Curbside Consult with Dr. Jayne 3/22/21

Both the virtual physician lounge and the informatics community were buzzing this week about the Amazon telemedicine announcement. For those that missed it, Amazon plans to expand its Amazon Care telehealth program nationally. The program will be available for all 50 states plus Washington, DC later this summer.

Amazon Care has been providing both telehealth and in-person primary care services to company employees and dependents in the Seattle area since September 2019 and expanded it throughout Washington state in September 2020. The first phase of the national expansion will cover other companies in Washington state, with the rest of the US following for in-person services in Washington, DC and Baltimore and virtual services in other locations. Planners note that the virtual clinic will offer both urgent care and primary care services as well as COVID-19 testing, flu testing, and vaccines. Patients also have the option of scheduling follow-up visits in their homes or offices. Patient can schedule them through the Amazon Care app, which also provides care summaries and follow up reminders.

Amazon has offered additional home services in the pilot program, including administering pediatric vaccines in patients’ homes as well as evaluation of the work-from-home arrangements of employees to help them avoid ergonomic issues. Employers will be able to access the service and offer it as a benefit to employees.

It will be interesting to see how it scales. In the current offering, patients are typically able to connect with healthcare providers in around a minute through the app, which offers live chat, messaging, and video. Unless they have a tremendous number of resources on standby, response times like that are typically only achieved when agents are managing multiple patient streams at a time. That’s what I’ve seen with some clinical call centers that add messaging to the mix. Maybe Amazon has some kind of secret sauce that will make things work differently.

The purported value as a workplace benefit is clear – employees would miss less time trying to seek care for minor illnesses or more straightforward services such as prescription refills. Those services are available through existing telehealth offerings. However, the Amazon name is likely to represent speed and efficiency, which are both attractive to employers. Amazon prescription delivery is also attractive.

Still, I wonder what their clinical quality data looks like in their pilots. How are they managing antibiotic stewardship? What are the metrics they are following to determine whether they are successful? Are they able to monitor downstream metrics, such as emergency department visits or hospital admissions? The availability of home visits is certainly a differentiator compared to other available offerings.

As a physician, I’m curious to understand what their compensation structure looks like for clinical resources. Are they using all employed physicians with enough licensure coverage to hit all 50 states? Are they using independent contractors? Most of the major telehealth organizations use independent contractors, who may have arrangements with multiple vendors and who practice on the different platforms depending on supply and demand factors. The Amazon press release notes that the service “allows employees and dependents to see the same dedicated teams of medical professionals, which creates long-term relationships that benefit overall health.” That would seem to describe employed physicians who would be focused on Amazon patients, but I would be interesting to understand how that kind of arrangement would compare to the salaries generated by brick-and-mortar physicians.

The Amazon press release also mentions same-day COVID-19 testing, so I’m curious to understand who they are partnering with to deliver the proverbial last mile of service for testing and vaccinations. That might not scale across the US in the same way it would in the Seattle area.

I’m concerned about the potential mismatch between patient expectations and reality, as well as how the extreme focus on convenience somewhat diminishes the value of the relationship with the physician. The release cites a patient who appreciates the convenience of Amazon Care and not having to wait at a doctor’s office. She states that using the services “makes me feel like I have more control over the healthcare system than the healthcare system has over me. It’s at my leisure. That’s power. I’m not waiting on someone else to show up on their schedule.”

I appreciate the need for patient convenience, but I think it’s important for patients to acknowledge that the vast majority of the time, physicians are not on schedule because they’re caring for other patients, whether in-person or asynchronously, because they are managing refills or completing paperwork. When my patients are frustrated because it’s taking 30 minutes for me to reach their exam room in my walk-in clinic, it’s usually because someone with a more acute need has arrived at the same time or before them. Although healthcare delays can be due to inefficiency or operational issues, they can also be due to me arranging a transfer to the emergency department or counseling a patient on a devastating diagnosis, such as a miscarriage.

In the case of Saturday night, the delay of care might have been due to the fact that our entire staff was busy performing cardiopulmonary resuscitation on a patient, trying to bring him back from the dead in the interval before the ambulance arrived. If you’re the patient in distress, you certainly don’t want me cutting you short because I have someone else who is waiting.

I struggle with understanding how they plan to balance the promised levels of convenience with the offered continuity, because they’re often in conflict. Team-based care can certainly help with this, but patients have to understand what that really means. As healthcare has become more transactional, I find that many patients don’t care who they see. While a brick-and-mortar practice can’t staff an unlimited number of physicians, online practices can certainly have a deeper bench. But we can only deliver face-to-face care (whether virtual or in person) to one person at a time, even if we’re running back and forth between exam rooms. The demand for instantaneous care has definitely impacted the relationships that we are trying to build with our patients, and at least anecdotally among my local peers, is one of the reasons some of them have changed jobs.

The devil will be in the details, but I can’t wait to see how this unfolds. Get your popcorn, folks. How do you think Amazon Care will play out nationwide? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/18/21

I completed my HIMSS21 rollover registration, so we can finally get some return on the money Mr. H fronted back in the fall of 2019. HIMSS is pre-managing any future refund requests by noting that it’s not a true rollover of the registration fees – it’s a “complimentary registration” for 2021 due to the cancellation of HIMSS20, and as such is non-cancellable, non-refundable, and not subject to the documented cancellation and substitution policies. If you’re going to do the rollover, you have to follow a specific link you receive via email. Interestingly, the link arrived in my inbox shortly after another one from HIMSS announcing a decrease in individual membership prices, so my previous membership is now good for an additional six months.

I’m not thrilled about the campus-style venue, which means traipsing or shuttling from the Venetian-Sands Expo Center to the Caesars Forum Conference Center and the meeting space at Wynn. I’m sure they’re doing it so that events can allow for social distancing, so I get it from a public health standpoint. When I’ve been to conferences that did the campus approach, the experience ranged from successful to downright painful. Hopefully, they’ll keep similar programs or tracks together to make it more likely to achieve the former.

HIMSS is not announcing its specific health and safety protocols at this time, but promises to deliver the info as it gets closer. I expect a fat waiver absolving HIMSS of any and all responsibility should attendees be exposed or infected during the conference. Since the badges are going to have headshots on them this year, I’m going to bring some stickers and put a mask on my badge so my photo matches the in-person version. There were some issues with the photo upload process where my picture was clear at the time of upload but grainy when I came back to the screen later, so who knows what it will look like in reality. I also got a kick out of the registration page’s recap of demographics, which due to the magic of formatting, displayed my professional title as something that evokes Pinocchio:

Since HIMSS will also have a digital track this year, it will be interesting to see what post-event surveys reveal about attendee satisfaction and perception of value. The boom in videoconferencing has created plenty of psychological research around its impact on users. Researchers at Washington University in St. Louis are looking at perceptions of self-image from those who are having increased video interactions. The findings were published in the International Journal of Eating Disorders and found that most women have not had a change in their satisfaction with personal appearance despite increased time spent on Zoom. They noted that people spend 40% of their time on Zoom looking at their own image, with some reporting 100% self-gaze.

I’m glad I ran across the article because it introduced me to Zoom’s “touch up my appearance” feature, which I had not been aware of. The researchers plan to follow up with a study to look at the same factors for male users. They note limitations of the study in that the research began in May 2020, and as the year has progressed, we all have spent more time on video chat, with the lead researcher noting that, “What it means to us now might be very different than what it meant to us then.”

The American Medical Association ran a recent piece that is targeted at helping physicians adjust to the new reality of patients seeing their visit notes. For many physicians, the idea of patients seeing their own documentation is terrifying, with physicians wondering if they are going to have to completely change their documentation style to avoid creating anger, confusion, or resentment in their patient population. The idea of open notes is not new for many organizations, and I’ve watched several physicians who come from institutions where this is practiced coaching those who are afraid.

The AMA encourages physicians to think about how greater transparency can benefit patients or help them have more buy-in with their care plans. Still, I think there will be opportunity for physician consultants to coach individual providers through the process of creating notes that adequately paint the clinical picture while avoiding potentially inflammatory content. I’ve done this a couple of times in the past and am always happy to put my literature background to work.

Best Buy Health has partnered with Apple to offer remote monitoring services via Apple Watch. Users can access the Lively app to contact Urgent Response Agents to assist with everything from medical emergencies to roadside assistance. Best Buy is also credited for working with Apple to create an upcoming fall detection features that “make it easier for older adults to stay safe, healthy, and connected.” Consumers who agree to a two-year Preferred Health & Safety contract will receive a discount off a watch purchase at Best Buy.

An article in the Journal of the American Medical Informatics Association caught my eye this week. It looks at how technology can be used to detect if people in video streams are wearing masks. Being able to pick up if people are wearing masks is a good thing, but even better would be to identify those who are not wearing them properly and perform some kind of remediation. It still amazes me that people are unwilling to wear masks properly now that we’re a year into this adventure. My state recently opened the vaccination tier that includes teachers, and my hometown newspaper prominently featured a photo of a teacher being vaccinated who had her entire nose exposed out the top of her mask. If the teachers can’t model correct mask-wearing, I’m not sure how they’re supposed to make sure students are doing the right thing.

By this point in the game, those of us who want to wear masks full time or those of us who have to wear them for work should have figured out what mask style works best for us and how to keep it from moving around. I have a handful of go-to styles depending on what kind of activities I’m doing and how long I have to wear it. What have you found as the most comfortable and practical mask, or just the one that makes you smile? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/15/21

For math fans, this weekend included Pi Day (3.14), but for me, it also included my one-year COVIDversary. Exactly 12 months ago, I cared for my first COVID-19 patient, who happened to be part of the first cluster of patients in my city.

I remember finding out two days later that the patient was positive, and then seeing on the news that she was part of the cluster and had been admitted to the hospital. Along with the physician assistant who also saw her, I spent the next two weeks checking my temperature and wondering if we were going to get it and if we were going to die. In talking to my med school friends who also work on the emergency and urgent care front lines, we all made promises to see each other “on the other side” not knowing what was next.

There are over two million people dead across the globe, and that includes several thousand US healthcare workers. It’s truly stunning to think about the road we’ve been down with our hospitals and healthcare employers and how we are still struggling with protecting these valuable resources. Many organizations are still managing N-95 respirators under extended-use protocols or even crisis standards of care. The majority of my healthcare worker friends have given up on N-95s because they’re so difficult to get even in the hospital, being saved for “known COVID-19” patients even though we know at this point in the game that a tremendous number of patients can be symptom-free. Many healthcare workers are vaccinated, which gives us some degree of relief that we’re protected. No vaccine can be 100% effective, though, and I have unvaccinated people in my household, so I’m sticking with the N-95.

Although very few people get to see my face these days (other than on a videoconference, that is) ,my skin tells the story of the pandemic, with ongoing creases from extended N-95 use and exponential growth of wrinkles. Maybe my skin would have been more resilient had I been in my 30s, but along with more than 70% of the physicians in the US, I’m part of the over-40 crowd, so I’m sporting the perpetually tired look. One of my residency classmates has an exclusively cosmetic practice and promises she can do wonders with modern pharmaceuticals, but the last thing I want to get into right now is an elective medical adventure.

As I wind down my clinical employment, it continues to be challenging. Our new owners have removed some of the protective policies that we previously had in place. Where they used to cap the number of patients in the building to nine per provider at a time (which was challenging enough), it’s now only limited by the number of exam rooms in the building, which can be 15 to 17 at some locations. That means patients have a secondary wait in the exam room after they’ve already waited in their car or at home, which means they’re often cranky by the time we make it into the room. I’m sure the folly of this change will be apparently when it starts hitting our patient satisfaction scores, but I’ll be gone by the time that lagging data turns up.

The cognitive dissonance involved in an urgent care shift is hard to explain to non-healthcare folks. We’re still seeing acutely ill COVID-19 patients, but are also seeing long-haul patients with ongoing symptoms. I might spend a significant amount of time with a patient who is in a bad way, or who just lost a family member, and then have to walk into the next room to see a patient who just wants testing so they can go on vacation. The majority of the pre-travel testing patients are oblivious to the suffering around them and often tell us how ridiculous it is that they even have to be tested. It’s a lot to tolerate sometimes, and in those situations, I’m grateful that my mask, goggles, and scrub cap obscures my facial expressions.

That’s a big contrast from my consulting work, which is challenging as well as fun, and makes me feel like I’m helping people get better care. I’m working on several projects to address the backlog of cancer screenings that were created by the pandemic. Knowing that my work will have a direct impact on patients makes a difference. Diagnosing cancer is never a good thing, but diagnosing it earlier certainly is, especially when it can be managed more effectively. Patients seem genuinely grateful that we’re reaching out to them to let them know they are overdue for screening and to educate them on current COVID-19 mitigation policies at the health system’s locations. Passing them a link to allow online scheduling has been very effective, and certainly more productive than postcards or mailed reminders.

The highlight of Dr. Jayne’s week was connecting with friends at Medicomp as the inaugural guest for their new podcast, “Tell me where IT hurts,” hosted by Chief Medical Officer Jay Anders, MD. I usually spend some time with their team at HIMSS shooting the breeze and it was good to catch up and talk about the industry, where we’ve been, and where we might be going. I’ would rather have done it in person with a glass of wine, but the conversation was enjoyable all the same.

The highlight of my personal week was some time in the outdoors. Even with some intermittent rain, it was good to be camping again and teaching a bit of outdoor school. I always enjoy time spent with like-minded folks who understand the pleasures of food cooked in cast iron, and the delicacies did not disappoint. The wildlife certainly didn’t care that people were out and about, as we got to experience the sounds of the Circle of Life as a coyote found its dinner. It was less of a highlight for the  members of our party who stumbled on the remains. Still, it’s a reminder that there’s a whole world outside where primal forces still rule, regardless of what we as people try to do to shape it.

For my healthcare worker readers who might be marking their own COVIDversaries, I salute you. It’s been a long year and none of has made it out unimpacted. Here’s to a better 2021 with less time putting out healthcare fires and more time tending campfires.

What’s your favorite cast iron recipe? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/11/21

I had an opportunity this week to do something I haven’t done in a while, and that was to support a go-live.

It was very different than my pre-pandemic experiences, with very few implementation support staff actually on the ground. I was pulled into it by chance. A friend of mine has been helping lead a major health system EHR replacement project for more than 18 months. Along the way, the health system acquired a small cardiology practice and had allowed them to stay on their legacy EHR until the main roll-out was complete. They planned to circle back and do the conversion.

I’ve been involved peripherally over the last couple of quarters since the cardiologists are on a fairly niche system and I had done a couple of conversions off of that system previously. Often people don’t realize until they get to an EHR conversion how bad the data management is in their current system. For example, the legacy system stores blood pressure values in a single text field rather than having separate fields for the systolic and diastolic numbers. It also didn’t have restrictions on it that prevented users from entering non-numerical values or excessively high values, so we had to make some difficult decisions on how much data we were going to try to bring into the new system and how we would prevent poor data from coming across.

Generally, the physicians understood the need to make those decisions, but they were a little more resistant to the overall conversion process because they would be giving up all their individually-customized visit templates and coming onto the health system’s enterprise version. I was asked to do a fair amount of “physician whispering” as part of the project, making sure that they understood the “what’s in it for me?” component of the conversion. We knew it would go more smoothly if they felt they were receiving a benefit as opposed to being forced to do something they didn’t want to do.

Surprisingly, one of the more difficult physicians was the youngest, who had actually trained on the EHR they were moving to. In breaking down his concerns, it seemed like most of his resistance stemmed from being upset that he had come into a private practice situation where he thought he would be on a partner track. Now he was one of hundreds of physicians employed by a large health system. There’s a lot of psychology to unpack there, and being able to explain the benefits of integration every time he threw up a red flag was helpful.

The practice’s super users were responsible for doing most of the support during the go-live, with backup from a vendor-specific consultant. I was engaged to be on call as escalation support for physicians who needed significant hand-holding or who had issues that would take a little longer to work through, since the super users were trying to do their day jobs as well as support the go-live. We knew that two of the doctors would be leaving early in the day due to other commitments and would likely need help in the evening as they logged back in to complete charts, and I was going to be plugged in there as well. One of them did really well and only sent me a couple of text messages with specific questions, but the other became an immersive support experience.

Most of his frustration was around the fact that he had decided to leave the office for a conflict that he decided wasn’t ultimately worth his time, and he was aggravated that he was now having to make up work in the evening. He wanted to do a web support session. We spent the first 15 minutes with me just listening to his frustrations as he worked through his inbox, which was full due to being out of office, not because of the new EHR.

He actually had a decent knowledge of the system, but felt like he needed someone to tell him he was doing the right things with his documentation rather than trusting his intuition. He kept getting interrupted by family issues and jumping off and on our support session, which didn’t help the situation. Having done this for a long time, I understand the importance of work-life balance and that family life happens, but the ability to focus on the thing in front of you is ultimately key for long-term success.

The physicians knew that their support window was closed between midnight and 6 a.m., so I did get a little bit of a break before starting the morning’s adventures. Everyone is scheduled to be in the office this morning (as opposed to being at the hospital or doing procedures), so that will be all hands on deck. Fortunately, the practice managers have held the line at making sure schedules are slightly reduced to allow the staff to adjust to the new system, so I hope things run smoothly. I hope the physicians who are used to being perpetually double-booked don’t find the relaxed schedule too shocking. Maybe they’ll be inspired by seeing how it can be when you’re not running every day on a steep uphill climb.

Everyone seemed to be in good spirits this morning and I’ve only had two calls, so that’s a win in my book. We’ll see what the rest of the week holds. I do like mid-week go-lives because they allow people to have a break after the first few days on a new system and then come back refreshed the following week.

I’m not on call for coverage this weekend, so I’ll be looking forward to a break as well. Spring has finally arrived in my neck of the woods and I will be spending some quality time outdoors. Although there’s a fair amount of rain in the forecast, it will be nice to get away somewhere out of cell service range and just enjoy the fact that winter is on its way out.

What are you most looking forward to about spring? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/8/21

The Washington Post ran a piece this week on Zoom fatigue. It brings up some good questions about whether calls really need to have a video component and links to a paper on the topic titled “Nonverbal Overload: A Theoretical Argument for the Causes of Zoom Fatigue.”

The author, Jeremy Bailenson, PhD, is a professor and founding director of Stanford University’s Virtual Human Interaction Lab. He concludes that there are four major causes of videoconferencing fatigue:

• Excessive direct eye gaze as people look at faces close up rather than at notes or other places in the room.
• Increased cognitive load interpreting nonverbal behaviors.
• Constant self-evaluation from seeing ourselves in real time.
• Reduced mobility for those used to walking and talking on phone calls or in person,

Bailenson recommends use of the “hide self” view and minimizing the video call screen as potential solutions. He also recommends that meeting hosts specifically ask attendees to look around their environments and move around as they would in an in-person meeting.

Another paper from Andrew Bennett, PhD, assistant professional of management at Old Dominion University, is pending publication in the Journal of Applied Psychology. It offers some specific suggestions for reducing videoconference fatigue:

• Hold meetings earlier in the work period.
• Enhance perceptions of group belongingness.
• Mute if not speaking.
• Take breaks from looking at the screen, both during and between conferences.
• Establish group norms for mute, camera, acceptability of multitasking, hand raising, etc.

Interestingly, Bennett’s research found inconclusive evidence for changes in webcam usage or using the “hide self” view.

Other potential solutions to videoconference fatigue might be to do calls as audio only. Those of us who have been videoconferencing for years have already been through this and created solutions.

At some companies, the first few minutes of a call includes video so that everyone can see each other and have a time of relationship building with a little bit of chit-chat. Then cameras go off as the meeting gets underway. I like that approach personally because I take a lot of notes during meetings and people sometimes find my downward gaze to look like inattention. I’m still a pen-and-paper girl for many of my notes because I find it helps me remember content better. I also like to keep my microphone live all the time so that I don’t forget to unmute before speaking. I have a quiet work environment so this generally works, and my pen makes far less noise than my clacking keyboard would.

I personally find Zoom calls to be fatiguing only when dealing with individuals who haven’t figured out how to effectively use the system. We’re a year into this pandemic and if you don’t know where the mute button lives by now, I really feel for you. This sentiment is found in numerous comments on the Washington Post article, along with other positive impacts of remote work including decreased commuting time and expenses. I was also annoyed with a recent Zoom call that I knew was going to be audio-only when it wouldn’t let me in because I tried to access it on a computer that doesn’t have a webcam. I don’t know if that’s a setting on the host side since usually I just use my laptop, but it resulted in some last-minute scrambling.

I might be in the minority, but I find the use of Zoom backgrounds to be distracting, especially when there is a lot of bleed-through or issues with people moving around a lot and having parts of their body disappear. If you’re a fan of backgrounds, I definitely recommend investing in a green screen so you can get the best performance out of the system. Otherwise, I would recommend trying to find a calm corner to customize for when video is needed or considering something like a folding screen to provide a neutral background.

I am on far too many calls where people have children and pets running around in the background, and that’s definitely distracting. I once terminated a call when I dialed in to find my coworker sitting by her pool with her children in it. She said she didn’t want them to be in the pool without her, but thought it was OK to be on a call. I’m a firm believer that if you’re supposed to be supervising your kids in the pool, you had better be giving them your full attention. She disagreed, but I certainly didn’t need to enable her dangerous behavior.

Another angle on Zoom fatigue is to make sure that you are leveraging the leisure time benefits of videoconferencing as well as the work-related ones. I have monthly happy hours with people all across the country that wouldn’t be as much fun if we were only on the phone. It helps establish the role of videoconferencing in building relationships and not just driving one crazy. I’m about to embark on a trip with one of my video happy hour friends, and if our conversations are any indicator, it should be a doozy of an adventure. Without building a friendship on video, we might not have even thought about this since our previous interactions were mostly built on emails about cute shoes and boots.

Zoom has also allowed me to continue to take music lessons despite the pandemic. I previously studied in my instructor’s home, and since she has an elderly relative in the household, she stopped in-person lessons fairly early in the pandemic. I was happy to avoid the 90-minute round trip commute. Although Zoom isn’t perfect, the platform has made some significant enhancements to allow it to better handle events such as music lessons. The “original sound” feature has been enhanced, along with other audio settings, to allow a truer audio representation. My only issue with it is that I can’t seem to default it on, so sometimes I forget to turn it on for every lesson. As an adult beginner on this particular instrument, I was definitely less anxious about playing my first recital via Zoom than I would have been had I been in an auditorium with my 5- to 9-year-old peers.

What do you think about the idea of Zoom fatigue? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/4/21

The states continue to add complexity to the vaccination process, which is unfortunate for patients, but handy for those of us who depend on billable consulting and technology support hours to pay the rent.

Florida is my new cash cow this week. It issued a form Tuesday to certify patients who have a “COVID-19 Determination of Extreme Vulnerability.” Some of my clients brought this to my attention and asked for a quick migration of this form into their EHRs so that they could complete it without patients having to bring it to the office. I have a couple of consultants frantically building them to include auto-fill fields and blobulized and digital signatures, which hopefully the public health authorities and/or vaccinators will accept.

I found it interesting that they require the physician to “certify that I have a physician-patient relationship with the patient named above,” which would seem to indicate they’re concerned about certification mills or people just buying signed notes. On the other hand, they specifically left out NPs and PAs who provide a substantial amount of primary care in the state, which is unfortunate for both providers and patients.

Additionally, these medically vulnerable patients can only be vaccinated by physicians, nurse practitioners, or pharmacists, which doesn’t make sense with medical standards of care. Not to mention, let’s use our most expensive resources to do tasks that could be done by a less-expensive resource, such as a registered nurse, licensed practice nurse, medical student, paramedic, or military medical staffer. Score one in the “poorly thought and executed” column yet again.

I continue to see a lot of poorly planned initiatives among organizations. One created a shingles vaccine campaign that brought patients in for immunization, only to launch their COVID-19 vaccine campaign shortly thereafter, which created confusion as patients were turned away due to having had a vaccine in the previous 14 days.

I’m still seeing aggressive intake forms and pre-screening processes that exclude patients from in-person visits for findings that may or may not be COVID-related, such as fever. I guarantee that the six year-old who is attending in-person school and had exposure to a child with strep throat and who now has a fever and sore throat is much more likely to have strep then COVID-19, but algorithms are still pushing those patients to virtual care, which either results in antibiotics over the phone (less than ideal) or an additional in-person trip for testing or evaluation.

As someone who has passed the 1,000-patient mark for COVID-19 exposures, this is starting to feel similar to what we went through with HIV. We need to just start assuming that everyone might be carrying it and make sure healthcare providers have appropriate universal protections (including adequate and regularly replaced N-95 masks) and proceed accordingly. People much smarter than me are all similarly concluding that we’re going to head into a phase where this virus is endemic and we’re going to deal with it for a long time, so we need to start retooling our processes for the long haul. This includes IT systems that haven’t been updated. I still see electronic intake forms with questions about travel to China and we’re long past that being relevant.

Lots of attention this week to a pre-print research study that suggests that wearing glasses might reduce COVID transmission, a phenomenon jokingly referred to as “nerd immunity.” Although we know that protective eyewear can be a barrier to viral particles entering the eyes, the backlash on this one was swift, with multiple people pointing out that pre-print studies can be problematic. Fact-checkers concluded that there is no definitive evidence that wearing simple eyeglasses make someone less susceptible to COVID-19 and that the study cited was low powered (304 patients with disease) and noted that the study has not gone through the peer review process. There are additional design problems in that the researcher only included patients with mild disease and excluded those with moderate or severe illness. If we’ve learned one thing during this pandemic, it’s that watching science unfold in real time can be messy and confusing to those not involved in the process.

HIMSS recently put out a call for nominations for its Changemaker in Health Awards. Nominators were asked to put forth “inspiring senior health executives who rigorously challenge the status quo in their journey to build a brighter health future.” As part of the nomination process, one had to submit an essay on why their candidate was deserving of the Changemaker designation, as well as providing the candidate’s CV and other supporting materials. On March 2, my nominee received a notification that he had not been selected as a finalist, but no communication was made to the nominator. He was encouraged to visit the Changemaker page to see the finalists and vote, but it took HIMSS a full day to get it live despite it being March 2 and the website encouraging people to come back on March 2 to vote.

The page finally went live sometime on March 3. It looks like a fairly solid bunch of people, but none of them are big-league rabble rousers or changemakers in my opinion. Most have led steady careers as CIOs or equivalent, and work for large hospitals or health systems. There was little representation from entrepreneurial or cutting-edge technology interests. In order to help the public vote, the site lists the individual’s title and a link to their LinkedIn page, but doesn’t include any of the color or meaty information that some of us included in our nominating essays, which is disappointing.

I wish good luck to those who are in the running, although selection is a mixed bag because the winners have to engage in various HIMSS events and panels as a condition of recognition. My candidate suggested that perhaps HIMSS “wasn’t looking for the real troublemakers” and suggested we have our own “Rebels in Healthcare” list and party at HIMSS. In the absence of a HIStalk kegger (and don’t get me wrong, that would be perfect for the half-baked HIMSS that we might be all walking into this August), it’s sounding like a fairly decent idea. If you have a rebel you’d like to nominate for inclusion, or just want to nominate yourself, leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/1/21

My calendar made me smile today with an appointment reminder that had 2020 been a normal year, I would be in Las Vegas attending HIMSS21 and drinking martinis with all of my healthcare IT friends. Alas, it was not meant to be. Instead, I’m ever-present in my home office digesting a constant stream of email, press releases, and journal articles.

The theme of the week seems to be telehealth, with different companies in the news. MDLive, which was thought to be setting up for an IPO, was instead acquired by Cigna’s Evernorth subsidiary. At the same time, Mercy and Humana teamed up to expand access to telehealth services for Humana Medicare Advantage members. The latter agreement is particularly interesting because it specifically called out a value-based care component of the relationship. Once the US healthcare system begins to fully process the burden of COVID-related care, I suspect there will be a greater drive towards value-based care.

Due to the fragmented testing strategies across the country, many patients are receiving high-cost testing at urgent care centers that require a physician visit to justify the testing. A better strategy would have been to enable public health-based testing, where patients could have been tested under standing orders from local public health authorities, reducing the overall burden on the system. The nation has been walking a tightrope, balancing the need to ensure access to testing with the potential for out-of-control testing costs.

I see this in my urgent care practice, which is one of the organizations requiring a provider visit prior to testing. Patients are seen and examined, then the most appropriate test is determined, ordered, and obtained. Over the last few weeks, we’ve seen a shift in testing behavior. Previously, the majority of our tests were done on symptomatic or exposed patients, with rare testing for travel. Now we’re seeing a boom in pre-travel testing, and doing that kind of testing in an urgent care setting is a significant waste of resources. We are also seeing people just coming in to be tested weekly because they can, and because they don’t have any financial skin in the game. They’re going about their lives unmasked and practicing unsafe behaviors and the rest of us are picking up the tab.

Out of necessity, we don’t want to create barriers to testing, and as a physician, I totally get that. Recent executive orders and subsequent guidance from federal agencies make it clear that patients must be tested with no cost sharing or utilization management oversight. As someone watching the costs mount, especially in states that didn’t bother to prioritize low-cost testing options, it’s anxiety-provoking.

Fast-forward then to a new world where payers are going to be looking to make up for all of those expenditures. Premiums are certainly going to rise, and they’re going to crack down on payments for other services. I predict that use of low-cost telehealth services will be pushed to the forefront. That’s good for patients who are technology-savvy and value the convenience. It’s not so good for patients who don’t have access to technology or aren’t skilled with it, or for whom an in-person visit would be better. Telehealth may become an additional layer of triage that helps control which patients receive more expensive in-person services, and this is most certain to happen if payment parity for telehealth services does not continue.

Practicing in a telehealth environment doesn’t come naturally to physicians, and few schools taught telehealth skills prior to the pandemic. I enjoyed reading a recent article in the American Family Physician journal which explained how to do high-quality management of musculoskeletal issues through a telehealth encounter. That’s the kind of practical retraining that many physicians are going to need if they’re going to be expected to practice in that world. They shouldn’t be expected to just figure it out on their own, as most have had to do.

But if they are going to be held to the same value-based care metrics and standards that they are held to in the brick-and-mortar world, they’re also going to need adequate telehealth infrastructure to deliver it. This means being able to coordinate visits with ancillary providers such as registered dieticians or certified diabetic educators and being able to leverage high-quality remote patient monitoring services. Although these are great concepts, we’re not remotely close to delivering that level of care to most of the US.

I’ll be watching the recent telehealth acquisitions, agreements, and expansions closely to see who is hitting the mark and who starts drifting off course. Many organizations will be forced to migrate from make-do virtual visit platforms to robust telehealth solutions that integrate with the EHR. Physician groups will have to determine how they figure telehealth into evolving physician compensation strategies. Much like groups might pay physicians less when they stop taking overnight call, will they pay physicians less if they elect not to come into the office? Will they create different kinds of practice-share arrangements for teams of virtual and in-person physicians to partner together? Will telehealth be part of a continuum of care, or will it continue to be a bit siloed?

I’ll also be watching lab and other ancillary businesses. Will the big lab vendors start performing COVID testing in person, so that a patient could receive a telehealth-driven order for testing and go to a lab patient service center to have it collected, just like they might go for a blood draw or a urine culture? Or will local public health agencies step up to fill that void, especially since those states that had mass testing centers are starting to close them down? Will we see COVID testing booths on street corners like you might see in other countries? The devil will be in the details as far as how we try to contain costs and deliver the medical services that provide the most value to our patients without breaking the bank.

Looking in your crystal ball, what do you think are the next steps for telehealth in the US and around the world? Will we see massive shifts in utilization? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/25/21

Today’s web-based entertainment was courtesy of Nuance and its Dragon Ambient eXperience product. I’ve been keeping an eye on it since seeing it at HIMSS19.

Their demo at the time involved an orthopedic visit, which tends to be a lot more straightforward than most of the visits we have in primary care. I was hoping they would show a truly complicated visit and how the system could handle it. It was encouraging the host said they would be doing an “unscripted” demo based on attendee input through a Zoom poll with randomly generated options.

However, it quickly turned into the same old orthopedic visit that they typically show. They asked the audience to have input via poll on past medical history elements, but many of what we were given to choose from were just standard conditions like hypertension or an ACL repair.

I have yet to see a demo where the system can manage the real-world things we see in practice. Where is the history of “heart surgery” where the patient has no idea what was done or what the underlying diagnosis might have been? What about the problems that were more complex than injuring your ankle while walking your dog Lucky, which was the demo they actually showed? They showed the voice recognition streaming during the demo, and there were a number of elements where it wasn’t capturing exactly, so I was curious to see what the process would be to resolve those.

The command “Hey, Dragon, show me the x-ray” brought up an x-ray example with no patient identifiers, which failed my realism test. The physician also interpreted the x-ray before examining the patient, which is a no-no for many of us. The physician used a fair number of medical words, but didn’t really explain to the patient what those meant, including the anatomical names for the affected areas.

I wasn’t impressed by their simulated assessment and plan, which didn’t entirely follow the standard of care in that the patient was given a scheduled controlled substance for her ankle sprain, which most of us wouldn’t do until the patient failed other pain management strategies such as anti-inflammatories or acetaminophen, neither of which she said she had taken.

I know I tend to be critical since I’m a practicing physician, but it’s all part of credibility. It’s hard to find the messaging to be credible when they missed the clinical mark. Was it intentional, or did they not find it important to be clinically credible? Interestingly during the interview, the clinician ordered tramadol, but when the host reviewed the medication orders, the canned display on the back wall showed Tylenol, which maybe was an indicator that it was a little more unscripted than they planned. The final note did mention both Tylenol and tramadol, however.

They cut away to videos from physicians, including family physicians and orthopedic physicians, but they didn’t really show what this would look like in family medicine. I asked a pointed question via the Q&A chat about how the system would manage vague elements like I mentioned above. Not surprisingly, it was skipped. They did mention that they have a four-hour service level agreement for note turnaround, although they noted it can be shorter in the real world. As a physician who likes to have my notes done when I walk out of the room, that would take some getting used to. They did demonstrate how the system could filter out the conversational parts of the visit in order to create a concise note, which is promising. Still, I’d love to see how it handles a complex primary care visit.

Today’s patient-side entertainment was courtesy of my local hospital, which continued to underwhelm. I’m living the nightmare shared by a number of female healthcare providers who received the early rounds of the COVID-19 vaccines. Since it’s been two months, and statistics do what statistics do, one-sixth of us over a certain age have been due for an annual mammogram since receiving their vaccines. Both of the current vaccines tend to cause swollen lymph nodes, usually in the neck or underarm, and sometimes those nodes turn up on a mammogram. It’s a widespread enough issue that mammography centers are adding questions to their intake forms asking about vaccine status and which arm was used for the administration. The Society of Breast Imaging sees this as a big enough issue that it has recommended women delay screening mammograms until at least 4-6 weeks after receiving their last vaccination. However, for those of us who were due for screening prior to the recommendation, we are now chasing down rogue lymph nodes that could be due to the vaccine or to something more sinister, such as breast cancer or lymphoma.

I had a difficult enough time scheduling my follow-up ultrasound due to my clinical schedule and the limited appointment slots. Today’s actual appointment could have served as a case study of what not to do from a technology, operational, and clinical standpoint.

It started with patients reporting 15 minutes before their appointments as instructed, only to find that they had a single registrar who was taking names and instructing people to be seated until called. The problem: six patients and five chairs in a waiting room that had been stripped of furniture for social distancing. Patients were slowly called to the desk, where they were forced to fill out the usual clinical history form (completely from scratch, once again not pre-populated from the Epic system as it could have been) standing there in front of the registrar. This delayed additional check-ins and I’m sure was frustrating to patients.

Despite arriving early, I wasn’t called back until 10 minutes after my appointment time, where I was taken to a changing room that fed a sub-waiting room with an additional four patients (although there were five chairs, but this time we got to sit around with each other in flimsy gowns). Plus, instead of watching HGTV in the main waiting room, we were treated to a screen displaying a version of the imaging center’s tracking board, showing all the patients and their appointments and how backlogged they were. Although the names were truncated like we were flying standby, it felt like an invasion of privacy since we could see all the procedures scheduled for the day. There was a Windows popup on the screen that looked like an error or alert message, and although I couldn’t see the details, I wondered if we were really supposed to be seeing it.

After finally reaching the exam room, I was treated to a brusque sonographer who acted like I hadn’t followed appropriate prep instructions (despite having received none). I felt like reminding her that even though she does this a dozen times a day, each patient was enduring the harrowing experience of wondering if they have cancer or not, so they don’t need her attitude. It was clear she was having trouble getting the images she wanted, but she finally went to review them with the radiologist while leaving me draped on the table.

When the radiologist came in, she started spouting medical terminology and I’m hoping it was because somewhere my chart was flagged as a physician because as a “regular” patient I would have had no idea what she was talking about. I guess I’m also more sensitive to the patient’s comfort than she was, because I rarely have conversations with patients while they are draped and lying on the table. At a minimum, it would have been nice to sit up and have a conversation at eye level.

I don’t think I have unreasonably high expectations. They have been shaped by the way I was trained and how I’ve seen medicine practiced for the last two decades. But it seems they’ve substantially diverged from the post-COVID reality of healthcare in my city. Patient advocacy and patient empowerment are supposed to be major factors influencing how healthcare organizations operate, but apparently for some they’re little more than buzzwords.

The perfect cap on the day was when the sonographer walked me back to the changing room, where she told me to “enjoy the rest of your day.” As I looked at the faces of the other women in the sub-waiting room, knowing that their lives might be changed dramatically today, it didn’t seem like what patients might want to hear, especially knowing that some of them would go home to sit and wait for results. Perhaps “take care and thank you for choosing us as your healthcare team” might have been a better option.

Have you experienced a decline in patient services in the COVID era? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/22/21

I’m not sure if I’ve ever met Nordic Chief Medical Officer Craig Joseph, MD in person, but he’s definitely on my list of “people I’d like to have a cocktail with” at some point. His Twitter posts @CraigJoseph always have interesting tidbits, such as a recent white paper from ECRI’s Partnership for Health IT Patient Safety. He notes, “Lots of smart people with clinical and EHR vendor chops outline specific actions to consider.”

I checked out the paper, titled “Optimizing Health IT for Safe Integration of Behavioral Health and Primary Care.” It resonated with me because this is an issue I’ve had to deal with for years – navigating the intersection of those two disciplines while trying to coordinate care while maintaining privacy. Many organizations, including some of my current clients, choose to keep primary care and behavioral health records siloed. This results in fragmentation of care and lack of understanding around whole-person factors that drive both physical and mental health.

It lays out clear reasons why primary care and behavioral health need to be integrated:

• 80% of behavioral health patients will visit a primary care provider (PCP) at least annually.
• 50% of behavioral health disorders are treated in primary care settings.
• 48% of appointments for psychotropic medications are with non-psychiatrist PCPs.
• 67% of people with behavioral health disorders don’t get behavioral health treatment.
• 30-50% of patients referred from PCPs to outpatient behavioral health don’t keep their first appointment.
• Two-thirds of PCPs report being unable to access outpatient behavioral healthcare for their patients.

Additional barriers for mental healthcare access include provider shortages, health plan barriers, and coverage issues. In my major metropolitan area, we recently opened a dedicated mental health emergency department unit that is staffed full time by specialist providers. The community accepted it readily because we know we don’t do the best job for patients needing non-medical services who present to other care venues, such as the emergency department or urgent care facilities.

Even for health systems or provider-side organizations that want to try to integrate the behavioral health and primary care realms, EHRs aren’t always supportive. Psychiatry notes, therapy notes, and documentation from social workers are often kept under separate access where the primary medical team can’t see them. Especially when we’re dealing with medical conditions that can have significant behavioral components, it would be useful to be able to see all the information about the patient. The white paper does a nice job explaining different levels of integration, from “coordinated” care to that which is “co-located” to fully “integrated” care. Right now, many primary care practices are struggling to deliver even minimally coordinated care.

One of the major participants in the creation of the paper was the HIMSS Electronic Health Record Association (EHRA). I have some experience with EHRA from a past life and know many of the members of the project’s working group to be knowledgeable individuals with a deep understanding of EHRs and care delivery. EHRA has a code of conduct for EHR and health IT developers that addresses the need for collaboration described in the paper.

However, working as someone outside of an EHR vendor, I’ve found it nearly impossible to access the materials that we relied on when I was on the vendor side. This forces those of us who work on homegrown or in-house systems to re-invent the wheel trying to determine best practice as we develop our technology. Since this is a partnership with ECRI and this paper exists, I take that as positive signs. Still, non-commercial developers are going to have to do a lot of figuring out on their own unless there are maneuvers to standardize at the federal or payer levels.

The paper talks about standardizing screening and documentation tools so that data is consistent across an enterprise. Although this would be good, many patients may receive their care across multiple organizations. I cared for a patient the other day who receives medical care primarily through a county health clinic because she doesn’t have health insurance, but receives a telehealth benefit from her employer, so she’s using that for urgent care services and psychotherapy. She came to our urgent care because she needed stitches and we have an affordable self-pay program. Given the vast differences in the systems used by those entities coupled with the relative immaturity of our state’s HIE, there’s no way there will be coordination any time soon.

There are also legal barriers to sharing of data under both HIPAA and 42 CFR Part 2, especially around sensitive health information. Many organizations find these restrictions daunting and either don’t have the wherewithal or the manpower to try to tackle them, especially while simultaneously coping with a pandemic and the generalized dysfunction of healthcare delivery in the US. Patients also struggle to understand the protections and restrictions and become frustrated when we try to explain why we have to ask the patient to summarize their care because we can’t access the information that we need without recreating the proverbial wheel.

The document has some great appendices, including a literature review and tables of evidence used during its creation. The summaries of EHR challenges and existing workarounds were fascinating case studies in dysfunction: lack of integration between the EHR and tablet devices used for patient-completed screeners and surveys; copy and paste to add the same note to the PCP and behavioral health EHRs; printing and scanning of medication lists from the behavioral health EHR to the medical one; and more. My favorite is “Reliance on patient or clinical recall for inaccessible clinical information – providers describe this as ‘flying blind.’”

Due to my employer’s lack of integration with our state HIE or nearby health systems, I’ve been flying blind for the last six years, except for when patients use their phones to access MyChart and then hand them over. That’s been useful in a number of medical situations, but I have to admit I’ve never seen psychiatry notes or therapy notes in any of those encounters, and I usually can’t see a full medication list history to know what’s been tried in the past — only current medications are typically displayed.

The paper also contains pages of recommendation tables, some of which push back on ONC, CMS, and other agencies to provide easily accessible standards for developers to use when creating documentation. It also calls on ONC to drive adoption and implementation guidance for APIs to improve integration. There is also a bid for the federal government to incentivize patient care organizations to implement standardized tools. There’s a great swim-lane diagram of an ideal IT-enabled workflow for safe integration. It will be interesting to look back at this paper in a couple of years and see how far we’ve come or whether we’re still living in the land of siloed documentation.

Has your organization done work to support integration of primary care and behavioral health? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/18/21

I had a moment of excitement in my pre-HIMSS planning when a friend clued me in to reasonable rates at The Palazzo. I’m happy to be rebooked somewhere that is attached to the meeting facility so I don’t have to melt in the August heat on the way to the show. The HIMSS room reservation system shows that the resort fees are optional this year,  which is great for those of us who never get to experience the “resort” component since we’re frantically trying to see everything possible then write it up before collapsing every night. I also had a thrill when I came across this ad featuring a vintage booth babe. I’m a sucker for opera length gloves and a dramatic up-do, so it certainly got my attention.

People always ask what kinds of things I’m interested in looking at when I attend HIMSS. Smart glasses are back on my radar. It’s been years since Google Glass came and went, but I’ve seen two articles in the past week that featured some variation on smart glasses. Specific use cases include helping a remote clinician better visualize a patient during a telehealth consultation or using the glasses to deliver diagnostic information from AI-powered clinical support systems.

One of the articles noted the potential for patient-side wearables to capture clinical information for later review by the care team. There’s always a lot of talk about wearables, but I haven’t seen a tremendous body of evidence that they can significantly drive clinical outcomes. We’ll have to see what companies bring to the table come August.

The American Medical Informatics Association issues a call for proposals for the AMIA 2021 Annual Symposium, to be held October 30-November 3 in San Diego. A quick scan of the website showed they are currently planning for a live event “with a limited component of live streaming.” It goes on to note that the AMIA board will make a decision in June if this needs to change. For those interested in presenting, submissions are due March 10.

Although I read a number of journals regularly, I enjoy JAMIA because of its focus on informatics issues. One recent submission looks at gender representation in US biomedical informatics leadership and recognition within the biomedical informatics community. The authors assessed data on AMIA members, academic program directors, clinical informatics fellowships, AMIA leaders, and AMIA awardees. Not surprisingly, men were more often in leadership positions, including 75% of academic informatics programs, 83% of clinical informatics fellowships, and 57% of AMIA leadership roles. Men also received 64% of awards.

I’ve worked with a number of informatics organizations and have seen significant differences in how they approach the creation of a diverse workforce. While some hope it will happen by chance, others work quite intentionally to provide opportunities for groups that are traditionally underrepresented in technical fields. I recently met with a group of women informatics leaders and learned about their strategies for recruiting diverse teams. We certainly can benefit from broader perspectives.I look forward to seeing what those numbers look like in five or 10 years.

JAMIA publishes a study that examines the impact of after-work EHR use and clerical work on burnout among clinical faculty. Specifically, they looked at faculty across Mount Sinai Health System, with 43% of eligible faculty members participating. They concluded that spending more than 90 minutes on EHR work outside the workday and performing more than one hour of clerical work per day are associated with burnout. The findings were independent of demographic characteristics and clinical work hours.

I’ve spent a good chunk of my career trying to help organizations improve their workflows and am always gratified to see an organization that cares about how technology is impacting workers. Unfortunately, many groups don’t see this as a priority or are happy to watch their clinicians absorb increasing amounts of non-clinical work.

Challenges with personal protective equipment are once again in the news, as healthcare organizations have been saddled with millions of counterfeit N95 respirators. Impacted organizations include Cleveland Clinic, the Washington State Hospital Association, Jersey Shore University Medical Center, and Hennepin County Medical Center in Minneapolis.

I was discussing this article on a local physician forum and ended up talking with a local academic faculty member who couldn’t believe that community hospitals and private organizations are still struggling to provide adequate PPE. My clinical employer provides a limited number of N95 respirators to our team and makes their use inconvenient by only stocking them at a single location, requiring people to travel on their days off to pick up a new supply and to rotate that supply over an extended number of days. Some of us are providing our own respirators to avoid reuse, but the counterfeit issue is still a concern. Co-workers who don’t go through the steps are still being diagnosed with COVID-19 despite vaccination.

I have friends who are nurses at community hospitals that sometimes receive N95s only once a week since they’re not on dedicated COVID units. Others have to beg supervisors to replace their PPE when straps break, or they become wet from wear. It’s a tragedy that we are still dealing with this a year into the pandemic. I can’t help but think that if the Centers for Disease Control made N95s mandatory for patient care encounters that we would stop seeing healthcare workers being infected. Employers would be forced to raise their game and to support those employees who want the highest level of protection. But as long as they say that surgical masks are an OK alternative, we’ll continue to see cases.

Fortunately, I have enough masks to make it through the end of my current clinical situation, since I’ve officially tendered my resignation. The fact that I made the right choice was confirmed a few days later when the organization announced some fundamental changes that will significantly alter how the business operates. It will be interesting to see how many people jump ship. I was asked not to reveal my resignation to staff until a couple of weeks before I actually leave, so for all I know, there could be others in the same position. It should make for an interesting couple of months. In the mean time, I’m looking forward to having a break from work-related COVID while I figure out my next move.

The Washington Post reports that Europe’s oldest person, a 117-year-old French nun, has survived COVID-19. Lucile Randon, who took the name of Sister Andre in 1944, was diagnosed on January 16. She was born on February 11, 1904, which means she also lived through the 1918 pandemic. Her birthday celebration was slated to include foie gras, capon with mushrooms, and red wine. Best wishes to Sister Andre for an uneventful 2021.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/15/21

Like many parts of the US, my city has spent the weekend heading deeper into the polar vortex. I’m not a big fan of sub-zero temperatures, let alone wind chills in the negative double digits. We’re expecting snow throughout the night and into the morning, which will make for less-than-fun conditions driving to work in the morning. While some of my physician colleagues were scrambling to move their in-person patients to virtual visits, I reminded them that some of us have to work in person regardless of the weather.

I’m a bit tired of being an all-purpose clinical safety net for practices that don’t want to or otherwise can’t see patients in person, and especially having to see those patients without any supporting medical information. That’s one of the pitfalls of being part of an independent organization. We don’t have access to anyone’s broader medical records, unless you count patients who log into MyChart and hand you their phone. Our state charges exorbitant rates for independent physicians to participate in its health information exchange, so we don’t have that data, either.

Back when I was a community-based family physician, I used to call ahead when I referred patients to urgent care or to the emergency department to let them know what I was thinking and why I was sending the patient. It doesn’t seem like anyone does that any more. Half the time when I try to call a patient’s personal physician to discuss their case, either I don’t get a call back or they act bothered that I even called in the first place. I’ve had a total of two physicians thank me for calling them about their patients in the last six months. One of them was an orthopedic surgeon who not only gave me advice on how to handle the patient’s unique problem, but made the patient an appointment for first thing in the morning while she and I were on the phone discussing the case.

I try to keep positive situations like this one at the top of my thoughts when I’m dreading tomorrow’s bone-chilling and potentially dangerous trek. Due to the pandemic, plenty of people are out of practice driving in poor conditions, so who knows what it will look like. I’d much rather be at home working on technology projects. I have some interesting ones in the works. One takes me into a world where I haven’t had a lot of experience outside the clinical realm, and that’s the perioperative services arena. I’ve been contracted by a health system that is trying to be proactive about the significant number of surgeries that patients have delayed during the pandemic. As COVID-19 numbers begin to fall across the region, they are looking at the best ways to bring those patients back into care.

As you can imagine, a number of the cases are orthopedic in nature – hip and knee replacements, shoulder reconstructions, and the like. For those patients whose procedures were on the books at one time and were rescheduled or canceled during the pandemic, outreach is fairly straightforward. The challenge is identifying the patients who never made it to the surgical scheduling team. Perhaps the procedure had been discussed with a surgeon, some of whom are employed by the health system, so we have access to medical records and can begin to identify those patients depending on how the visits were documented and whether the procedure recommendations were captured in discrete data. Others had surgeries recommended by community-based physicians who are on staff at the system’s hospitals, and identifying those patients is more challenging.

Beyond identifying the patients and their respective procedures, there are several other related projects that I’m being pulled into. They look at various details including surgical scheduling, staffing for perioperative personnel, equipment management, sterilization and central supply processes, and more. One sub-project looks at the surgical instrument preferences for various procedures across surgeons and how they might be standardized. That’s where it gets exciting for me, because I get to try to look at relationships between surgical outcomes and a number of factors, including level of standardization, number of cases performed at the different facilities, staffing, and how those factors might influence each other.

Right now, I’m overseeing the gathering of the data from various sources and its aggregation into a central database. We’re designing the questions we need to ask and looking at known pain points in the processes, from scheduling to day of surgery to follow up. This is where it’s fun to be the outsider, because I don’t know any of the people or the personalities and I’m eager to let the data speak for itself.

I don’t know that Dr. X has been on staff for 30 years and that people tolerate his quirkiness because he’s considered the elder statesman of his subspecialty. I am not swayed by people’s claims that their patients require special equipment different than that used by all their peers. I don’t know any of the stories about why one hospital has been allowed to operate outside the system’s standards or why everyone else is in alignment. I’m eager to see what stories emerge as the data begins to tell its tale. I can also look at data that overarches the procedures and surgeons, such as operating room turnover time, housekeeping data, central supply factors, length of stay data, surgical complications, readmissions data, and more.

The other element that excites me about this project is having support staff to work with who know the system from the inside. It’s not the usual “let’s outsource this” type of project of which I am usually on the receiving end. I get to work with people across the health system who possess deep experience in quality improvement projects and clinical transformation work and are similarly motivated to try to find ways to improve the process as well as patient experiences and outcomes.

I knew this was going to be an interesting project, but now that I’m really involved, I feel like a kid in a candy store. What projects are you most looking forward to this year? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/11/21

Even with all the turmoil the US has gone through in the last several months, the institutions of government are still going strong, and the folks at CMS have not missed a beat. They did, however, extend the deadline for submission of 2020 data for the Medicare Promoting Interoperability Program. You now have until April 1, 2021 at 11:59 p.m. ET to attest through the QualityNet portal.

New Hampshire lawmakers have introduced HB 602, which aims to eliminate existing provisions protecting telehealth coverage. It would eliminate coverage entirely for audio-only services, which may have the unintended consequence of reducing access for those either not able to access the internet or who aren’t technically savvy enough to manage audio/video links. Surprisingly, one of the bill’s sponsors, Representative Jess Edwards, was one of the co-sponsors of the 2020 law that created payment parity for telehealth coverage.

As a telehealth physician, audio-only visits can be high quality interactions. In addition to the limitations above, some patients are just not comfortable on video due to their living environment or other factors. We’ll have to see whether this bill makes it through the process or not.

The ongoing usefulness of telehealth is discussed in this recent Journal of the American Medical Association editorial. The authors note that both patients and clinicians may want to continue virtual visits and that those visits could be as effective as in-person visits or used in conjunction with in-person visits as a hybrid model. Concerns about use of telehealth in the absence of hands-on examinations are valid, particularly when considering the overuse of expensive tests in lieu of physical diagnostic skills. Still, some conditions don’t require extensive physical examinations, but do require a physician’s cognitive effort.

For example, I was diagnosed with a food allergy a few years ago and I now doubt that diagnosis. I’m trying to get a second opinion from an allergist. The next available appointment that meshes with my work schedule is two and a half months away. No physical exam elements are part of this evaluation, and I recently had a full physical exam with the findings available in the shared EHR. Essentially, I need a learned expert to perform a review of my existing records and have a discussion with me about the risks/benefits of testing to determine whether it’s worth trying to proceed.

I’m willing to pay for the physician’s knowledge, experience, and time, but the construct in which we operate requires me to drive halfway across town to do it instead of being able to teleconference with the provider in the open slot that she has on Friday that would work with my schedule except for the drive time.

Of course, not every visit is suitable to a non-visit approach, but it’s time we think outside the box and focus on patient access, delivering high-value care in ways that are win-win for everyone involved. Real concerns also exist about fraud, abuse, and low-quality care. I would argue, however, that telehealth can be an important adjunct to whole-person care and for scenarios where a physical exam isn’t necessary or a recent exam is well documented. It could save a substantial amount of time and money for all parties involved.

I’m continuing to follow up on some random leads from the Consumer Electronics Show. One of them was a note that I made for voice-activated faucets. Kohler has launched a not only operate on command, but can measure specific amounts of water. The faucet also connects with a smartphone app that allows households to monitor water usage and be notified if it appears anything is out of the ordinary. Some models even offer a “wash hand” command that will instruct a user through the recommended steps for handwashing, including audible guides for lathering, cleaning, and rinsing. For parents who are tired of hearing two rounds of “Happy Birthday” as they try to instill good habits, it’s tempting, but the $1,700 MSRP is daunting. Most of us will have to go back to the old-fashioned egg timer and some adult supervision.

I enjoyed having easy access to the CES materials and sessions for a reasonable time after the show. Whatever HIMSS plans for its hybrid conference in August, I hope they improve their learning management system, because trying to find the sessions you want to watch after the fact is sometimes daunting. As someone who used the HIMSS sessions in the past for Maintenance of Certification credit for my informatics boards, it always seemed like the sessions I wanted to attend were on top of each other and watching after the conference was the answer. I hope they announce more information soon about the hybrid format, because I need to make some hotel decisions soon.

I had some additional adventures as a patient this week. The local hospital sent me an email reminding me that I had a bill due that I actually paid a month ago. I tried to use the integrated chat function to get it clarified, and the first thing I experienced was that despite the chat requiring me to enter the bill’s ID code along with the amount due (so that it could presumably be made available for the agent when he arrived in the chat), the agent asked me whether the bill was for a different amount that has never appeared on my account. I also quickly noticed that the chat client had no audio indicator that the agent had messaged me, so I had to sit there and stare at it to know if there was a communication. The agent kept telling me I had a zero balance despite the email and the home page that clearly showed a balance, and then told me not to worry about it.

I asked him to please escalate the fact that the system is sending balance due emails to patients with zero balances, since I’m a referring physician as well as a patient and know that would bother my patients as much as it bothered me. He then decided to tell me it is a known issue and that they are working with the vendor to resolve. I’m not sure why he didn’t tell me that up front when he realized my issue looked like one of the known issues, or why he decided to tell me once I said I was a physician, but either way, It wasn’t outstanding customer service. I hope the vendor gets their act together and fixes the defect soon because it’s annoying to say the least.

Do you feel like your healthcare team has accurate billing practices? Or do you see a high volume of patient complaints? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/8/21

It’s been a pretty crazy week in the clinical trenches, with COVID cases ticking up in my area. I’m approaching my one-year COVIDversary, memorializing one year since the day I saw my first COVID case, which happened to be one of the first five in my city.

I laugh a little thinking about it, since of course it presented itself at the urgent care as so many other health conditions do. It wasn’t some diagnostic mystery at a tertiary medical center, or an academic puzzle for someone like House. It was a household contact of someone suspected to be infected, who presented to our office saying she had a fever and couldn’t smell dirty diapers. My physician assistant and I spent the next several weeks wondering if we were going to die. Little did we know that the day would come when we would be seeing 15 to 20 known positive patients a day, with essentially the same level of employer-provided personal protective equipment we had prior to the pandemic (although many of us are supplying our own N95s).

Urgent care centers are healthcare’s front door for many patients who might not have a primary physician or who can’t see theirs during hours that are convenient. Even before COVID, our practice was seeing significant growth, having expanded from five locations to more than 20 in the five years I had worked there.

In November, I was having heated phone calls with our governor’s office about their vaccine plan that left non-hospital-owned urgent cares out in the cold. They were incredulous that urgent care offices treat COVID patients. “When did that start?” they asked. That would be March 14, when COVID-19 first crossed our state lines. The staffer seriously thought that all COVID patients were being seen in the emergency department, which doesn’t give me great confidence in our state understanding how healthcare is delivered to its residents. They also didn’t fully grasp that my practice performs almost 10% of the state’s COVID testing and diagnoses sometimes 500 new COVID cases a day. Seeing more than half a million patients a year, damn straight we’re on the front lines, so how about sending us some vaccine?

As I reflect back on the last year, it’s been a wild ride. At the beginning of COVID, we had to temporarily close several of our locations due to low volumes. I was furloughed without pay, something I never expected to happen as a physician. Once we started offering testing, though, it was off to the races, with volumes going crazy. I’ve mentioned before that in my clinical world I’m just a worker bee, an hourly physician with no leadership responsibility. However, due to my experience and as a consultant, I’m constantly analyzing the actions of my employers against what I might do or recommend that my clients do in a similar situation.

Some of the things they’ve done have been good. Retention bonuses for our clinical support staff helped boost morale and prevent turnover, particularly when patient volumes were high. However, they never did anything to bolster physician morale. When we brought it up, we were told that we should be glad to have jobs since one of the local health systems had completed a significant physician layoff. That never makes one feel good.

Neither does learning that your employer accepted millions of dollars in Paycheck Protection Program funds despite a clinical rebound that had us seeing more patients than we have ever seen in organization’s existence. It’s particularly special when you read about the PPP amount on the front page of the local paper right after seeing an email from your boss that everyone needs to tighten their belts because of the finances. They weren’t following any communications playbook that I would recommend as a consultant, that’s for sure.

The “acting poor” strategy also didn’t play very well when they announced that we were opening additional locations even though we couldn’t fully staff the existing ones. As a part-timer with other sources of income, I had the luxury of being able to push any negative reaction to the back of my mind, but I watched some of my full-time colleagues begin to look for employment elsewhere. Burnout is real and 12-hour shifts are rough, especially when they routinely stretch to 13 or 14 because you’re never allowed to say no to patients who are streaming in the door. I watched several of my favorite physician assistants leave for jobs with eight-hour shifts at local hospitals and have to say I was a bit envious.

I suspected something major might be up several months ago when they hired a new member of the C-suite, but didn’t announce his presence to the physicians. I met him walking through my patient care area after he had been on the job for a couple of weeks. I was underwhelmed by his demeanor and the fact that he was oblivious to my full patient board and the 40+ patients on the parking lot wait list and wanted to stand there and chat. I was even more underwhelmed a week later when his announcement email finally arrived, not from the CEO or COO, but from himself. At that point, I decided to start looking for other clinical opportunities, even though I knew that part-time physician spots basically don’t exist in my community and I’m only in this one because I’ve been here so long.

Toward the end of an already busy clinical week, we received an invitation to an all-hands meeting a couple of hours from when the email was sent. That’s never a good sign. Most of our staff meetings are at 6 a.m. so people can get to their shifts on time. During this quickie Zoom call, we learned that our previously physician-owned practice had gone the way of so many before us in being acquired.

I can’t say I’m surprised knowing the personalities involved, but it explains so much about how they’ve been managing the finances and some of the other decisions that have been made over the last several months. I’m sure it was all targeted towards making the balance sheet look as healthy as possible.

I’ve seen many versions of this movie before and I’ve never seen an ending that works out well for all parties. Inevitably, the investors want their money back and then some, and that money has to come from somewhere. I’m at a point in my career where the plot has to be pretty compelling for me to stay until the end and I’m not sure this fits the bill. I’ve done some research on the investors and I’m not impressed by their healthcare experience. Having participated in due diligence exercises with other organizations looking for outside funding, what I could find on them left me with quite a few questions and not as many answers as I would like.

Most people don’t realize that when physicians leave a clinical position, it’s not like quitting other jobs. It’s not unusual for physicians to be required to give a 90- or 120-day notice so that patients aren’t left in the lurch. Sometimes non-continuity practices like mine will accept less notice, but that’s not the case with my employer, who actually lengthened the notice period for some recent hires. There are some other things that were announced in addition to the investors, and frankly I’m not sure I want to be around when those proverbial bombs begin to drop.

I’ve been thinking about leaving for a while, and this might just be the push I need. When the handwriting on the wall wasn’t done with Sharpie but rather with red spray paint, it’s likely time to dust off the resignation letter. It’s an unsettling feeling since I’ve only resigned from two long-term jobs in my career, but I trust my gut, even in the middle of a global pandemic and without another clinical gig on the horizon. Time for my next leap into the unknown.

What’s your best job quitting story? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/4/21

I’m not sure what to make of the recent communications from HIMSS regarding HIMSS21. They are eager to confirm that the event will proceed and to tell us the next milestone where they plan to tell us more about it, but I personally would rather have information at hand than the promise of information down the road. It’s clear that the exhibit hall will be much reduced and the sessions will be a mix of in-person and digital, but beyond that, I’m not sure what we know. The reality is that HIMSS is about making money and they’re going to structure their communications in the way that they think will be most profitable.

What I do know is that August in Las Vegas is deathly hot, and the things that many of us have been doing to avoid COVID — such as having social events outside — may or may not be tenable there at that time of year. The average high for the week of August 9-13 is 103 F, with a low of 80 F. Even in a “dry heat,” it’s not my favorite way to travel back and forth from the hotel to the conference center. I’d like to stay at one of the connected conference hotels, but the charges are prohibitively high for those of us who are paying our own way for the privilege of attending a conference where we have no idea what to expect.

We also have no idea what vaccination status will look like as we move towards August, since vaccination administration is still rather messy across the US. Based on anecdotal reports, many of the would-be HIMSS attendees from US health systems may be vaccinated, since many of those health systems seem to have had plenty of vaccine for non-patient-facing workers under the premise that everyone supports the patient journey. My friends who are part of independent practices and federally qualified health centers are still struggling to find vaccine, and the process has become more challenging now that states have prioritized the elderly.

I honestly don’t have a bead on what vaccination processes look like elsewhere in the world except for the UK and Australia, where friends keep me posted on what they are experiencing. They have employed different strategies than the US or each other, so it remains to be seen who will ultimately be judged by history as having the best approach. Certain countries and alliances have bought up enough vaccine supply to more than vaccinate their own populations, and it’s not yet clear what will happen to any surplus in the end. The goal is of course to vaccinate people quickly, but there are still plenty of barriers worldwide.

Being a clinical informaticist in the midst of a global pandemic has its challenges, since many of us are armchair quarterbacking the charts and graphs we see and trying to determine whether they’re accurately illustrating the facts or are in danger of looking like someone changed the data with a Sharpie. A neighboring state just got caught cooking the books on their COVID positivity numbers — they decided to exclude test results that have been performed by any other methodology than PCR. Many of the large urgent cares are using rapid molecular testing like the Abbott ID Now devices in use at the White House, and those numbers are going unrepresented. Also not included in the totals are other rapid tests, such as antigen tests. We use both of the latter in my practice probably 80% of the time, only sending PCRs when required, so failing to include all the data seems like a no-no.

The state health director tried to explain it away by saying that there’s enough “saturation of PCR tests in the market to be representative,” and although I understand what he’s trying to say, it just seems like it would be better to use all the data, especially since the state requires practices to report it. Why would you want to not use data that you have? Those are the kinds of decisions that lead people to question the truthfulness of public health officials and that give rise to conspiracy theories. There have been enough irregularities with data and reporting throughout this pandemic that future academics can teach full semester classes on what went wrong.

February 3 marked National Women Physicians Day, which occurs on that date to honor the birthday of Elizabeth Blackwell, who in 1849 became the first woman to achieve a medical degree in the United States. I spent the day caring for patients, some of whom were particularly cavalier about spreading COVID to their friends and family members, which is always frustrating. I didn’t even realize it was today until I got home and was curled up with my laptop, surfing the internet while waiting for my face to stop hurting from wearing an N95 mask for 12 hours. It typically takes about three hours for the mask marks to go away and a couple more for the headache to improve if I don’t take ibuprofen or drink a martini. I’m surely in a place I never expected to be when I started my medical career.

I was proud to be part of the first majority female class at my medical school, and to be part of an all-woman residency class well known for shaking things up in the world of graduate medical education. As the first physician in my family, I didn’t really appreciate what that meant until the day I took my mother to visit the gross anatomy lab. It was there I learned, as we stood there holding a human heart, that she might have liked to have been a physician, but when she was in college women were steered towards career paths in teaching and nursing. I was surprised that she hadn’t mentioned it while I was pre-med and applying to medical school, but maybe there was something in the genes that kept me going even when training got rough.

Here’s to all the women physicians that came before us, breaking barriers, putting up with enormous amounts of harassment, and paving the way for us to be where we are today. Your courage and dedication will never be forgotten.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/1/21

I mentioned in last week’s EPtalk my ongoing healthcare adventures with Big Health System. As a patient, the organization unfortunately continues to provide plenty of material for HIStalk.

It’s an interesting setup there, with the academic medical center and the non-academic hospitals not fully aligned. That leads to somewhat of a “let’s do it separately together” approach to not only the EHR, but operational and workflow elements, too.

The academic side of the house continued to have their act together. I had specifically requested that my skin biopsy be sent to the flagship hospital’s pathology department after hearing about a friend’s disastrous experience at one of the community hospitals. They didn’t disappoint. Pathology was turned around in less than 48 hours and I received a phone call from the dermatology office bright and early on Saturday morning. When I went to look at the report via the patient portal, not only was it there, but also present was a full copy of my visit note and not just the post-visit summary.

The community hospital where I was scheduled for my MRI continued to underwhelm. I showed up at 6:45 a.m. as requested. There was a backup of people waiting to enter the hospital at the COVID screening checkpoint. Based on the predominance of running shoes and scrub pants peeking out from long winter coats, I assumed that many of them were employees arriving for a 7 a.m. shift change.

It would have been useful for the facility to have separate lines for employees and patients to get people more quickly to where they needed to go. No one was standing six feet apart, but everyone was masked, so I guess that’s something. After finally making my way into the building. I noted that at least the line at the coffee kiosk was well spaced, so that was good.

I quickly found my way to the “imaging pavilion,” the name of which made me laugh since it looks like just another hallway branching off in the bowels of the mammoth complex. I’m sure the naming had something to do with fundraising, but a decade after its addition, it just seems silly. The hospital has grown up around it, and once you’re in that part, you still have to snake around to get to the particular area where your study will occur.

Despite my compliance with the pre-registration team’s phone call, they had no record that my file had been updated. I had to answer all the questions again, this time while yelling through Plexiglas to someone who acted like they couldn’t hear me despite the fact that my patient-facing work has made me very good at speaking clearly while wearing a mask. I had to sit for a full 15 minutes, which was annoying since I was the first patient of the day and had arrived at the time they specified. There was no explanation of the delay, and I was somewhat tortured by the overly-loud TV blaring a local morning show.

When I finally made it back to the MRI suite, I noted that they had turned the two curtained changing areas into a single larger one, presumably for distancing. They had rearranged a credenza and chair in the changing area, but unfortunately had not rearranged the herd of dust bunnies and leftover hair on the floor, which kind of grossed me out. I know that hospitals are running on razor-thin margins, but skimping on housekeeping services isn’t the answer.

As I finished changing, they brought in a second patient. That person was using the changing area while I was in the adjacent IV chair, so they got to listen to all kinds of personal questions that I was asked. Starting my IV was challenging, resulting in multiple attempts in which the second patient was the audience for the latter two.

I’ve had this study done numerous times and have never had someone right behind me like that. As a patient, it was unnerving. I don’t expect total privacy, but I do expect that they pace appropriately so that staff doesn’t feel rushed while they’re trying to complete satisfactory IV access.

I was greeted in the MRI room by the team member who was going to do my actual study. Turns out I recently cared for her daughter at the urgent care, so we had a bonding moment. Since this particular MRI study is face-down, they don’t make patients wear masks. We had a laugh when I handed my mask to her at the last minute — the MRI magnet was attracting the metal nose piece, and I felt for a brief second like I was in some weightless space movie as it floated upwards.

The rest of the procedure was uneventful, and I slept through it as planned. Any day the IV works right and you don’t get an arm full of contrast material is a good one. I headed home to await my results.

I usually get a call from the nurse coordinator who manages my program, but this time I got a call from the physician because they’re changing my follow-up protocol. She explained the situation and the next steps and promised to send the information through MyChart. The results arrived more than 24 hours later with this header:  

Result Letter: Not Sent
Error: The exam failed to generate a default result letter. Please review the exam information and select the correct result letter or contact your helpdesk for assistance.

Just what every patient wants to read, right? I don’t know if the issue was on the part of the radiologist or the physician who called me, but either way it’s a poor user experience and one that patients should not have to deal with. Fortunately, I’m a physician informaticist who understands what this means, but for other patients, it might have generated anxiety and phone calls.

I wonder if the institution explains to physicians how to prevent this, or what things need to look like on their side to make sure the patient gets the right letter. I have the notes I took during my phone call, but that’s it as far as commentary on the results. I also wonder what kind of user acceptance testing is done from the patient perspective, if any. I know of too many hospitals and health systems that never test the patient-side views.

I would be interested to hear how other organizations manage testing for scenarios like this, and whether they’re doing any post-visit quality checks to ensure it’s not a common occurrence. Have you seen this at your institution? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/28/21

In response to my recent piece about hospital price transparency, Jenn clued me in about Turquoise Health and their pricing website. It’s still in beta and doesn’t have data for my area yet, but comparisons for a neighboring state were pretty easy to understand. It looks like they’re still building their insurance rate database, but their cash-pay display was clear.

A reader also sent some thoughts about the whole transparency situation. He notes that based on some vendor-side experiences, a large number of hospitals seem to be deliberately dragging their feet and don’t want to be the first in their market to show what’s behind the curtain. Either that, or they’re not able to meet all the requirements since many of them assumed that the rule would be killed or further delayed. He notes, “Many will presumably quietly delay until HHS starts embarrassing some folks with bad PR and the compliance / penalty process.”

He goes further to note that the online tool I mentioned in my piece isn’t compliant, since “the Rule requires that a consumer be able to access the pricing info for all contracted payers WITHOUT providing any identifying information or agreeing to anything.” He agrees that third-party aggregators (presumably like Turquoise Health above) will take the machine-readable files and create the equivalent of “Travelocity for Hospital Prices.” I think that’s going to be the best approach that will benefit consumers from an experience perspective, but agree with him that the behind-the-scenes benefit will be when plans and networks and benefits brokers can see the information and use it to drive pricing negotiations.

My reader predicts that price transparency will ultimately lead to hospital closures, as hospitals will no longer be able to “cross-subsidize underfunded services with high commercial rates.” I always love hearing from readers and understanding what’s going on in different parts of the country and this was a great discussion. Rather than watching hospitals close, I’m hoping that health systems will take this as a wakeup call and begin to help lobby for better public health infrastructure and more public funding for early prevention, screening, and treatments so that we can push back against the chronic diseases that are driving healthcare expenditures.

Unfortunately, that approach will erode the profits of hospitals and payers, and some people feel it smacks of “socialism” and we’ll see politics and economics forcing public health into the back seat again and again despite the fact that strong public health measures make good economic sense long-term. The resignations of public health officials across the country due to their COVID-fighting stances has been disheartening. I hope we’ve seen as much of that as we’re going to see for a while. I’ve enjoyed seeing Dr. Anthony Fauci smile again this week, though, so I’ll stay hopeful.

I had another round of healthcare adventures with Big Health System this week. The first was for a physician appointment with their academic faculty dermatology practice. I received my appointment reminder in Epic and completed the online check-in process, which was seamless. I was surprised that they’re not doing any virtual waiting room strategies and that I had to physically come to the office to check in and sit in the waiting room, which is very different than what my practice does. At least the wait was brief and I was impressed by the documentation of the cleaning protocol that was posted on the exam room door. Since this was a dermatology practice, they also had signage explaining how they do a full skin exam in the time of COVID and to keep my mask on — the physician would tell me when to take my mask off and reminded me not to talk when my mask was off.

The second encounter was an unsatisfactory pre-registration phone call prior to an upcoming MRI. Apparently, my data in the system journeyed through a portal to another time and reverted to values from 2018. I just had another radiology study at the same facility less than five months ago, when I updated everything on a lovely paper form that I assume would have been uploaded. Somehow today they had my employer from 2018 listed and the wrong emergency contact. Having been in the CMIO trenches there, I asked what system the registration agent was working from, since they still use another system for some financials and Epic for clinical. She said she was working in both systems, but the data in question was not in Epic. Apparently, they  don’t have a bidirectional interface, or no one updated the information provided back in August, or both, so I got to do it all over again over the phone with someone who wasn’t that interested in my responses and wasn’t really paying attention.

She also went through the same COVID screening questions I had just answered an hour earlier, and I asked her to verify that I was flagged in Epic as an emergency doc since this was an issue during some previous visits. She actually admitted that she really didn’t look at the screen because she’s just so used to asking the same questions over and over. When I clarified that yes, I’m regularly exposed to COVID in my work, she replied, “So, you currently have COVID?” and I had to explain again. Here’s hoping she was actually doing what she said she was doing and updating their revenue cycle platform rather than just going through the motions, because I don’t want to have to update everything again at my radiology visit at the crack of dawn on Friday. These were the kinds of issues I enjoyed fixing when I worked there – making the patient experience seamless. I wonder if anyone there even knows it’s messed up, and if they do, whether they really care.

I’m not exactly looking forward to having my molecules magnetically spun, but it is what it is when you’re playing the early cancer detection game. Usually I schedule the test first thing in the morning when I’m tired so I can sleep through it, which the technicians find hilarious since “no one ever sleeps through an MRI due to the noise.” Maybe they just don’t scan enough sleep-deprived urgent care docs to have a good sample size. I figure the first appointment of the day is also good for COVID-prevention purposes.

What’s your strategy for being a patient in the time of COVID? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/25/21

Many of my healthcare IT colleagues are deeply involved in their organizations’ COVID vaccine administration efforts. They’re involved in creating pre-registration and wait list systems, running analytics to determine who should be invited to receive a vaccine next, managing outreach efforts, then scheduling those patients. It’s a massive effort that, like many IT projects, can be subject to external disruptions.

One of our local health systems just went through a massive cancellation of vaccination appointments after they received fewer doses from the state than they anticipated. The sheer volume of appointments that had to be canceled and rescheduled created havoc. As their API-driven chatbot was reaching out to patients to offer them new appointments, it was creating temporary locks on the appointment slots that were being offered, which is standard when you’re doing scheduling outreach. However, the magnified consequence of trying to reschedule thousands of patients at once prevented the call center from being able to reschedule anyone else, including patient-facing healthcare providers who were needing to also reschedule after missing vaccine appointments while awaiting negative COVID tests.

The answer to the latter problem became decidedly low-tech, with the system standing up a temporary walk-in vaccine clinic to accommodate the healthcare providers with its remaining available doses. A Google Doc was used to keep track of the employees who were approved to come to the clinic and what time they planned to come, so that the vaccination team could coordinate with the call center to ensure that the correct number of doses were available real time. Since they weren’t running the public-facing vaccine clinic, they had a surplus of workers who could handle the manual scheduling, but the fact that the situation arose at all shows how much difficulty the US is having with the last mile of vaccine distribution.

With recent stories about vaccine spoilage due to temperature issues, those running the vaccination operations could learn from their IT colleagues. A Veterans Affairs hospital in Boston recently had a freezer failure from multiple contributing causes. First, a pipe burst leading to a water leak in the building, which led to the arrival of a cleaning crew who had to move a freezer to get to some standing water. The power cord for the freezer apparently wasn’t properly secured to the freezer, causing it to disconnect. Then the freezer’s alarm system didn’t function properly, which coupled with the lack of daily monitoring, led to the loss of 1,900 doses of vaccine.

The VA is still investigating why the alarm failed, but proper daily human monitoring could have saved the vaccines since the freezer was unplugged for several days before being discovered. Any small-practice primary care physician who has had to maintain thousands of dollars of vaccine inventory knows that even though you have thermometers with alarms, you still need to have someone check the logs daily and document the ranges. It’s shocking that a larger organization that is responsible for such a precious commodity didn’t have the right processes in place. However, based on some of the IT failures I’ve seen over the last several years, I’m not surprised.

Many healthcare organizations have complex automated backup systems and sophisticated disaster recovery systems that promise a rapid fail-over to sustain clinical operations. However, they may not test them often enough, and some organizations don’t test them at all. We’ve all heard horror stories of clients who went to restore from a backup, only to find that the backup contained no data or was corrupted in some way.

We’ve also encountered the unforeseen. Early in my career, a car that was involved in a police chase crashed into our hospital’s data center, which led to a small fire, which led to discharge of the fire suppression system and a complete shutdown of the building. There was a failure of the network switches that should have rerouted everyone to the disaster recovery site as well, which led to a multi-hour outage since no one could get in there to see if they could switch things manually since the building was now a crime scene. I’m sure “what if the building becomes a crime scene” was never in the minds of those who designed the downtime policies and systems, but you can bet it’s on the checklist for my consulting clients.

Organizations may also be missing physical safeguards that are needed for their systems to be effective, like the VA hospital’s freezer was missing a couple of screws that could have prevented the vaccine loss. I worked with a client not too long ago that thought they were creating nightly backups of their system. They were using removable hard drives as the media. An employee would come in every morning and disconnect the drive, place it in a manila envelope with the date, then pull the oldest backup drive and connect it to the system. They failed to lock the door to the data room consistently, however, resulting in the disappearance of the box full of envelopes and drives.

As I tell these stories, I feel a bit like a Monday-morning quarterback. However, except for the crime scene part, the preventive maneuvers for these situations are already well documented. HIPAA requires a Security Risk Assessment where covered entities must look at physical, administrative, and technical safeguards for protected health information. Participation in federal and state vaccine programs requires signing agreements on vaccine storage and accountability. Although there were technical failures in the situations above, the human error component is strong as well.

This story out of Boston isn’t the only vaccine loss story out there. Much larger losses were recently documented in Maine and Michigan. The COVID vaccine is such a scarce commodity. If I were in charge of an organization that was a vaccinator, you can bet that I would have daily touch points with the leaders involved to ensure accountability and that systems were in place to approach zero waste. Every dose that doesn’t go to someone who wants it is a tragedy in the making.

My parents and elderly relatives are scheduled for vaccines over the next two weeks. I’m crossing my fingers that they don’t get caught in one of these situations. Based on the horrors I see in my clinical role, I’ll be holding my breath to some degree until everyone in my family is fully vaccinated.

How does your organization approach disaster recovery planning? Do you have plans in place if you need to execute a massive rescheduling operation if vaccines are lost or delayed? Leave a comment or email me.

Email Dr. Jayne.