them to the brink. It’s hard to get people to want to engage with you around designing order sets or evaluating potential clinical workflows when they are worried about childcare. We’ve seen a drop-off in participation in some of our committees and work groups as well. It seems people are just not willing to spend any more time at the workplace than they absolutely have to.

It doesn’t seem like video calls are the answer due to a tremendous amount of Zoom fatigue. We are having to think outside the box on how to engage people while also respecting their need for work/life balance. It’s important that we have good representation from different types of users with different types of needs, so we’re going to have to figure it out.

As clinical users become more stressed by patient care activities, they have less tolerance for misbehaving technical systems. What used to be small annoyances that users would ignore now seem to be more disruptive. If the EHR is running slow or there are any performance lags, it causes much more angst. Any buffer of resilience has been completely eroded over the last year. Most of the clinical organizations I work with have placed new non-essential tech initiatives on hold in order to give their budgets some breathing room, and it’s probably a good thing because it also gives their personnel some breathing room. For those that are moving ahead with big projects, I’m making sure they think about how they’re going to best support their users through the transitions.

I’m curious how other organizations are coping with the stresses of our new healthcare normal. Maybe there are some change leadership Jedi tricks that I haven’t learned yet that would be of benefit. Or perhaps the solution is to just slow down and give people some breathing room so that they can focus on patient care and self-care. Or maybe there are no good answers, and we just have to continue putting one foot in front of the other each day and hope for the best.

How gritty are your clinicians, and will they be able to rebound? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/22/21

When I was deep in the primary care trenches, I used to fantasize about insurance companies that would allow you to skip their prior authorization process if your track record had no previous denials. That might become a reality in Texas, as a recently passed law takes effect this fall in which physicians who have a certain track record can be exempted from prior authorization process. They will need to demonstrate that 90% of their treatments in the previous six months met payer criteria for medical necessity. Now we’ll have to see whether EHR vendors update their clinical decision support algorithms to capture whether a physician has to deal with prior authorizations or not. Still, it’s a victory for patients who won’t have care delayed and for physicians who can reduce overhead spent on needless bureaucracy.

I’m lamenting the fact that both of my local medical schools have apparently decided that the pandemic is over, canceling virtual access to Grand Rounds and other presentations. For those of us who practice in the community or who aren’t near the medical campuses, being able to attend sessions from a distance was a tremendous boost. I attended more lectures in the last year than I had in the previous five years. Hopefully, some of my out-of-state sources will continue offering virtual options.

I admit that sometimes trying to do a virtual / hybrid offering can be challenging, but at a minimum they should record the sessions and allow people to access them later. They’re already doing those kinds of recordings for medical school lectures (and had been doing so long before the pandemic) so the technology is largely in place. Why wouldn’t you want to get your message to as many physicians as possible? Seems puzzling to me, but maybe some readers have more insight.

Surgeon General Vivek Murthy takes aim at health misinformation this week, urging communities, health professionals, and tech companies to help patients understand the reality behind COVID vaccines, treatments, and overall status of the disease. His call to action takes the form of a Surgeon General’s Advisory like those that were used in the past to address smoking and other serious health threats. The document calls on researchers to better qualify the damage done by health misinformation. It also calls on tech companies to monitor misinformation and to protect health professionals from harassment.

Banner Health is on the naughty list with many of its employees this week for issuing a commemorative coin to those who supported the health system’s pandemic efforts. A Banner spokesperson stated they hope it “will be a reminder in years to come of what we were able to achieve together during this once-in-a-lifetime event.” This rings hollow because we’re certainly not out of the woods yet and their putting the efforts in the past tense doesn’t reflect that many of the impacted workers are still grinding it out in the trenches as COVID infections keep rising. Also, some of us don’t want to remember what it was like in the worse parts of the year, because it gives us great anxiety and increases our stress levels. I’d be interested to see the statistics on whether the coin ended up in a random junk drawer for employees or whether it went straight to the trash.

HIMSS21 is trying to lure attendees to its digital edition with Dr. McSteamy himself. One of my shoe-loving BFFs clued me in on the advertising campaign, noting “who at HIMSS thought it would be better to highlight an actor overall those other great speakers?” I get the philanthropist angle, but I’m guessing they went for the eye-candy factor, since the rest of the lineup includes healthcare leaders, innovators, and CEOs. I didn’t even get the email hyping Patrick Dempsey’s participation, so thanks again for keeping me informed. For those with more insight into the whole HIMSS21 situation, I’d be curious to hear your anonymous reports about the truth of registration numbers or the proportion of attendees who plan to participate in-person versus digitally. Everyone I’ve reached out to is being tight-lipped about the registration numbers.

Now that he’s not busy with Haven — the defunct effort by Amazon, JPMorgan Chase, and Berkshire Hathaway which failed at fixing healthcare like so many others before it — Atul Gawande, MD is being nominated for assistant administrator for the United States Agency for International Development’s (USAID) Bureau for Global Health. Gawande will need to be confirmed by the Senate, but tweeted that “With more COVID deaths worldwide in the first half of 2021 than in all of 2020, I’m grateful for the chance to help end this crisis and to re-strengthen public health systems worldwide.” USAID is tasked with advancing US interests abroad, but I sure hope there is a focus on advancing public health systems within the US. They’re under attack, and if anyone doesn’t believe we’re headed towards a dystopian universe, check out what’s happening in Tennessee, where the legislature has bullied the Department of Health into stopping vaccine outreach for teens, even for flu shots or other proven lifesaving vaccines.

I spent a few days out of town this week and was happy to be somewhere less-COVIDy than my home state. In case you’re interested, free vaccinations are available at the Orlando airport. The US has already administered 337 million doses, with 161 million individuals being fully vaccinated. With everyone unmasking these days, it’s clear to most of us in healthcare that vaccines are going to be the only way out of this thing without an ever-climbing body count. We are now almost a year past when the Pfizer clinical trial started, with more safety data in the first year of this vaccine than any vaccine in the history of vaccines. If you’re still holding out, remember this: your choice isn’t necessarily between vaccine and no vaccine. Unless you’re going to stay in your house with no visitors or wear a delightfully snug N-95 mask everywhere you go, it’s more likely that your choice is between vaccine and COVID-19. Let’s fight this thing, folks.

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Curbside Consult with Dr. Jayne 7/19/21

Due to changes in licensure waivers as states decide that the pandemic is over, despite the fact that we’re not even close, my telemedicine work is becoming rather spotty. Unlike some of my colleagues, I don’t have a dozen state licenses, so I’m limited on the patients I can see.

For part-time people like myself who the telehealth vendors hire as independent contractors, it’s difficult to justify the effort to obtain multiple state licenses, not to mention the ongoing costs. Licensure in the US is a patchwork across the states. Although some belong to an interstate compact, others don’t, which makes it even more confusing.

Looking at my nearby colleagues, however, nearly everyone is practicing some flavor of telemedicine, whether it’s some evening moonlighting or as part of expanded offerings on behalf of their practice. I’m always interested to hear about telemedicine experiences from my proceduralist colleagues, so I enjoyed reading this article in JAMA Surgery last week. It specifically addresses the use of telemedicine in surgical subspecialties, proposing that telemedicine will go beyond being a “pandemic adaptation” and will continue to evolve. The article outlines the timeline of increasing telehealth surgical services – initially when elective surgical procedures were suspended and surgeons began to use the technology for preoperative, follow-up, and emergent surgical care visits, but then later in 2020 as COVID-19 cases began to spike.

The authors note that current telehealth technology can make it difficult for surgeons to physically assess their patients and may impede interpersonal communication. However, many patients are able to report specific data points, such as vital signs and pain scale that are often gathered during a visit, and patients are certainly able to tell a physician whether it hurts when they move or touch certain parts of their body as well as what their current level of activity might be.

They cite several potential advantages for telehealth surgical services, including improved access, continuity of care, and reduced disparities. Additionally, patients may have less travel time and expense. Although the authors don’t specifically mention it, I know from personal experience that surgical telehealth consultations have opened up availability for second opinions across the US. One of my close friends was able to have consultations with multiple renowned surgical oncologists in a matter of days, which might have been weeks to months had she needed to travel. Of course, that doesn’t take into account the time she would have missed from work or the travel expenses.

The article goes on to focus on three factors that will most impact the degree to which telemedicine will replace and/or supplement in-person visits.

First, they note that “with interpersonal relationships being a core attribute of high-quality surgical care, perhaps more targeted implementation of telemedicine is required.” They propose established patients as “an attractive subset” for postoperative visits or routine follow up. My only major surgery was somewhat emergent, and I certainly didn’t have the opportunity to form an interpersonal relationship with the surgeon, who came to the hospital early on a Sunday morning to remove a gallbladder that had gone rogue. The next morning, I was seen by a nurse practitioner from the office, handed a script for 10 Percocet, and hustled out the door. A post-op incision check took less than 90 seconds, and I honestly can’t remember if there was even an exam or if it was just a visual inspection of the surgical sites. The idea that our physician-patient relationship was a core attribute of anything kind of makes me laugh.

Second, they note that “substantial technological innovation is still needed to enhance surgical diagnostic capacity of telemedicine.” They propose the use of remote monitoring and wearables to provide supplemental biometric data such as heart rate, sleep time, activity levels, and electrocardiogram data. They note a need to process the data “in clinically meaningful and easily presentable ways” to “accelerate their use in clinical practice.” I don’t disagree with that. None of us want to see hundreds of disparate data points that might be out of context. However, this bullet might relate better to some surgical subspecialties than others.

Third, and I think most of us agree with this, “given the direct relationship between insurance coverage and adoption of health care innovation, continued coverage for telemedicine services and further refinement to the existing policies are needed to sustain this mode of health care delivery.” They go on to mention that payers are already rolling back coverage for telehealth services not related to COVID-19, and if it hasn’t happened by the time this piece comes out, it’s likely that Medicare will soon end coverage for audio-only telehealth visits. This is going to be the end of telehealth services for many patients, especially those who struggle with technology or who might not have the capability of executing a video visit.

A few messages down my inbox was another article about telehealth. Specifically, “how to bring warmth to your virtual care visits.” This piece from the American Medical Association seeks to answer the question: As the US health care system remakes itself into one that includes more virtual visits, how can physicians maintain the empathy and “human touch” that are so crucial to a strong patient-physician relationship?” It summarizes comments from the AMA’s Telehealth Immersion Program, which is designed to help physicians implement, improve, and build their telehealth efforts.

The speakers quoted in the piece have some good points, such as seeing things in the context of a video visit that they wouldn’t have seen in-person – such as fall hazards in the home, companion animals, etc. However, they note the need to focus additional effort on communication skills and relationship management. Most of the tips offered though are the same we’d recommend for physicians struggling with in-person communication – communicating clearly, showing respect, taking time, and displaying empathy. I didn’t find anything new or earthshaking in the article, but then again, I rarely do when the AMA is the source.

One thing that I think health systems and other entities need to think about when they’re talking about expanding telehealth is balancing the convenience factor with the need to support physicians. For example, if an in-person visit typically has a support staff member who documents the chief complaint, assesses and documents vital signs, reconciles medications, and updates histories, then there’s no good reason to simply shift that work back onto physicians. Unfortunately, that’s what we see in a lot of telehealth practices. Some of it is because organizations are still using telehealth solutions that are not fit for purpose or integrated with the EHR, and other times it’s because organizations are just taking advantage of their clinicians.

Those organizations that offer more transactional or direct-to-consumer telehealth services need to be careful about expanding those offerings without thinking about their providers. Many telehealth-only physicians moved into that sector because they prefer the transactional nature of that model of care. Simply put, they don’t want to go back to doing the things they hated in practice, such as tracking gaps in care, refilling medications, reviewing pages of blood pressure logs, and more. If they’re asked to take on additional responsibilities, they’re likely to ask for greater compensation, which will be interesting in an industry with a fairly thin margin.

All in all, it’s clear that telehealth is here to stay. I’m sure it’s going to continue to evolve, although I don’t have a crystal ball to know which way things might go next.

What do you think about the evolution of telehealth in the US? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/15/21

So many health systems placed everything on hold during the pandemic, so I was excited to hear about a health system not only taking something live but building it themselves. Holy Name Medical Center’s emergency department went live on its homegrown EHR, powered by Medicomp’s Quippe solution. I’ve had the opportunity to test drive the Quippe Clinical Data Engine multiple times in recent years and it really is an impressive solution, so I can’t wait to see how Holy Name implemented it. It will be on display at HIMSS21 in the Medicomp booth and I’m looking forward to kicking the tires. Kudos to this team for the implementation even in the face of a pandemic.

Telehealth is here to stay, and I enjoyed reading a Medscape piece on “What should I wear to see my doctor?” Telehealth has changed the paradigm for care delivery at the same time that life in general has become more casual. I still balk at the idea that my telehealth employer wants us to wear white coats, since there’s no purpose to it other than having it shout, “hey, I’m a doctor.” The article shares a couple of anecdotes about multitasking patients, one who tried to do a medical visit while multitasking on a work Zoom meeting and another where the patient was cooking a meal during the visit. Those are certainly extreme examples, but there are many more where virtual visits have clued us into situations in the patient’s environment that we wouldn’t have known if they presented for in-person care.

There are also some pretty amazing stories about physicians being too casual for patient care, including one telehealth physician who lacked a shirt during a consultation. Another provider was written up by his network for drinking beer and eating chicken wings (both visible to the patient) during a behavioral health therapy session. I’m guessing he wasn’t trying to document real-time, because the grease load on anyone’s computer keyboard wouldn’t be desirable.

I personally use my telehealth patient care days as excuses to dress up, to bring out those chunky necklaces that I normally wouldn’t wear in person for fear of toddlers grabbing onto them or the dangly earrings that typically remained in the drawer for the same reason. I still don’t wear sassy shoes, though, mostly because I’ve become entirely too accustomed to living in the Kino sandals that have been my constant companion since the first time I visited Key West. That will all change in a couple of weeks, though, as I get ready for HIMSS.

HIMSS released the details of its COVID-19 vaccine verification process. All attendees, exhibitors, and staff will have to provide proof of vaccination through one of three processes: Clear Health Pass Validation, Safe Expo Vaccine Concierge Validation, or Safe Expo On-Site Validation. I decided to try the Clear Health Pass option and the experience was less than stellar. Once I clicked on the HIMSS-provided link in my email, I had to enter my phone number so I could receive a link via SMS to download an app. After waiting 10 minutes for it to install, I restarted the process, which started over in the download phase despite having been in the installation cycle previously. After another 40 MB of downloading, there was another three minutes of installation, after which I was asked to enter a code that I didn’t have. I guessed at HIMSS and HIMSS21 and the latter was successful.

From there, I went through multiple terms of use screens and consents, which I know the vast majority of users don’t or won’t read. From there I had to scan both sides of my driver’s license and then take a picture of myself, which rivals my passport for hideousness due to the app’s smile detection feature which forces you to basically frown. From there, I had to go through another selfie process, which converted my picture to a line drawing and seemed tricky to try to fit my face into its weird oval frame.

The next step was adding my vaccination information, for which I had to go through another consent then an electronic authorization to release data to Clear. From there I was instructed to log into MyChart and went through another disclaimer, followed by four panels of information regarding consent and release. Finally, I was asked to give permission to the HumanAPI app to release every scrap of data in MyChart, including allergies, the name of my physicians, demographics, documents, health goals, implants, lab results, medications, problems, orders, procedures, immunizations, vitals, appointments, clinical notes, encounters, referrals, smoking status, and OB/GYN status. It asked to allow sharing for the next 90 days.

I denied permission and went back to the option to submit a photograph of my vaccine card and to key in the vaccine information and dates. After less than 30 seconds, I received my validation, and I didn’t have to share a boatload of PHI to do it. The overall process took 26 minutes, which was way too long, and I imaginethat  if I had actually read all the consents and disclaimers, it would have been close to an hour. I’m sure everyone involved (except the patient/consumer) is making at least a little money on the sale of the personal data that thousands of people will release without thinking too much about it. Just say no to the API, folks.

Amazon Care has asked major health payers to cover its services on par with other in-network care options. Reported targets include Aetna, Premera Blue Cross, and Blue Cross Blue Shield of Massachusetts. Amazon Care was originally piloted with Amazon’s Seattle-area employees, but the company has tried to expand the product since March of this year, not only nationwide to Amazon staff, but also to other employers. Based on the challenges with getting coverage for telehealth, let alone some of the asynchronous services the platform purports to offer, it will be interested to see how long it takes for the big payers to bring the service into the fold let alone provide payment parity.

A recent article in JAMA Network Open looks at the ability of wearables such as Fitbit and Apple Watch to identify the long-term effects of COVID-19 infections. The data is from the Digital Engagement and Tracking for Early Control and Treatment trial (DETECT) which was led by researchers at the Scripps Research Translational Institute. More than 37,000 people enrolled in the study, which ran from March 2020 to January 2021. Subjects used the MyDataHelps research app to report symptoms and COVID-19 test results and shared data from their devices. Researchers concluded that when they looked at wearable data and symptom data together, they could detect COVID-19 cases more accurately than looking at symptom data alone.

A follow-up trial looked at Fitbit users with fever, cough, body aches, and COVID-19 test data. It found pronounced changes in COVID-19 positive patients compared to others. Symptoms included increased sleep, decreased walking, and higher resting heart rates. On average, the COVID-19 positive patients took 79 days for their resting heart rates to normalize compared to four days in the non-COVID-19 group. Definitely food for thought for all those who are still refusing vaccination and especially for those who think that COVID-19 is a hoax.

COVID-19 is on the rise in my area in a big way, and my former colleagues are being slammed. My former partner had 38 people on the wait list at urgent care this morning. Of those patients, 15 were COVID-19 positive. The most tragic story of the day was a family who came in for testing after seeing pictures of their COVID-positive cousin in the ICU on social media after they were all together for a July 4 event. The cousin didn’t even call family to notify them, just posted on social media. It sounds like they were beside themselves and I’m sure the positive results didn’t help things.

Speaking of social media, I’ve written before about some of the lesser talked-about aspects of social media, such as its role in the grieving process and how strange it feels for “memories” to pop up that might not be happy ones. I definitely had some strong emotions at the memory that popped up for me today, which was a picture of my mask-damaged face during a lengthy shift in the emergency department. It was a stark reminder of all that we’ve been through in the past year.

It also gave me pause because we’re still not learning the lessons we need to learn to deal as effectively with this pandemic as we need to. Many of us who read the medical literature and have close relationships with researchers understand that we’re literally one “variant of concern” away from being back at square one with this virus. There’s a constant sense of waiting for the other shoe to drop, and for some of us, I’m not sure we’ll ever be able to feel the sense of relief that we had in a pre-COVID world.

A close friend of mine is a counselor and executive coach who works predominantly with physicians. He agrees that there are thousands of us who meet the diagnosis criteria for post-traumatic stress disorder but who have not addressed it with employers or sought treatment, and in reviewing the criteria during our discussion I’m betting a lot of clinicians don’t know they have it. I’m curious to know if employers are doing any specific outreach to help manage these pandemic-driven symptoms in the workforce, or to know more about the experiences of those who may have reached out for help.

What’s your experience with pandemic-driven PTSD? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/12/21

Sometimes a headline catches my eye, as did the one for this article about workers “epiphany-quitting” their jobs. For many, the COVID-19 pandemic has brought life into sharp focus and has accelerated decisions around what families find valuable and what can be done without. It’s been interesting to watch the flow of people both into and out of healthcare as people search for different work-related attributes: more meaning, better compensation, increased security.

One of my favorite co-workers at my former clinical employer was a seasoned professional sports mascot. He had worked for an NFL franchise before relocating and then hired on with the local baseball team. During the changes of the pandemic season, he saw the mascot workforce reduced from four to two, and despite being a pro at the signature strut and being able to do a backflip in a full-head costume, he decided he needed a change. He signed up for an emergency medical technician course and the rest is history. One of his favorite parts of being an EMT was being able to interact with people directly rather than through pantomime and oversized gestures. It was easy to see he enjoyed being around people and making them feel comfortable, even in stressful situations.

For him, moving into healthcare was about predictability and steady employment after having things pulled out from under him. It was a way to feel like he was controlling his own future, and especially with forecast shortages of healthcare workers, it’s probably a pretty solid bet. He was relatively lucky due to his age (mid 20s) and lack of family responsibilities. Not all workers are in that same situation, and I saw plenty of other co-workers leave healthcare because they couldn’t meet family responsibilities. One of my favorite medical receptionists quit because she couldn’t find reliable childcare to cover the 12-hour shifts that often stretched to 13 or 14 hours. Instead, she started providing in-home childcare, which allowed her to spend more time with her daughter as well as to help out young families in similar situations.

One of my favorite scribes was in the process of applying to physician assistant school when not only the pandemic hit, but one of her parents was diagnosed with a terminal illness. She decided to defer the application process to allow for more time with her family and also requested to go part-time at work. Although the company had a track record of refusing to allow people to go part-time unless they were enrolled in school, the pandemic forced them to adapt. Given the time needed to train a scribe and having someone willing to work in the uncertainty of a pandemic, it was a good solution for everyone.

Not everyone’s employers were that flexible, however. I watched a couple of nurses leave the workforce because part-time employment wasn’t an option and working 12-hour overnights on the COVID wards had simply worn them out. It was gut-wrenching to see these women quit jobs that they liked and would likely have stayed with had they been able to achieve flexibility, while the hospitals paid double or triple their salaries to travel nurses to cover the responsibilities.

Another friend who stayed in her ICU role out of a sense of duty and calling is still bitter about the bonuses paid to travel nurses who actually did less work than the employed nurses since they weren’t approved to use certain kinds of devices or equipment in patient care. She recently took a six-week “job swap” sabbatical where she moved to another part of the hospital and out of the ICU, which has allowed her to recharge to some degree. Still, she’ll be an empty nester in a couple of months, and I wonder if that sense of calling will still be there or if she will put the ICU behind her once and for all.

Even in healthcare technology roles, I’ve seen a change in some of the language used in promoting positions and during the interview process. Companies are more likely to advertise their flexibility and options to help workers achieve work-life balance. I see more mention of programs to allow employees to interact on non-work topics. such as support groups for employees caring for aging parents or small children, or as part of diversity efforts.

However, for every bit of flexibility, it seems another company is swinging the pendulum the wrong way. My local health system is hiring IT workers, but even though the positions are officially tagged as remote, they require relocation to the company’s headquarters state “for tax purposes.” Maybe the hospital just doesn’t want to deal with the paperwork, but they’re losing quality candidates and hiring manager friends are disgusted by the situation.

The sense that workers are evaluating their situations and deciding whether various aspects of their jobs are worth it or not is playing out across a number of industries. Due to the stressors that the pandemic has placed on healthcare organizations, however, it feels like we are experiencing it more acutely. I was having a discussion with one of my favorite revenue cycle folks recently, and in follow up she sent me an op-ed piece that I missed back in December when I was so busy trying to keep my head above water at the urgent care. It’s by Claudia Williams, former White House senior advisor and former director of health information exchange at the US Department of Health and Human Services. Although the question it asks is “Do hospitals need a chief burden reduction officer?” I would argue that the concept reaches beyond the hospital walls. Instead, we should be asking whether any organization would benefit from someone whose main role is to reduce burdens and look for ways to streamline work.

Williams cites the “must-do list of priorities for health systems in 2021” as including the following: recover the bottom line, provide frontline care for the pandemic, address health inequities, reduce provider burnout, and prepare for value-based care. Nearly all of these goals are impacted by frustrating (and often outdated) processes, multiple sets of reporting requirements that might be at odds with each other, rising costs, and the somewhat unpredictable factors of dealing with an ongoing pandemic for the foreseeable future (and perhaps indefinitely). Williams proposes a new title to join the chief experience officers, chief growth officers, and other recently created roles: that of chief burden reduction officer.

I think it’s a fantastic idea having someone who could work across multiple disciplines and service lines to identify solutions that could benefit everyone. They could unlock the potential of all the technology solutions that have been purchased over the last decade and help get rid of paper workflows once and for all. They could help streamline the patient experience as well as the clinician experience so that the two elements work together rather than at cross purposes. A chief burden reduction officer could also work with governmental agencies to help develop policies that make sense not only philosophically, but in their actual execution. No more of the “great ideas, poorly executed” that we’ve all experienced.

One of my favorite lines in the piece is this: “Health systems deeply disrespect patients when they waste their time.” The same goes with their treatment of employees (whether they call them as such or try to use cutesy titles such as associate or co-worker). An employee whose time is wasted is one who could be using that time for patient care, professional development, stress reduction, or a number of other worthwhile pursuits. Williams sums this up beautifully in the closing sentences of the piece: “All of these processes – the email, the paper, the intake form, the chart download, the fax – they are fundamentally wasteful of this beautiful human energy that we desperately need to transform healthcare. We are a nation facing multiple health crises. We need to free precious human time to address them.”

It’s a great way to think about the challenges in front of us. Who’s ready to take the leap and employ their first chief burden reduction officer? Leave a comment or email me.

Email Dr. Jayne.