EPtalk by Dr. Jayne 6/24/21

In follow up to this year’s changes to the Evaluation & Management coding requirements, the American Medical Association announces clarifications that will hopefully make the codes easier to implement. The technical corrections updates are supposed to “add clarity and answer lingering questions.” The code updates were originally designed to reduce administrative burden on physicians while making it easier to document, although many organizations still have their providers hunting for bullet points because they haven’t made the required educational efforts to ensure everyone is on board with the changes.

The technical corrections include clarification on what constitutes “major” and “minor” surgeries as well as refinement of the meaning of “discussion” between physicians and other members of the care team, adding texts and instant messaging as methods as long as the process is interactive. It also further defined the meaning of “analyzed.” At this point, the corrections only apply to codes for outpatient or office settings.

For providers who are terrified of coding audits, anything that adds clarity is certainly welcome. My former employer took E&M coding completely out of the hands of providers, locking us out of the coding screens and shifting the work to coders. Although skilled, they were not certified professional coders, so the idea that charges were going out without my review always made me a little uncomfortable and was one of the reasons leading up to my departure.

The VA’s Cerner EHR modernization project is poised to receive an additional $56 million in budgeted funds for the 2022 program year. The additional funds are slated to support implementation at additional medical centers as well as to support infrastructure upgrades. According to a May report by the Office of the Inspector General, the VA’s facilities need electrical work, HVAC upgrades, and additional network cabling. More than two thirds of the VA’s medical centers are over 50 years old, with the average age being 58.

I’m always excited to learn about how technology is impacting public health, so I enjoyed reading a recent JAMA Surgery article about the “Association of Rideshare Use With Alcohol-Associated Motor Vehicle Crash Trauma.” The authors set out to determine whether use of rideshare services decreased impaired driving, resulting in changes to motor vehicle trauma rates. They looked at data from the Houston, TX metropolitan area that included hospital data and court records on convictions for impaired driving, along with rideshare data from Uber and Google. They found that “rideshare volume had a significant negative correlation with the incidence of motor vehicle-associated trauma, and this was most evident in those younger than 30 years; a significant decrease in convictions for impaired driving was associated with the introduction of rideshare services.” That’s fantastic news for those of us who have ever had to staff a trauma bay.

I thought summer was going to be a slow time for me, but I’ve picked up some projects that are going to take a lot more of my time than I thought. Based on some of the slowdowns in 2020, I’m happy to have the work and even happier that organizations feel stable enough to go back and work on projects that were truncated or even canceled by the pandemic. Some of the things I’m working on include vaccination campaigns, chronic disease outreach, and cancer screening campaigns. (As far as colorectal cancer screening is concerned, did you know that 45 is the new 50? If you’re 45 or older, it’s time to consider a colonoscopy or stool testing.) These are the bread-and-butter kinds of initiatives that I wish more organizations would work on. I’m working with a handful of patient engagement solutions across my clients and it has been an interesting exercise to compare their capabilities.

I was glad to enjoy some blue skies recently, though, and would encourage everyone to find time to just let your brain turn off. Or, if you’re not into just sitting around watching crops grow, consider reading a book just for enjoyment or hanging out with friends you haven’t connected with in a while, even if it has to be virtual. Many of us have been working hard over the last year and a half that COVID-19 has been with us and it’s time to recharge our batteries. Although I’m very confident in the performance of vaccines against the virus as we know it now, it feels like it’s only a matter of time before some kind of other proverbial shoe drops. When it does, I want to be rejuvenated and ready for action. I’ll be taking a couple of days to do some rock climbing and other adventures and to continue to reset my brain and to get ready for whatever gets thrown at me next.

HIMSS is approaching and I received my first emails this week, asking if I was interested in scheduling meetings. Both vendors were ones I hadn’t heard of, so maybe the “new normal” HIMSS is an opportunity for smaller companies to share their messages without being buried in the noise. One of the vendors has a lot to learn about email marketing – other than the “schedule a meeting” link, nothing in the email was dynamic. I couldn’t even click on a company logo to go to a website and learn more about what the company does. The scheduling link at least took me to a part of the company’s website where I could tour, but I still don’t fully understand what they do.

In talking with some of my usual HIMSS buddies, one is moving to the Caribbean so will not attend, one is putting their final plans together, and the other is onboard with planning our annual booth crawl. I am still curious what the social scene will look like and whether there will be off-campus events with food and beverage offerings or whether most vendors are doing the Wednesday afternoon exhibit hall happy hour.

Have intel on the HIMSS social scene? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/21/21

I’m a little over a month past my departure from the world of brick-and-mortar patient care. Since then, I’ve been seeing patients in a couple of different telehealth venues, and it’s been a good experience overall.

Putting on my clinical hat, I would say the biggest weaknesses of the systems I use are that they don’t have the same EHR features as you would find in an in-person practice. Sometimes that makes it difficult to understand the patient’s history or their medication list, but given the transactional nature of urgent care telehealth services, it’s not insurmountable. I never thought I would say that I felt “spoiled” by having a certified EHR with all the bells and whistles, but maybe that was the case.

Most of my friends who are in traditional practice settings are still doing some percentage of their visits as telehealth, even as the pandemic eases. This applies to both specialists and subspecialists. Even surgeons are doing plenty of virtual visits, especially in the post-operative, follow up, and second opinion arenas.

Patients like the convenience, but I hear a lot of stories about physicians trying to juggle virtual and in-person appointments in the same day. There are plenty of initiatives across the US to make telehealth a permanent fixture in our healthcare system and the majority of people I’ve spoken with think this is a good idea.

The few naysayers that I’ve heard from are concerned that telehealth is becoming a way for physicians to increase their bottom line, performing telehealth visits where they previously might have a phone call with a patient. This leads to a concern that telehealth will drive up overall healthcare expenditures. Kaiser Health News cites data from PitchBook that the yearly global telehealth market could top $300 billion by 2026, nearly five times the levels seen in 2019.

I don’t doubt that there are bad actors in some organizations that claim to be offering telehealth. Certainly I’ve heard the stories about the two-minute visits and the services that essentially sound like pill mills. On the other hand, I’ve heard the stories of patients spared hundreds of miles of travel in order to get second opinions along with those who are now able to see subspecialists of a caliber not available in their home communities.

I’m trying to arrange a telehealth consultation for a family member who requires genetic testing. Their insurance carrier will only pay for the testing if it is ordered by a genetic counselor, who typically doesn’t perform a physical exam and so there’s not a lot of need for an in-person visit. The patient has had multiple physicians recommend the testing and understands the ramifications of testing, so requiring the additional visit feels like a barrier to care, especially since the patient is an hourly worker in an essential field.

There’s no question that telehealth needs to fit into the overall plan of care for patients, and that it shouldn’t be another source of fragmentation. I’m not sure how well the direct-to-consumer telehealth companies do with sending records back to the patient’s primary physician or other members of the care team. From what I hear, interoperability is pretty low unless the patient belongs to a health system who has partnered with the telehealth company.

In my past life as an urgent care physician, I frequently saw patients who had been referred for in-person care by a telehealth physician who felt that the patient’s condition wasn’t appropriate for telehealth or for specific testing, such as a rapid strep test or a COVID-19 test. Out of curiosity, I always asked which platform the patient had used, and very few of them actually knew the name of the service. Usually they arrived at it from an employer website, so I’m not sure the telehealth platforms are creating much loyalty beyond that with the employer representatives who handle the contracting.

I also saw plenty of patients who had been treated via telehealth in a manner that was inconsistent with the current standard of care. Often these patients came to urgent care because they weren’t getting better or because they had spoken with a friend or family member who said the course of treatment didn’t sound right. Those visits frequently require some degree of finesse because you don’t know exactly what happened in the previous visit or how the patient’s symptoms might have changed between that time and your visit.

Other times, however, you know the care provided didn’t pass the sniff test, especially when patients were given antibiotics that were not indicated for a given diagnosis or when they pull up their visit summary documents on their phones and the care plan can only be described as off the wall. We certainly see those issues play out from in-person care encounters as well, so it’s not necessarily a telehealth problem.

Being in the telehealth trenches allows me to do my work from anywhere, which I tried out for the first time recently. It was a little strange to pack my required white coat in my suitcase along with my sunscreen and flip flops, and I have to admit I was worried about whether I could get the right camera angles to make it look like I wasn’t in a hotel, but everything worked out. I still think that wearing a white coat to show that you are a physician (versus wearing it because it has nice pockets to hold all the things you need) is a little strange, but it’s required on my platform as a sign of professionalism. Personally, I wish the white coat would become extinct for infection control purposes, but it will probably stick around for the remainder of my career.

I see a need for large organizations, especially integrated delivery networks, to spend some time thinking through their telehealth strategies and make sure they make sense for growth and care delivery since many of them reached their current states out of desperation and necessity. There are still plenty of people out there using freestanding telehealth platforms that force physicians to do a lot of data entry and double work, and for their sake, I hope they can transition to integrated systems. The next two to five years will be interesting as far as seeing where telehealth takes us and what value it can deliver.

Ever talked to your doctor while she’s sitting on the beach? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/17/21

Today’s big news is the Supreme Court’s dismissal of a major challenge to the Affordable Care Act. This is the third time that the healthcare law has been upheld. This challenge was based on the concept that since the individual penalty portion was eliminated in 2017, the entire law should be struck down. The court voted 7-2 to block the suit, stating that the plaintiffs did not have appropriate standing to bring the case. I don’t think that we’re done with challenges to the Affordable Care Act, but I know that patients who count on its provisions are breathing a sigh of relief.

I ran across a great op-ed piece recently that focuses on how “humans are getting in the way of digital health.” It cites the piecemeal application of technologies as a major barrier to transformation as compared to other industries like banking or logistics, where everyone involved jumped on the bandwagon. Other challenges include a lack of technology education and training for the people who need to use digital health along with teaching stakeholders to assess the value of new technologies so that they can add the right systems at the right time. The author calls for meaningful provider education through structured training, including peer-to-peer training, formal education, and inclusion of evidence-based guidelines. These seem like they would be basic tenets for successful clinical / digital transformation, but there are a lot of organizations missing the boat.

I went to visit a new PCP this week. We used to work together and he knows my informatics background, so he was happy to give me a tour of my Epic chart after I asked if he could see the results of my recent genetic testing. It turns out they are buried as scanned documents. He noted that the governance and quality control on the scanning can be a bit lacking at times. Having done numerous quality improvement projects and revisions to organizations’ document management systems, I know what a pain it can be when documents are filed or tagged in the wrong place. Hopefully, the majority of their results are coming in electronically at this point, but I’m sure there’s plenty of scanning going on with referral letters, consultation letters, hospital discharges, and more.

He happily reviewed the blood pressures I had logged in the Withings Health Mate app on my phone. We both agreed with liked the display because it shows averages in numerical form that can be filtered by month as well as a graphically-based view that gives a red / yellow / green view of the ranges for a patient’s values. That’s the kind of data we need to be incorporating for remote patient monitoring rather than burdening physicians with thousands of data points that need to be sifted through. He agreed with me that my crazily high blood pressure a couple of months ago was likely due to a combination of work stress and too much ibuprofen. I enjoyed watching my lab results arrive throughout the afternoon and all was well, so I’m good for another year.

Business Insider reports that Google is shrinking its health team, reassigning 130 workers from its health division into other areas of the company such as Search and Fitbit. The company restated its commitment that Google Health “will continue to build products for clinicians, conduct research to improve care and make people healthier, and to help ensure all health-related projects at Google meet the highest standards.” The count of those employees has now dropped to 570 from a March headcount of 700.

The publication also reports that Walmart Health has filed documents to expand its virtual care solution to 16 additional states, doubling its count. I don’t know anyone who has used the company’s telehealth offering, but would be interested to share (anonymously, of course) any reader experiences. The company’s brick-and-mortar offices are limited to a handful of states, so we’ll have to see how long it takes them to cover the entire US for telehealth.

Meanwhile, CNBC reports that Amazon Care has signed multiple corporate clients who plan to make use of its telehealth services. They’re holding announcement of those names until later in the summer, but I’m extremely curious – if anyone has rumors they would like to report anonymously, we would be happy to entertain them. The program was launched in 2019 as an internal employee benefit and includes virtual urgent care visits, free telehealth consults, and fee-based in-home visits for testing and vaccinations.

Having been part of the healthcare IT industry for a while now, I’ve been exposed to various company cultures. Some have included some hard-partying aspects and a fair amount of alcohol consumption. One vendor I worked with had an open beer tap in the office on Fridays, while another frequently referred to its staff as “a drinking company with a software problem.” That seems to have become a bit more tame in recent years, but I came across an article mentioning concerns that increased alcohol use could be a secondary consequence of the pandemic. Especially with work from home, juggling household responsibilities, economic worries, and the stress of the pandemic itself, alcohol use is on the rise. Given pandemic precautions, it will be interesting to see what the level of alcohol consumption looks like at HIMSS. Hopefully as things return to normal, consumption will stabilize. Still, let’s look out for each other, and if you see one of your colleagues struggling, offer your support.

Fast Company skewered Epic recently over the rollout of the Deterioration Index clinical prediction tool, which is designed to help physicians determine when patients can be moved into or out of higher levels of care. The authors note that the Index was deployed without independent validation or peer review and that physicians cannot see how the raw data is used to calculate the score. There are concerns about the potential for bias in the model based on the underlying data sets upon which it was created. Other worries involve the risks of medical trainees relying too heavily on the index rather than developing their own clinical intuition. The authors call on Epic to release the underlying logic for peer review along with the anonymized data sets used during the internal validation process.

I’d be interested to hear from clinical informaticists whose institutions use the tool. How do you think it’s working, and have you identified any issues? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/14/21

Today’s post is an interview with Laura Miller, founder and CEO of TempDev of Miami, FL.

Tell me about yourself and the company.

I started TempDev back in 2000. We are primarily a NextGen Healthcare consulting firm, working in practice management and EHR. We tend to be technology driven. I have my degree in computer engineering, we have quite a few engineers on staff, and we have quite a few female engineers. We have development solutions and we also focus on implementation and training as well as project management.

You started as a NextGen application specialist at a physician organization. What gave you the confidence to go out on your own?

I had a good mentor, and a lot of women have that story. I had somebody who encouraged me to do this and also helped me establish myself and my career, who taught me a little bit about consulting. It was a time where I don’t think there were that many people with engineering backgrounds doing development for NextGen clients, and so I think the market was primed for it. As I started exploring, I realized that there was a lot of business opportunity.

I was lucky that on a personal level, I didn’t have a ton of financial obligations. My husband works at Microsoft and we had full benefits. It wasn’t the riskiest of moves, but when I try to tell people that, everyone says, “It still was.” I ended up leaving my full-time job and starting TempDev, and here we are 14 years later.

As an entrepreneur responsible for the livelihoods of others, what kind of thoughts were running through your head as the world began to shut down due to COVID-19?

That was the scariest time I’ve ever had in my career. We have always grown as a company. We had never had to have those difficult thoughts and conversations. We have been incredibly fortunate in our trajectory to never had that enter the picture for us at that level.

As COVID started to happen, at first it was a slam of work. Everybody was implementing telehealth and they didn’t know how to see patients or how to bill it. All these organizations we were working with didn’t even know how they were going to keep their lights on, much less that they were going to spend their money on consultants to try to deliver telehealth, and then let us go.

We were fortunate that there were a couple of companies that kept a lot of our consultants working. It was the first time we had ever had a bench in our entire 14 years. We took the time to say, let’s invest in us. It was the first time we had taken a step back and said, let’s build some things for TempDev. We have some people who aren’t busy. Let’s build some products so that when things come back, and they will come back, we will be ready for them. 

We did. We invested heavily in a couple of products. We invested in COVID testing templates, COVID vaccine templates, and credit balance tools. As things started to come back, it took off and we are busier than ever now.

For the COVID-19 vaccine templates, have you seen a lot of ambulatory practices that have had access to the vaccine or being able to distribute it to their patients?

I’ve actually been pleasantly surprised at who I’ve seen get access to vaccines. It has not been my private practices, the big groups that typically are engaged with consultants. It has been our smaller community health groups and tribal groups. It has been the groups that, as you talk equitable vaccines and you have those conversations, it’s who you want to have these vaccines. It’s who you want to be out there giving them to the community. That was who had the vaccine and who we were talking to in December about vaccinations. A lot of our private clinics didn’t get them until more recently.

Are ambulatory medical practices  starting to rebound?

Most of our clients have rebounded. The investment in FQHC, we’ve definitely been seeing a pickup in that market. They are starting to feel some of the investment that came earlier this year in them and are starting to be able to make improvements they have been wanting to make for a long time. I would say that for most of our groups, their volume is back.

As they are getting back up to speed, what kind of trends are you seeing as they reprioritize their technology goals?

Telehealth is here to stay. Everybody is asking, in what capacity? How are we going to get reimbursed? What does that look like in the future?

As both a patient and a consultant, I love telehealth. I think it’s so wonderful, especially since many of us waste so much time getting to a doctor and sitting in waiting rooms for a five-minute appointment, a checkup, or a talk about a result. It’s so great to be able to have a quick conversation. That needed to happen and a physician can get reimbursed for it, so I think telehealth is here to stay.

TempDev has always been a remote company, so as the pandemic started to unfold, we were well positioned because everybody already worked from home. But for most of our clients, a lot of people aren’t going back to work. Some of the smaller groups tend to be where we see the IT people going back. But a lot of the groups we work with, they’re scaling down on their real estate. If they are talking about maybe getting people back, it is certainly in a much more limited capacity, because I think people got accustomed to working from home and they think it works for a lot of people.

Patients having direct access to their visit notes is a hot topic. Have you seen an increase in requests for help meeting those requirements?

People are still confused by information blocking, especially with the fact that that rule happened during the pandemic. It caught a lot of people off guard. I don’t think they entirely know what it means. I know there were countless webinars. I know people were telling them about it. But I don’t think everybody has grasped what is going to happen there because we don’t get a ton of questions about it other than “Hey, how do I meet this requirement?” which we will walk through with them. We don’t get a lot of questions around, what’s the downstream impact, what if my patient reads this, and should I put this in a note? These are things that you have to think about now that you’ve opened the gate to all of that information. I don’t think people have gotten there yet.

As the only woman in your computer engineering degree classes, what advice do you have for women who are pursuing the STEM fields?

Stay in it.So often we get intimidated, or we often feel like it’s not our place and we don’t belong. I personally never felt like I fit into that culture. It’s not who I am. I love technology, but I do not like a geek culture. I don’t have anything against it. That doesn’t mean that I wasn’t good at math and science or that I couldn’t code, but I didn’t always fit in, and that was OK. I think I brought diversity to something that maybe wasn’t diverse.

Also, a lot of us women just are not showboats. It’s not who we are naturally. That doesn’t mean that we don’t know the information. You also don’t have to have a 4.0 GPA to do well in businesses and to do well in engineering. You can get a B in a class or you can struggle through some engineering classes and that doesn’t mean you’re not cut out for it, it just means that sometimes you might have to work a little harder.

So many cultural things are set up to make us believe that it’s not a place where we belong. I so often just want to tell girls, hey, you belong here. That’s one of the reasons we tend to have a lot of women here, especially for being a tech company. People ask, how did you get all these female engineers and how is your tech team led by all women? It’s because it’s a place where women want to be, because culturally, we fit in here. We didn’t define the culture that a lot of other tech companies have out there. That made something special and something different where people wanted to be and where people wanted to stay, because it is tough.

It’s not the easiest field to be in. In college, they used to tell us things like, you’re going to be up until 3 a.m. in a lab before you’re going to launch a product, and that’s the way life is. I thought, I want a family. I don’t want to be in a lab at 3 a.m. before a product launch, I want to be home in my bed sleeping, and I want to have a life, and I want to have balance. I’m here to tell you that it’s totally fine, and you can have that. It’s not how life has to be. That isn’t necessarily what is presented to you early on in college and in your early career.

You have your children on your team. What advice do you have for young entrepreneurs who are building a company to make sure they have time for family?

You have a limited time with your children because they go off to college. You get 18 years with them, hopefully. Or they’re at home and you don’t want to waste it. I have made it a rule to pretty much to stop work from 5:00 to 8:00 each evening. I have my phone on me, so if something blows up, I will get on it, but things can wait. You can’t work your entire life. Your children are good at making you understand what your priorities are and keeping them in check. From 5:00 to 8:00 every day is my kids’ time. Then I put them to bed and I will probably go back on my email and I will probably finish up my workday. But I make sure I always have time for them. I make sure they know that they are number one and everything else is number two.

That doesn’t mean I won’t go out of town or that I don’t sometimes treat work with a high priority that needs to be, but it can never be above my kids. That’s who I am and that drives me. I’ve never run into a problem with it. So many times we as women are set up to believe that there’s something wrong with that and there isn’t. Going back to work from home culture, I can run out and get my kid who is sick from school and bring them home. They can lay in their bed and be sick from school and nobody at work is judging me. They don’t even know I’m gone, and they don’t even know my kid’s home sick. That’s something so nice about being able to be a mom and being able to balance your work.

Do you have any final thoughts?

If you’re not working in a place that makes you happy, build a place that makes you happy. Try to do the right thing at that place and make whatever decisions are needed to build a place where people want to be, where women or employees feel valued and feel like they can put their families first, feel like they can take care of clients and still have time, and still have work-life balance. Build that as a company because you can’t run down your employees. Your employees are your number one asset. If you ever ask me the hardest part of my job, it’s recruiting and finding employees to fill the positions we have. Losing an employee is even harder for us. Make sure to respect that and build a place where employees want to be, and always have that as your guiding light.Make sure it’s a place where all employees want to be and not just a certain subset.

EPtalk by Dr. Jayne 6/10/21

I recently completed a short-term consulting engagement where I was asked to evaluate a health system’s physician training strategy and to make recommendations to make it more effective. Like many organizations, they’re struggling with physician burnout and many fingers are being pointed at the EHR. The IT department is convinced that the technology can’t possibly be at fault, so it must be how the physicians are using it, and therefore the training team’s fault. Since the IT team has a stronger political voice in the organization, training went under the microscope and a friendly CMIO was dispatched to the scene (virtually, of course).

I’m no stranger to these scenarios and was happy to take the engagement. I’ve seen enough failed EHR implementations to know that the success and happiness of physicians is directly proportional to not only the level of configuration of the EHR to meet local needs, but also to the amount of training required by the organization. For a complex system that will be ever-present within patient care, expecting physicians to know how to use it well after a couple of hours is not realistic. There’s often a belief that physicians won’t tolerate a greater amount of training, but I’ve found that they will be glad to attend if the training is high value and helps them use the EHR effectively. What they won’t tolerate is poorly delivered training with inappropriate clinical scenarios and lack of recognition of how they do their work.

Often training teams lack sufficient budget to be able to deliver the type of training needed, so I always arrive armed with journal articles and case studies. One of my favorites is from Applied Clinical Informatics. The title says it all: “Local Investment in Training Drives Electronic Health Record User Satisfaction.” It’s from the pre-pandemic era, published late in 2019, and I suspect that it might not have been widely read because by the time it was getting into circulation, most of us were laser-focused on COVID-19. The authors surveyed over 72,000 clinicians across more than 150 organizations to identify opportunities to have better return on EHR investments. One overarching theme is that there are “critical gaps in users’ understanding of how to optimize their EHR” and a proposed solution is to invest “in EHR learning and personalization support for caregivers.” I can’t tell you how many practices I’ve visited where the physicians don’t have any medication favorites built, don’t have defaults set properly, and have their drug/drug and drug/allergy checking settings at annoyingly high levels. Just fixing those few things typically reduces provider frustration immensely.

In evaluating my client, it turns out that the training team, IT, and operations all share the fault around poor usability and poor adoption. The users haven’t been able to take advantage of individual configuration and personalization settings because IT told operations it would make the system difficult to support. Training can’t deliver content around what’s not available, and unless physicians had used the same EHR in another venue, they wouldn’t be aware of what they were missing.

For the training content that the organization was attempting to deliver, they were lacking in resources, not only in headcount to deliver the training, but in having someone with expertise in adult learning who could design appropriate resources. They had decided that all training would be classroom style and group oriented, often with mixed subspecialties which added to attendee confusion as people asked questions that were not relevant to other attendees.

When the pandemic hit, they just migrated everything to Zoom and hoped for the best. Indeed, what wasn’t working before still wasn’t working, and for those not accustomed to online meetings, the training strategy truly failed to deliver. I had to do some significant education around learning styles, the risks of multitasking, and the need to assess mastery rather than simply presenting content. Fortunately, my client was receptive to the suggestions and is hoping to use some adult learning experts from an affiliated university to help fill the gaps. They’re also going to send members of the core application team back to training so they can fully understand the EHR’s personalization and customization features, since the people who made the decisions not to use them are long gone.

They’re also surveying the physician user base to find out how they want to learn and what works best for their needs. Some are going to still want/need classroom training, but in the post-pandemic era, they might value the convenience of a remote approach. I’ll check back with them once they have their survey results and the application team finishes training, and hope to be able to help them finalize a plan for rolling out additional personalization features to their user base. I see some additional satisfied users in their future.

I had some things to celebrate this week, and after reading a recent article about the Promoting Interoperability program, I decided that not having to worry about whether I was going to attest or take a penalty should be added to the list. A recent study showed I’m not alone at saying no. The study looked at Florida Medicare providers who participated in the Meaningful Use (and successor) programs between 2011 and 2018. Only 43% of those receiving a first-year incentive payment went on to achieve payments in subsequent years. This translates to a cessation in funding that was intended to help support EHR adoption and practice transformation. I certainly don’t fault physicians for failing to continue participation – the reporting requirements were painful and for smaller practices the additional work was daunting.

However, since Medicaid providers tend to serve the state’s most vulnerable patients, it may mean that those practices that didn’t continue participating haven’t fully embraced the tools in their EHRs that could help them close care gaps for those populations. On the other hand, it could just mean that they were sick of the reporting requirements and decided to use their scarce resources to work on initiatives that provided direct patient benefits. I’m interested in hearing from practices that stopped participating, and whether they were able to continue to advance EHR adoption and use of additional technologies such as patient portals and outreach tools without receiving additional funding.

Are you part of the Meaningful User Drop Out club? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/7/21

Last month, the National Academies of Sciences, Engineering, and Medicine released their report on high-quality primary care for US residents. The National Academies are private, non-profit organizations formed with the goals of informing US public policy and providing independent analysis and advice. After spending a couple of decades in academic medical centers and integrated healthcare delivery networks, I have a greater degree of trust for independent analysis compared to some of the output I’ve seen from “not-for-profit” organizations that have billions of dollars in the bank.

The report is titled “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care.” The Academies’ press release is quick to note that “no federal agency currently has oversight of primary care, and no dedicated research funding is available. The report recommends the US Department of Health and Human Services (HHS) establish a Secretary’s Council on Primary Care and make it the accountable entity for primary care, as well as an Office of Primary Care Research at the National Institutions of Health (NIH).”

The report outlines a plan where patients should be able to have consistent primary care and that they should declare their primary care provider annually so that payers can ensure accountability and quality measures. This sounds similar to what I experienced on a rotation in the United Kingdom many years ago, where patients were expected to “register” with their general practitioner so that they would have a source of care if they needed it. This is very different than some of the consumer-oriented models of care that are booming in the US, where healthcare has become purely transactional, and many patients value convenience above all else. The decline in primary care availability over the last several decades has fueled growth in urgent care and retail clinics, and patients no longer see continuity or having a relationship with a primary care provider as something important.

In my experience, that erosion of respect and responsibility has contributed to a decrease in the number of students who want to go into primary care fields. Compensation is another big factor, and the report recognizes that as well, calling on more equitable compensation for primary physicians as compared to subspecialty care. There’s still a perception in the US that the best and brightest medical students go to the high-dollar subspecialties. As I sat doing my quarterly board certification questions tonight (which were quite difficult), it made me reflect on how much better it would be if the best and brightest were drawn to primary care, where they could solve diagnostic dilemmas firsthand rather than having to refer those cases out or potentially order tens of thousands of dollars in diagnostic testing.

The report notes that primary care practices were initially left out of COVID-19 relief packages and that they have not been fully utilized in support of testing, contact tracing, and vaccination efforts. It suggests that pandemic-related changes should become permanent, including coverage for telehealth services and reductions in documentation requirements.

I was intrigued by some of the suggestions made by the committee. One was that CMS should increase physician payments for primary care services by 50%. For practices struggling with a razor-thin margin, that would be a good start. Even better would be if non-CMS payers followed suit or increased their rates even higher than 50%. Another recommendation would be that CMS identify overpriced healthcare services and reduce the rates on those services to make them less attractive. I’m sure professional groups and vendors will oppose that, though, depending on whose cash cow might be in line for the sacrifice.

One of the major things that goes unsaid in the report is the massive culture change needed in US healthcare. We need to shift from a culture that venerates technology for the sake of technology to one that venerates knowledge and wisdom, with the appropriate and judicious use of technology as appropriate. Patients have grown to equate high-tech care with high-quality care, even when studies show that the technology is not helpful. I’ve seen dozens of patients come to urgent care hoping we will order advanced imaging studies, such as MRI scans, where they’re clearly not indicated, because patients feel like having an MRI will give them an easy answer. Why do four to six weeks of physical therapy and conservative management to see if your problem gets better when you can just have an MRI?

The needed culture change also applies to pharmaceuticals. We have to make some of the best initial treatments, like diet and exercise, more attractive than just popping a probably-expensive pill. This is a place where technology might really give us a boost, if we can use gamification and people’s inherent competitive natures to spur them to action. Technology can help give positive reinforcement and provide interventions and coaching that patients may not have had access to without it. Attitudes towards non-pharmaceutical interventions aren’t going to change overnight, though.

The committee also calls on leadership to use digital technology to make primary care more efficient, higher quality, and more convenient. It calls on the Office of the National Coordinator for Health Information Technology to address clinician user experience part of the next set of certification requirements.

A big piece of efficient data management though isn’t going to be the user interface of individual systems – it’s going to be addressing once and for all the absurd level of information blocking that goes on between health systems in the same city. As an independent urgent care physician, I could not get a single one of the four health systems in town to grant me access to their systems for “refer and follow” data access, regardless of how many patients I sent them or how many of their patients I cared for when their own physicians were unable to see them. I wish I had a fraction of the dollars I wasted ordering duplicate tests because I didn’t have full access to my patients’ health records.

I don’t think that anyone disputes the idea that a strong primary care infrastructure would not only improve people’s health and save lives, but would save our country a tremendous amount of money. Other nations (whether wealthy industrialized ones or middle-tier countries) have seen this value and have constructed their healthcare systems accordingly, while we have constructed ours around special interests, shareholders, and profit. According to the Organization for Economic Cooperation and Development, 5% of US health spending goes to primary care compared to 14% in other wealthy nations.

Although I started my career in the primary care trenches, I struggle to encourage medical students to follow that path unless they have a full understanding of the current state of things. I enjoy focusing my informatics work on trying to strengthen technologies that support primary care, but it’s going to take a lot more than bells and whistles to truly make it an attractive career again. As the pandemic eases, we’ll have to see what governmental entities have to say about the recommendations in the report, and how many decades it might take to make them a reality.

What do you think about the need to rejuvenate primary care? Will culture continue to dominate regardless of how much technology we try to throw at it? Or will we just watch history repeat itself? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/3/21

I had a virtual happy hour this week with some friends who also practice telehealth. We were swapping war stories about trying to help patients navigate their technology so that we could have more productive telehealth visits. One of them mentioned a story that they had seen recently about California-based Welbe Health and its goal to integrate telehealth into their PACE programs.

For those of you who might not be familiar with the CMS Program for All-inclusive Care for the Elderly (PACE), it’s been around for approximately 30 years. It is designed to serve older patients who are covered by both Medicare and Medicaid. The goal is to keep the population healthy and provide additional supports beyond traditional medical care, including meals, socialization, and day programs.

Welbe Health has partnered with a company called GrandPad to provide “senior-friendly” tablets to allow program participants to easily access their care team along with additional health and wellness resources. Since PACE programs typically include a multidisciplinary team of physicians, social workers, dieticians, and home health staff, it makes sense to be able to bring all of those players into the patient’s home virtually when the patient can’t travel or otherwise needs to remain distant.

GrandPad published a case study on Welbe Health. It looks like they did a rapid rollout to more than 250 seniors over a few days, with the average age of users being 85. I’ll definitely be keeping an eye out for more data and information on the project since it’s not one that many organizations seem to be tackling. If the devices are truly as intuitive as they sound, I’m sure all the grandchildren who may be used to performing tech support for their elders will be breathing a sigh of relief.

Speaking of telehealth, Teladoc health has announced its annual Forum, to be held July 20-21 as a virtual event. They held a similar event last year that had some great speakers and offered some solid telehealth perspectives, so I’ve added it to my calendar. There are also regional receptions being offered for both face-to-face and virtual interaction, so it will be interesting to see how those play out.

I hope the Mayo Clinic System offers telehealth services to support the patients at the six clinics that it is closing across Iowa, Minnesota, and Wisconsin. The clinics are said to have had low patient volume even prior to the pandemic. Patients are being referred to nearby communities for care. It’s never easy to have to change doctors, and I hope the transition is as seamless as the Mayo Clinic Health System website makes it sound. Physicians continue to retire at a rapid pace in my community and others who aren’t quite to retirement age are starting to reduce their practice commitments. The next few years will be challenging to those who are looking for primary care physicians.

As someone who has spent many years dealing with patient matching, I’m always eager to read about initiatives dedicated to solving the problem. The Patient ID Now coalition recently released a document titled “Framework for a National Strategy on Patient Identity.” The coalition, which has 40 healthcare organization members, calls for a public / private partnership including the federal government, public health authorities, and the private sector. Many of us have experienced the perils of poor matching for decades and are gratified that the COVID-19 pandemic has shined a light on some of the challenges. We’ve seen problems with making sure that test results are affirmatively matched with the correct patient regardless of the site of testing or the setting of downstream care, and also issues with trying to have accurate vaccine data when patients may have received doses from a National Guard-run drive through clinic and also a retail pharmacy.

The Patient ID Now workgroup formed in January 2021 and includes representatives from HIMSS, the American College of Surgeons (ACS), the American Health Information Management Association (AHIMA), CHIME, Intermountain Healthcare, Premier Healthcare Alliance, the American College of Cardiology (ACC), academic institutions, hospitals, and more. Only time will tell whether the group can help kick the patient ID issue forward after years of congressional roadblocks and pressure from highly vocal opponents.

As many organizations are moving to make distributed workforce arrangements permanent, Epic has fired up its homing beacon to bring workers back to campus. Starting July 19, workers are expected to be on site at least three days each week. This increases to four days each week August 1, and by September 1, they will need to be onsite nine days out of every two weeks. Employees who are not fully vaccinated will be required to mask and distance. The annual Epic Users Group Meeting is slated for August 23-25, but only for those attendees that are fully vaccinated. I’m curious what solution they’ll choose for validating vaccine status. All of my colleagues who work at Epic-using systems are still under travel restrictions, so it will be interesting to see how many people are actually able to attend.

Uber continues to offer free rides for vaccine appointments. From May 24 through July 4, users can get up to four free rides (up to $25 each) to and from vaccination appointments. Users can select the Vaccine button to schedule a trip. Drivers will be paid in full, but according to the email I received, tips are still appreciated. I wonder how many drivers are thinking carefully about having unvaccinated or partially vaccinated people in their cars, as opposed to just generally not knowing the vaccine status of most of the people they are transporting. As a healthcare provider, whether my clients / patients were vaccinated or not gave me some sense of peace, but I suppose it’s different when you’re up close in a patient’s face examining them versus having them at least a couple of feet away in your back seat.

I was invited to become a beta user for Accelerate, which states it is “the purpose-built digital platform from HIMSS.” I’m not sure whether this is a true beta testing opportunity or if they are just telling everyone who signs up in the first wave that they’re beta testers, but I was intrigued. The invitation notes that “Accelerate is still in development, access to the platform as well as any content posted on Accelerate is shared with you on a confidential basis; we appreciate your discretion.” I feel a bit spy-like, so I won’t even tell you if I signed up or not. If anyone else signed up and wants to anonymously share your impressions, leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/27/21

Last week, Best Buy Health launched a smartphone designed specifically for older adults who want to connect to virtual care services. Named Lively Smart (in contrast to the Lively Flip device they launched last September), the phone allows users to have one-touch access to Lively Health and Safety Services. The urgent care services offered are 24/7 and don’t require an appointment, health insurance, or co-pay. Emergency response services are also available via contacting an agent. Best Buy Health notes that its services are tailored to the “active aging population,” which is one of its key demographics.

I visited the Lively website to try to get more information about the services and how they are doing urgent care without co-pays or insurance. Despite a label to “select each product to learn more about it, including plans and pricing” on the home page, there were no links to pricing. I had to tool through the website to get more information, visiting multiple pages before I found the pricing. The Preferred Plan includes Urgent Response Service, Urgent Care, and Lively Link (which keeps caregivers informed about the health and safety of the person using the Lively products) for $24.99/month.

Centene CEO Michael Neidorff fired a shot across the bow of the Missouri Legislature, questioning whether the company will keep its headquarters there in light of the legislature’s refusal to fund Medicaid expansion even after being approved by Missouri voters. Centene is the state’s largest employer and spends plenty of money on healthcare IT and related consulting services, so a potential move would likely provide a boost to some other part of the country should they leave. Missouri has been all kinds of last in the healthcare technology game, being the last state to launch a statewide immunization registry as well as the last to have legislative approval for a Prescription Drug Monitoring Program (PDMP). The latter isn’t remotely live yet, with St. Louis County’s PDMP serving as a de facto registry for the state.

The University of Pennsylvania Health System (UPHS) announced a requirement for all employees and clinical staff to receive the COVID-19 vaccine no later than September 1. Nearly 70% of staff are fully vaccinated at this point, and those who plan to refuse vaccine must apply for medical or religious exemptions. UPHS joins the mandatory vaccine club founded by Houston Methodist, which requires vaccines by June 1. Also in the clubhouse but not quite a full member is New Jersey’s RWJBarnabas Health, which is requiring vaccination for supervisors and executives by June 30 with an anticipated mandate for all staff to follow.

I was excited to hear that Change Healthcare is entering the digital vaccine record space. The enthusiasm about their vaccination record solution was tempered by the fact that the only information available on the site was in video format and didn’t have a closed caption option, excluding some who might visit. I’m much more likely to learn more about a solution if I can just read about it as opposed to having to watch a video. From what I could gather from the video, it’s still fairly conceptual. The only way to get more information is to reach out to the company, and I definitely don’t have time to go through the usual forms and emails. If anyone at Change Healthcare wants to drop me some information, I’d be happy to read it.

We’ll get a preview of what HIMSS21 might look like as Las Vegas allows most venues to move to 100% capacity effective June 1. First in the lineup at the Las Vegas Convention Center is the International Esthetics, Cosmetics, and Spa Conference, which typically has about 20,000 attendees. The year will wrap up with the return of the National Finals Rodeo, which moved to Texas in 2020 to avoid COVID-19 restrictions. Come January 2022, the Consumer Electronics Show will be back in town. Although the event typically hosts 170,000 people, it is anticipating smaller turnouts as travel restrictions remain in place for many nations.

Speaking of consumer electronics, an AI-enabled “Smart Toilet” is being developed that will photograph stool and transmit it for analysis, specifically looking at consistency and whether blood is present. Investigators hope that the real-time evaluation will allow patients with concerning symptoms to be referred earlier. Research found the smart toilet to be 85% accurate at identifying stool consistency and 76% accurate for detecting gross blood, with findings being presented at the Digestive Disease Week 2021 virtual meeting. The AI algorithm was tested on over 3,000 images gleaned both from study participants and the internet. Gastroenterology specialists also reviewed more than 500 images to evaluate agreement with the AI-driven ratings.

The authors, hailing from the Duke Smart Toilet Lab at Duke University, hope the smart toilet will be more accurate and reliable than asking patients to keep a symptom diary. The Smart Toilet Lab page is worth a read and I tip my hat to their copy writer: “Imagine a world where important health information is leveraged, instead of flushed down the toilet.” The prototype design performs image analysis post-flush with a fingerprint scanner on the flush handle identifying the user. Apparently, the authors are well versed in the many humorous comments they hear and are also being “very systematic” about documenting them in their collection. Monitoring of sewage for public health has been a mainstay for COVID-19 surveillance in many communities, so here’s to better digestive health at the individual level as well.

I started working on the questions for my upcoming “Women in Health IT” interviews. I’ve had several good suggestions for interview candidates, but would appreciate additional nominations focusing women entrepreneurs or those in leadership roles that you’d like to hear from.

If they have sassy shoes and will be wearing them to the upcoming HIMSS conference, that’s a plus. I’m starting to put together my plan for the week even though we don’t know what we don’t know about the conference. I’ll definitely be looking for sassy mask photos as well as sassy shoe photos this time around. Regardless, it will be good to see people in person again.

Monday is Memorial Day in the US, a day designated for honoring the military personnel who have given their lives in service of the US Armed Forces. This picture from my visit to the World War II Memorial still gives me chills six years later. Please take a moment on Monday to remember those who made the ultimate sacrifice.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/24/21

I experienced firsthand the confusion caused by the Centers for Disease Control and Prevention’s abrupt change in masking recommendations. Although it essentially stated that fully vaccinated individuals can go about their activities maskless, it completely failed to understand the dynamics of multi-age gatherings.

I was at a local park in an area where masks are required for groups that are outdoors, and it’s fair to say that the 11-and-under crowd isn’t going to self-select to wear masks when they see their parents and other adults kicking back with a cold drink and being maskless. Kids also aren’t going to stay three feet apart, let alone six, without someone giving them reminders. What I observed was similar to a rugby scrum made of unmasked 8- to 10-year-olds, so we can only hope that none of them were carrying COVID. Being outdoors doesn’t eliminate the risk if people are on top of each other. For the sake of all the healthcare providers who are having post-traumatic stress disorder symptoms, I hope we don’t get ourselves in trouble before vaccines are available for younger age groups.

As a primary care physician at heart, I hope that this push to get back to normal also involves patients being able to schedule appointments for needed healthcare. In my area, some primary care physicians are still limiting their schedules due to COVID-19 concerns. I’m curious how long their employers are going to be on board with it before there are repercussions. I’m sure those providers with RVU-based compensation plans are feeling the impact of limited schedules on their paychecks, but others on guarantees might just be in for a surprise when their next contract period comes around.

Third-party telehealth companies are still seeing plenty of patients asking for medication refills, often saying they can’t get an appointment with their primary physician or can’t get the office staff to contact them back. If access issues are real, you would think that practices would be eager to bring in part-time or contract physicians to help fill the gap and work through the backlog. None of the health systems in my area want to hire part-time physicians, which I find shocking. I’d love to see acute urgent patients one day a week somewhere, even just on an hourly or temporary contract, but everyone I’ve talked to would rather be backlogged than have part-time physicians on the books. It seems penny-wise but pound-foolish, but nothing is surprising any more when it comes to the people managing medical practices.

From the payer viewpoint, however, patients are getting back into the swing of things with preventive care services. Cigna CEO David Cordani said that in the first quarter of 2021, his company saw levels of mammograms, colonoscopies, pap tests, and childhood vaccine visits at levels not seen since the COVID-19 pandemic started. In an analyst call earlier this month, Cordani stated that Cigna has been focused on steering patients toward preventive services especially for services like cancer screenings. Cigna is my health insurance provider and I haven’t seen any outreach regarding services, so I’m curious what kind of programs they have in place.

Despite significant spending on COVID-19, Cigna seems to be holding its own financially. It’s Evernorth division, which includes pharmacy benefits management services, is growing, with total pharmacy prescriptions increasing by nine percent. I wonder what portion of those medications are prescribed to treat anxiety, depression, insomnia, and other conditions related to the stresses of the pandemic, distance learning, and altered family dynamics? Even in my limited time as a telehealth provider, I’m still seeing a fair number of those diagnoses. Patients are much more eager to just take a pill than to want to accept my recommendations for counseling or therapy. Although many think the pandemic is behind us, healthcare providers in the trenches know that there will likely be complications for years to come.

Speaking of telehealth, I was glad to see Arizona move to the front of the class with HB 2454, which supports telehealth policy. It allows for audio-only telehealth visits in some circumstances and also allows providers from other states to treat Arizona residents without having an Arizona-issued medical license. Essentially it makes emergency pandemic-driven measures permanent, identifying Arizona as one of the more progressive states in its treatment of the issue. Everyone talks about access to medical services for rural residents or those who struggle to get to appointments, but the press release from Governor Doug Ducey’s office also made note that the bill “allows snowbirds visiting our state to receive telemedicine from their home state.”

For those hoping to press forward with asynchronous care options, the bill does exclude emails, voice mails, and instant messages from the definition of telehealth. There are also some hitches in the way it manages license portability. Those licensed in other states who want to care for Arizona residents must register with the state board, register with the controlled substances prescription monitoring program, pay a registration fee, and agree not to have a physical office in Arizona. How arduous that process truly is will define how many telehealth providers want to reach their practices into Arizona.

The one thing I was surprised by in the bill was that medical examinations for worker’s compensation matters can be conducted via telehealth if all the parties involved are in agreement. Dealing with worker’s comp cases is one thing I will not miss from my brick-and-mortar practice, and personally I’d be surprised if there’s much uptake on telehealth delivery of those services.

I’m continuing to play the back-and-forth phone call and email game with some of my state regulatory folks, who can’t quite understand the idea that a physician has a “telehealth only” practice and doesn’t have a physical space where she treats patients. I’ve had several people tell me “you can’t do that” and I try to better explain it to them by saying it’s like a house-call only practice, but they still don’t get it. I’m going to try to make additional phone calls this week to get it sorted out, but until then, I’m running slightly afoul of a couple of regulations, but it’s a risk I’m willing to take.

Are you willing to give up your in-person primary care physician in favor of virtual visits? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/20/21

Since I’m no longer providing in-person clinical care, my schedule has a different level of flexibility and I’m trying some new things both personally and professionally. Today I enjoyed attending a medical school’s Grand Rounds presentation from the comfort of my bed, which was much nicer than being in a subterranean auditorium. I’ll be doing some travel and sampling the digital nomad lifestyle a bit as well as trying my hand at Locum Tenens coverage.

For HIStalk, I’ll be adding some interviews with women leaders and entrepreneurs in health IT. I’ve already identified a couple of potential candidates but am looking for suggestions. Drop me a note with your nominee and why they would make an interesting interview. I’ll start running them in June, so stay tuned.

Lots of chatter around the virtual water cooler this week about a Kaiser Health News writeup addressing parking charges for cancer patients receiving care. The article references a research letter in JAMA Oncology last summer that looked at parking fees at National Cancer Institute-designated cancer treatment centers. Although the idea of charging cancer patients to park while they undergo treatment is particularly odious, we should be looking at the broader idea of charging patients to park, period.

I recently had care at a major institution that has billions in its endowment, but can’t afford to allow patients to park for free. Given the preponderance of organizations getting on the facility charge bandwagon as a way to increase their bottom lines, one would think that parking should be part of those facilities. As a healthcare insider, I know that many organizations run on razor thin margins, but I would argue that if you can still afford to build marble foyers with fountains and landscaping, you should take a serious look at whether charging patients to park is the right thing to do.

Kaiser Health news also ran a piece this week looking at patient reaction to having greater access to health data. Patient-side stories include patients who were anxious when seeing laboratory results without the benefit of a clinician’s explanation and those who felt offended or judged after reading physician notes. Another story mentioned a patient receiving biopsy results on the weekend, blindsiding both the patient and the physician with a cancer diagnosis. Organizations including the American Medical Association are encouraging adjustments to the rule, allowing delays for certain tests (such as biopsies) to allow physician annotation prior to release.

For some organizations, this change has not been an issue since they already provided access for more than 50 million patients. Others are creating reference guides for patients to better understand their results. My former employer is in violation, although most of the providers at the practice don’t realize that greater accessibility is now a requirement. It will be interesting to see what enforcement on this looks like.

The last water cooler conversation piece was the recent JAMA Viewpoint editorial that offered suggestions for designing successful capitated payment models for primary care physicians. I agree with the seven design elements proposed by the authors (my favorite healthcare IT crush, Farzad Mostashari, MD included). However, in order for capitated contracts to succeed, we need better support for interoperability around healthcare data in order to facilitate patient care through home health, remote monitoring, and better coordination of specialist care.

Despite what the integrated delivery networks think, there are still a good number of independent physicians out there. As a family physician, I need easy access to all the information my referral specialists hold on my patients, whether we’re part of the same network or not. Despite information blocking regulations, large health systems continue to not play nicely with anyone outside of their network and patients pay the price, not only financially through duplicated services, but medically through poor care coordination.

The Journal of the American Medical Association published a recent article that looked at whether COVID-19 vaccine registration websites were accessible to those with disabilities. The authors looked at 54 official websites in the US and compared them against the Web Content Accessibility Guidelines (WCAG) 2.0 and 2.1 guidelines. They found “suboptimal compliance” with the guidelines among the sites evaluated, with only two meeting the WCAG 2.1 standards. They call for greater availability of text-to-speech functionality to better meet user needs along with better use of color, contrast, spacing, and other presentation features to improve visual understanding.

Navigation challenges were also specifically called out in the analysis, with recommendations for improved titles, headers, labels, and links. They also recommended user testing that involves people with disabilities and ongoing evaluation as websites are updated. None of these findings are surprising to me, as I regularly have to call out technology developers for non-ideal use of color and contrast when they’re creating user-facing screens. Accessible UX design helps everyone, and I would encourage those companies that don’t have experts on staff to consider using consultants who can get the job done.

I had to break down and try to find a primary care doc recently and the whole process was only describable as a disaster. Most of the family physicians in my community aren’t accepting new patients and those that are taking new patients have a greater than six-month wait. I finally broke down and reached out to a colleague directly to see if he’d make an exception to the “no new patients” policy, which fortunately he did.

I had to play some phone tag with the office, and since this was an exception situation, the appointment line couldn’t book my appointment. Instead, they needed to me to speak directly with the physician’s medical assistant. However, they made me go through the full verbal COVID screening questionnaire before they would transfer my call, even though the appointment I was trying to book was for a month or two out. If they’re doing the verbal screening for every patient who calls regardless of what they are trying to book, it seems like a lot of wasted energy collecting screening information that will be long invalid by the time the patients arrive.

How is your institution managing COVID-19 screening in the new era of vaccines? Have things changed? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/17/21

Last week, the US Centers for Disease Control and Prevention (CDC) dropped new recommendations covering the need for mask use for individuals who have received COVID-19 vaccinations. To be honest, Thursday was overly busy and I headed out of town on Friday, so I didn’t have time to read the primary source documents before my inbox started blowing up with questions from family and friends as well as updates from businesses I frequent.

As always with the CDC, the devil is in the details, and there were footnotes to the recommendations for educational institutions. Guidance for youth summer camps and activities is still forthcoming. Unfortunately, most people just latched onto the sound bites and it was off to the races.

I spent the weekend alternating sleeping on the ground with canoeing in the rain, which was actually a lot better than it sounds. Floating through the wilderness with one of my besties is always a good time. She’s a nurse who has been run into the ground during the pandemic and definitely needed a break. Even though things are easing, her hospital is chronically understaffed and nurses are being asked to continue to give more and more when their reserves are spent. COVID-19 cases in our area are at an all-time low and her unit is no longer a pandemic overflow unit, but case mix doesn’t really matter when you don’t have enough staff to properly care for patients.

The hospital is offering bonuses for people to pick up extra shifts, but I can’t help but wonder if increasing base pay and adding additional perks would keep people from calling in sick. Creating a dedicated float pool or paying people to be on call are also options, but those cost money up front, so I guess they would rather spend it on the back end and have burned-out staff instead.

It is in this context that most healthcare providers are listening to the CDC recommendations, which were dropped on states with little notice and effectively turned small businesses and community organizations into the vaccination police overnight. The way the recommendations were released stressed the system and did not give frontline providers enough time to digest the science behind them before being hit with loads of patient questions.

Anyone with any change leadership experience knows that consensus and communication are key to effectively managing change, and both were lacking. For healthcare providers who have been exhausted caring for COVID-19 patients over the last few months, an overwhelming sentiment involved the idea that maybe we could have just waited a little bit and given clinical caregivers a break. Would it have been so bad to allow six or eight weeks so that a good chunk of the 12- to 15-year-old crowd could become fully vaccinated? Could we have had just a little more time to recharge before throwing open the floodgates nationwide? Many of us have significant concerns about potential summer spikes and the growing body of information that shows that the long-term impact of COVID-19 is going to be more significant than initially thought.

The bottom line is that very few people seem to care what healthcare providers in the trenches actually think. Frontline clinical staff have become a commodity and there’s a sentiment that we can all be easily replaced even though in reality we can’t. You can’t just replace registered nurses with patient care technicians and expect things to turn out OK. Similarly, letting your seasoned physicians walk away and replacing them less experienced (and often cheaper) resources probably isn’t the best long-term play either. The idea that happy clinicians make for happy patients seems to be lost on most medical administrators these days.

The healthcare IT industry has significant focus on patient satisfaction and patient engagement, but there aren’t a lot of tools out there for care team satisfaction or engagement. There has been plenty of conversation about the usability of EHRs for years, but it’s not just that – it’s all the different systems that we have to engage with on a daily basis.

Take scheduling systems, for example. If it is difficult and annoying for employees to schedule their shifts, does that add to their satisfaction? If the learning management system doesn’t make it easy for you to complete required training, that certainly isn’t a win, either. At my last employed position, I had to use one system to submit my schedule requests and access another system to see how my schedule actually turned out. We had three different systems for employee education – one true learning management system, one intranet site, and then random text messages distributing critical information. It made it difficult to feel like you were in command of all the information.

Our EHR was a poorly configured version of a product that I know can do better, but that had been tweaked to support our particular (or peculiar, depending on how you look at it) workflows and policies. The CPOE for in-facility medications was beyond clicky and borderline unsafe, but we were expected to just deal with it. Our PACS went down on a daily basis because it wasn’t fit for purpose given the exponential growth of the organization, but no plans were made to replace it. When concerns were surfaced, we were essentially told to just deal with it, because replacing either would be too much of a hassle “and would distract us from our patient care mission.” We were also told that they couldn’t afford to upgrade the systems, but eventually organizations reach a point where they can’t afford not to upgrade the systems. I see these same concepts played out at organizations across the US, so I know it wasn’t unique to our situation.

Knowing how burned out everyone is from the pandemic, I can’t imagine what healthcare organization employees are going through when their employer is hit by a ransomware attack. It’s hard enough to care for patients today as it is without that added stressor. We’re all suffering from compassion fatigue and have little tolerance for things that make our lives harder. Many of us are also experiencing significant moral injury from having to make ridiculous decisions that shouldn’t happen in a large, industrialized nation in the 21st century. But that’s where things have landed, and at many organizations, we are told that we should be grateful to have a job.

I’m not sure what the answer is, but I think we need a greater dialogue around how healthcare organizations care for their employees. We need more exposure to the public about what the staffing pool looks like, and the potential negative impacts on care when the caregivers are still suffering. And maybe we need some fancy new technology to put the sexy back in employee satisfaction.

Got any ideas on how to rejuvenate the healthcare workforce? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/13/21

Not surprisingly, the big news around the virtual water cooler this week was the approval of the Pfizer COVID-19 vaccine for the 12- to 15-year-old age group. In my community, most of the health system vaccination sites began to schedule vaccination appointments for that group for Thursday and Friday in advance of the expected approval. Only the retail clinics held the line, and my guess is they were frantically updating websites Wednesday evening. Colleagues in several other states reported that vaccination sites weren’t waiting for the final CDC approval but took the FDA emergency use authorization as enough to go ahead and start vaccinating younger teens on Tuesday. It will be interesting to see what happens to vaccine rates now, with many parents wanting their children vaccinated so they can get “back to normal.”

Another boost to vaccination rates, particularly among young healthy men, might be this article that explores concerns about COVID-19 causing erectile dysfunction. Researchers at the University of Miami Miller School of Medicine found detectable viral RNA in the penile cells of COVID-19 positive patients at a substantial interval after the initial infection. They conclude that the same kinds of cellular dysfunction caused elsewhere by COVID-19 infections may be contributing to erectile dysfunction. I’ve been saying for a while now that this is a weird virus and we’re a long way from understanding exactly what it can do. I suspect this isn’t the last of the unusual complications that we’ll learn of.

Another journal article that crossed my desk this week should be near and dear to many healthcare IT professionals. Molecular Psychiatry published a piece describing how “Habitual coffee drinkers display a distinct pattern of brain functional connectivity.” Researchers used functional magnetic resonance imaging (fMRI) to assess brain changes. The findings support an association between coffee consumption, improved motor control, cognitive focus, and alertness. Similar changes could also be seen in the brains of non-coffee drinkers after consuming even a small amount of coffee. I’m not a huge coffee drinker, but do like an iced coffee from time to time, although too much tends to make my hands shake, which is not good when you have to sew people up for a living. Maybe I’ll be able to enjoy it more often now that I’m no longer in the urgent care trenches.

We’ve certainly moved into a new phase of the pandemic, and that’s the one where drug companies begin direct-to-consumer advertising for COVID-19 related treatments. Regeneron has started its advertising campaign for monoclonal antibodies. The advertisements are permissible under the FDA’s emergency use authorization, and four commercials have been developed. As with nearly every other drug ad, patients are told to “ask your doctor” about the treatment. We screened people for potential treatment at my former employer, and the reality was that very few patients qualified and even fewer actually wanted to go to the infusion center for a treatment. It will be interesting to see if the ads actually drive business.

The HIMSS21 schedule for in-person general education sessions is now live. I went ahead and dropped the keynotes, exhibit hall times, and registration info on my calendar, but it’s hard to get excited about choosing sessions just yet. Many of my healthcare IT colleagues are still debating whether they’re going or not, wondering if the expense will be worth it, especially if they have to pay out of pocket. My local university is still on a travel ban as are several of my favorite vendors, so right now very few of my besties are planning to attend. Those of us going will make the most of it, though, and it will certainly be good to see people in person.

Sometimes I run across products that are solutions in search of a problem, and I’m fairly certain the Q-Pad by vendor Qvin fits this description. The device is a menstrual pad with an embedded test strip used for laboratory-based hemoglobin A1c testing. The company differentiates itself based on needle-free blood testing without regard for the fact that patients who are in need of hemoglobin A1c testing also need a variety of blood tests that aren’t available on their platform. Like any good device vendor, the company provides a smartphone app. Direct-to-consumer pricing is available on a one-time, monthly, or quarterly basis despite the lack of evidence for random testing in the menstrual-age population. The website contains a video interview with the founder, who says the device appeals to the “quantified self” crowd.

I’m a big fan of the Honor Flight Network and had the privilege of traveling on a flight with my favorite Korean War veteran. It’s an amazing experience that was curtailed by the COVID-19 pandemic, with only one flight going in 2020 before everything shut down. I was glad to see an outstanding application for virtual reality technology to help continuing honoring veterans, as T-Mobile partnered with Healium and the Honor Flight Network to virtually transport veterans to see their memorials in Washington, DC. Honor Flight is gearing up to restore the trips as soon as it is safe and practical, but the reality is that we will lose many of our WWII veterans before they can travel, and many more are not physically able to make the trip. Kudos to these organizations for their support of our veterans.

Marketing folks of the world – I highly recommend testing your email blast software on a small distribution list before just cutting it loose. Clearly the email I got didn’t format as intended, and since it’s supposed to be coming from a communications specialist, it doesn’t inspire confidence.

For fans of “The Six Million Dollar Man,” the time for “bionic” eyes has arrived. Researchers at the Keck School of Medicine at the University of Southern California have created the Argus II to provide limited vision to blind individuals. Although it’s currently limited to helping people recognize shapes and patterns, they hope to eventually provide the ability to see colors and details.

What’s your favorite technology from vintage TV that has become a reality, or that you can’t wait to see some day? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/10/21

As the healthcare industry begins to shift more towards telehealth and non-office-based management strategies, there’s a greater need for devices that patients can use at home or on the go. I’ve long been a fan of my Garmin watch, which tracks my daily steps, maps my runs, and reminds me to get moving when I’ve been sitting too long. Beyond that, I’ve not gotten too deep into the quantified self movement. I’m more motivated by being able to watch frivolous Netflix on the treadmill than I am by tracking performance numbers, so I haven’t needed that external reinforcement.

At a recent medical visit, I had an uncharacteristically high blood pressure reading, which I mostly attributed to the fact that I was about to be stuck with a bunch of needles. However, as a student of data and given my family history, I figured it might be time to invest in my own home blood pressure monitor to make sure nothing more sinister was going on. Plus, as a physician practicing telehealth and relying on patients providing their own data, it would give me some visibility into the experiences my patients might be having.

A couple of my physician friends have hypertension and monitor themselves religiously, so I asked around the virtual physician lounge for recommendations. Nearly everyone recommended the Withings BPM Connect, which is supposed to be easy to use and compact. It also supports both Bluetooth and Wi-Fi connectivity. I’ve had some experience with the Withings scales as part of a congestive heart failure project I did for a health system client, so decided to take their recommendation. Through the wonders of internet commerce, I was able to have one delivered to my home quickly and was eager to get it up and running. Since I was evaluating the device from different perspectives – patient, clinician, and informaticist – I had a lot of different elements I wanted to look at.

The first challenge with the device was the printed instructions that came with it. The user manual appeared to be printed on environmentally friendly brown paper. Although it’s a good idea from a sustainability standpoint, for users of a certain age where contrast is important for printed materials, it was a bust. I became one of those folks that uses the flashlight function on their phone just to read it, which made one of the younger members of my household laugh. Rather than watch me struggle with it, he proceeded to take the manual and read the German version to me, seeing if I could figure it out from the bits and pieces of the language that I understand. Based on that experience, I can see how the written documentation alone would be challenging to older users or those with low vision.

Eventually I got to the point where I needed to pair it with my phone, which was an adventure in itself. I downloaded the app easily and followed the instructions to connect. That’s where things started heading downhill. After what seemed like an interminably long “trying to connect” screen, it failed to connect. I repeated the process multiple times with the same results. Even though my phone identified the cuff as an available device from within the phone’s connectivity settings, it wouldn’t connect. In true IT fashion, I rebooted the phone and tried again.

This time I was able to get it to connect, and a firmware upgrade was applied to the cuff. Unfortunately, it immediately disconnected and wouldn’t reconnect. Multiple trips through the “trying to connect” screen and a couple more reboots later, I finally got it to connect to the phone. Eventually it also allowed me to connect the cuff to my home Wi-Fi network and I was ready to try to take an actual blood pressure reading. By this point, though, I had a fairly ripping headache and was a bit frustrating, so I expected a less-than-perfect result. The cuff itself is fairly easy to put on and take off, although patients with less dexterity in their arms or hands might benefit from having some assistance.

The Withings Health Mate app has a helpful video for those who have never taken a blood pressure that explains how you should sit quietly for five minutes and make sure your arm is supported at the level of your heart prior to taking a reading. As a matter of logistics, these steps are almost never followed at medical offices, which re-emphasizes the role home monitoring devices might play in helping patients and physicians obtain accurate results. The cuff itself has two modes – one where a single blood pressure is taken, and one that takes three blood pressures over a short period of time and then averages the results. I decided three data points were better than one and gave it a whirl. The LED display was easy to read and includes your name in the final display, which is helpful since the device will support up to eight users.

The Health Mate app does a nice job of graphing your results as well as displaying your latest measurements and highest and lowest values. I found it annoying, though, that it keeps asking me to connect to Google Fit, which I have no desire to do. There didn’t seem to be a way to get it the reminder to snooze, so we’ll have to see if it keeps coming back. The app offers functionality to send patient data to the physician, but I haven’t experimented with that yet. The device advertises six months of use on a single charge (via USB), but doesn’t specify whether that’s one person checking blood pressure daily, or some other combination of variables. As a physician, the timeframe we recommend for BP checks varies from person to person, and sometimes it’s not ideal for patients to check it too often. The app does offer patient-facing reminders to encourage regular measurements.

Withings advertises the BPM Connect as “travel friendly” and I agree it’s rather compact – the cuff wraps tightly around the display unit and it’s about the same diameter as a flat iron used for hairstyling, although much shorter. The company also sells a protective travel case for $29.95 but I don’t think it’s necessary, unless you’re tossing it in a gym bag where it might come into contact with sweaty or dirty clothes or where it might be rattling around with something that might catch on the Velcro.

I got a kick out of reading some of the reviews on the Withings website. One noted that the device “feels like a premium home health product with soft, heathered fabric around the outside and a soft-touch plastic to the tube…” I guess I didn’t think much about the fabric or the feel of the plastic since I’m used to conventional nylon office-style blood pressure cuffs, but that might be an important aesthetic for some users. My absolute favorite customer review was a product manager’s wildest dream, stating, “I never thought I’d buy into the ecosystem so much, but they are *genuinely* delighting me with their user experience.”

My initial user experience was less than delightful, and had I been someone who was less tech savvy, I might have given up. It definitely felt like one of those moments where people call their grandchildren and ask them for help. Fortunately, even with the aggravation with the connectivity, my blood pressure wasn’t all that exciting and I’m glad to know I still have a resting heart rate that borders on being abnormally slow. We’ll have to see how it performs over the next several months and whether the old adage about what gets measured gets managed applies.

What’s your favorite piece of home monitoring equipment? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/6/21

I was intrigued by an article in the Journal of the American Medical Informatics Association (JAMIA) that looked at “Public vs. Physician Views of Liability for Artificial Intelligence in Health Care.” The authors found that although a majority of both physicians and the public believe that physicians should be liable for errors occurring during AI-assisted care, the public was more likely to do so (66% versus 57%). Compared to the public, physicians were more likely to believe that both vendors and healthcare organizations should be liable. In summarizing the background, the authors note that there are more than 60 AI-based algorithms and devices approved by the US Food and Drug Administration. Although they didn’t find significant differences across specialties, they only surveyed internal medicine physicians, oncologists, and radiologists. The number of physicians surveyed was also fairly small – 750 physicians were invited, but only 192 responded.

Another article, also in JAMIA, reported on interviews with medical scribes and how their work might reduce clinician burnout. I’ve got a fair amount of experience with scribes, from using them in practice to helping health systems set up scribe training programs. It was a fairly small study with only 32 interviews. The authors looked at different types of clinical tasks from documenting visit notes to tracking down clinical information. I liked the way they referred to clinicians delegating these tasks to their scribes as “outsourcing.” Especially if you have an EHR that makes finding information challenging, as many of us do, it’s a heck of a lot easier to ask your scribe “what was her blood pressure at the last visit?” versus having to dig for it yourself, especially if you’re on the high-volume hamster wheel where you’re asking patients questions and synthesizing information at the same time you are conducting your examination.

Unfortunately, some organizations don’t embrace scribes fully and leave it up to individual physicians to determine if they want or need a scribe, which usually means that the cost of hiring, training, and using the scribe falls entirely on the single physician. Practices that incorporate scribes as part of the overall infrastructure can see additional benefit, including being able to have appropriately-trained scribes help perform clinical tasks (such as rooming patients or helping handle phone calls) during any downtime where the physician may be doing work that isn’t best supported by a scribe. In my soon-to-be-departed clinical gig, it was also a plus that nearly all the scribes were doing a gap year between undergraduate studies and hopefully being admitted to medical school or a physician assistant program. Across the board, they are a highly motivated bunch who seem to genuinely want to learn about clinical care and the health system. Unfortunately, that meant that nearly the entire scribe workforce turns over every spring and summer, which is a challenge.

JAMIA hit the trifecta with an article on reducing EHR-related burnout through a “personalized efficiency program.” This is the kind of work I do as a consulting CMIO – helping organizations figure out not only how to technically optimize their EHR, but how to get providers to adopt time-saving workflows. There are a variety of strategies I like to use, so I was eager to hear what kind of offerings their efficiency program included. I felt validated in my approach – their individual coaching sessions included a focus on increasing EHR knowledge and maximizing user-level customization. In the study, a good number of providers participated in the optimization sessions, 87%. However, not all participants returned both the pre-survey and post-survey, so they weren’t included in the research sample.

This week’s Health IT Buzz blog focused on sunsetting the interoperability roadmap. It was a nice walk down memory lane, thinking back to 2015 when the roadmap was introduced and sparked plenty of comments before it was finalized. It made plenty of people nervous, especially the parts that talked about patients having expanded access to their records. Many of the milestones it laid out have been achieved. The last pandemic-filled year has been impactful on health IT and has accelerated numerous interoperability projects. Although the new developments are appreciated, let’s hope it doesn’t take a pandemic to continue moving organizations and the industry in the right direction.

As a big-time science nerd, I was excited to see that the team at Fermilab published an article that they have successfully achieved sustained, high-fidelity quantum teleportation. It’s a step closer to a quantum internet, which would revolutionize how we use and manage data. The research team — made up of folks from Fermilab, AT&T, Caltech, Harvard University, the University of Calgary, and the NASA Jet Propulsion Laboratory — plans to continue to upgrade its systems over the next several months to further refine its results.

May is Mental Health Awareness Month. The ongoing pandemic has certainly brought discussion of many mental health issues to the forefront. Among my patients, I’ve seen increases in depression, anxiety, and insomnia. Many people have their symptoms compounded by difficulty accessing both primary care and psychiatric services, and although I know the urgent care isn’t the best place to handle those issues, we can typically help connect patients with additional resources and supports. A good number of my colleagues have had their own mental health struggles during the past year. Due to the challenges with physicians having to report mental health treatment in many states, a number of them are untreated or undertreated, and that is a sad commentary on healthcare in the US and our willingness to understand that everyone is human.

I’m glad we are past the panic attack-inducing days of the early pandemic, when we didn’t know what we were dealing with or whether we would make it out the other side. There are a number of physicians and other clinicians who may be whole in body but not in spirit, and I hope the health system starts to look seriously at what needs to be done to help them heal. In the short term, I see a lot of them leaving medicine. I’m curious whether other countries that don’t have the same stressors are seeing the same outcomes. In the immortal words of U2, “we get to carry each other.” If you sense your colleagues are in need of help, do what you can to get them to a better place.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/3/21

HIMSS invited me to complete “a quick five-question survey” regarding attendance at HIMSS21. I’m no stranger to research around user and consumer needs, so I was curious what kinds of questions they would ask. The first question was “What are you most looking forward to at HIMSS21?” Choices included: attending world-class sessions, building new relationships, finding tech solutions, reuniting with colleagues, or other.

In the past, I’ve struggled with the quality of sessions. Part of that is due to HIMSS-related factors, including the long lead time between when the submissions are due and the actual conference. Presenters can’t show off the latest and greatest when they have to declare their intentions 10 months prior to the conference. We’ll have to see what that looks like this time since HIMSS20 was canceled and HIMSS21 was pushed back. To be honest, I haven’t paid much attention to the submission process or timeline because I wasn’t sure this year’s conference was even going to happen.

The second question was about professional goals, and to be sure, “getting material for everyone’s favorite healthcare IT blog and looking for sassy shoes” was not a choice. Maybe I should have selected the “other” block and done that as a write-in, but knowing HIMSS, there was probably tracking information attached and I wouldn’t want to give up my anonymity.

The options for this question included: attaining actionable education, building peer connections, developing my career, earning CE credits, experiencing innovation, finding new partnerships, job seeking, and problem solving. I’m not sure how well HIMSS21 will be able to deliver on some of these options given the relatively small number of exhibitors and the hybrid virtual / in-person format. Not to mention that many organizations are still under travel bans. A number of my favorite CMIOs aren’t going to be able to attend in-person for that reason. Most of the big exhibitors are staying home as well.

The third question was whether we’ve booked hotels yet, which I’ve done. I’ll be staying at one of the connected conference hotels so I can minimize my time outdoors in Las Vegas in August. I’m not fond of the heat even when people remind me “it’s a dry heat” and the best people watching in Las Vegas happens after the sun goes down, anyway. There are supposed to be sessions at Caesar’s which would involve a trip outside, so it may not help as much as I thought, but I’m playing the odds as most gamblers do.

The final question was “How can HIMSS staff make your conference experience exemplary?” At this point and specific to HIMSS21, I really don’t know. It’s going to be an interesting year and we just have to keep open minds. Thinking more broadly though, HIMSS needs to consider lowing the attendance costs for individual attendees. It’s a relatively pricey conference considering the minimal return on investment for those of us who aren’t attached to institutions that are footing the bill. Plus, as we all know, nearly all healthcare costs are ultimately passed on to the patient in one way or another, and it’s really difficult to justify attending at times.

I precepted a nursing student today, and due to a relatively slow urgent care day, she didn’t get a lot of clinical experience. She did learn how to work through an EHR downtime, though, and I was grateful that we weren’t completely slammed with patients when it crashed. Fortunately, this outage lasted less than half an hour and we still had access to our PACS, so we could keep seeing patients. It was nostalgic to pull out the paper script pad, though. She also learned a fair amount about healthcare finance, as one of my clinical assistants is working on a health administration certificate and wanted to pick my brain about operational structures at for-profit versus not-for-profit organizations.

Most people that fall into the student category tend to be younger and have had fewer interactions with the healthcare system. They have not experienced the sticker shock of receiving an out-of-network explanation of benefits statement for a hospitalization and may not have had the experience of receiving multiple bills from all the different vendors and clinicians involved in a diagnostic procedure. Most people go into healthcare fields because they want to help patients, and I think understanding the sausage-making that goes on behind the scenes is critical to their education. Understanding the costs of healthcare helps them appreciate why patients may not fill their prescriptions or make the specialist appointments that we recommend.

We also had a good conversation about health insurance and how most patients have their coverage tied to their employers, which is something most students who are still on their parents’ coverage or using student health services at their universities might not understand. She was surprised to learn that sometimes patients stay in jobs they don’t like strictly because of insurance benefits and not wanting to change because of the risk of having to change to new providers or a different care team just because their coverage changes. My state requires all high school graduates to take a personal finance class, and although the curriculum covers things like homeowners’ insurance and auto insurance, there’s not much discussion of healthcare expenses. Since I’ll have some free time after I finish up my last urgent care shift on Friday, maybe I should volunteer to teach a session on understanding health insurance, how to read an explanation of benefits statement, how medical billing works, and how to navigate referrals and prior authorizations. Failure to understand those elements can have an impact on your personal finances, indeed.

Back to thinking about educational conferences, my friends at West Virginia University are offering a seminar that seems like a much better use of limited conference dollars, focusing on point-of-care ultrasound. It’s being hosted at a resort that caters to whitewater rafting enthusiasts, and attendees can take advantage of the whitewater at the New River Gorge National Park. Having run this section of the river in 2019, I would rather be there than Las Vegas. See if you can spot me in the photo – I’m the one in the helmet.

What are your favorite conference locales? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/29/21

The big news around the virtual physician lounge this week is the decline in COVID-19 vaccination rates. President Biden is pushing for small businesses to make use of tax credits to support paid time off for employees seeking vaccination.

At this point, anything we can do to incentivize people to become vaccinated is welcome. The more the virus continues to spread, the more it can mutate, which counters the progress we’ve made. Some employers understand this. Supermarket chain Kroger has offered cash incentive payments for employee vaccinations, as has hospital Houston Methodist and several health systems. Some decry this as coercion, but the reality is that someone won’t get a vaccine if they really don’t want one, based on a $100 cash payment. The incentives are also rewarding those who do the right thing, as additional vaccinations help strengthen the workforce and reduce burden on co-workers.

I remember when I received my first vaccine, we thought it would really be something if we got a million doses in arms. That would really be an indicator of safety and effectiveness. Now that we’re at the 200 million dose point, it’s clear that the risks of the vaccines are minimal. Even with the questions around the Johnson & Johnson vaccine and the potential for increased blood clots, these vaccines are remarkably safe and effective. Based on what I’ve seen with the COVID-19 illness in my patients, the vaccine is much more desirable. On the home front, I’m just waiting on a couple of second doses within my family, and then I’ll really be able to breathe a sigh of relief. It’s been a long year, for sure.

Healthcare workers have been at the tip of the spear, not only fighting the pandemic, but also dealing with increasing numbers of unstable patients and sometimes public hostility. The Journal of the American Medical Association published a recent article on “Navigating Attacks Against Health Care Workers in the COVID-19 Era.” Initially, health workers were on the receiving end of discrimination as well as violence. Several colleagues were asked not to attend church or told that their children couldn’t participate in activities because they were potentially in contact with COVID-19 patients. There are also social media attacks – I’ve experienced them personally, although what I’ve encountered has been on the mild side compared to that experienced by others.

During my career, I’ve experienced patients ranging from “creepy stalker” to verbally abusive to downright threatening. Fortunately, the only physical threats have occurred within the hospital emergency department, so I had security staff at the ready. Still, there’s always that worry that a disgruntled patient or drug seeker will be waiting for you at the end of your shift. Hospitals and larger facilities may have security staff that can help mitigate this risk, but for healthcare workers in small practices or isolated environments, we’re pretty much left with the buddy system to help keep each other safe.

Uber sent me an email this week, inviting me to schedule my COVID-19 vaccine at a nearby Walgreens through the Uber app, while also being able to book a ride. Of course there were caveats about vaccine availability and whether Uber Reserve service is available in my area, but it’s still a good option for people who might not otherwise be able to get a vaccine scheduled. In my area right now, there is an overwhelming surplus of vaccines and a lot of hesitancy, so anything that gets people to think about the process is okay in my book.

I was excited to hear that Meditech is integrating genomics into its EHR. If you are an EHR vendor thinking about incorporating it, there are some serious options not only for documenting the data for how they enable clinicians to use it. The most basic need is to be able to document specific genes that patients have in a discrete fashion so that they can be used by clinical decision support algorithms. That’s critical for those genes associated with diseases where the mere presence of the gene changes the need for preventive screenings or management. Systems need to be able to track what type of genes are present, whether they are sex linked or not, and whether patients have a single copy or two copies of a given mutation. They also need to be flexible enough to manage new discoveries, such as when a gene is found to have a new level of clinical importance.

For its Expanse Genomics solution, Meditech is partnering with First Databank. To be honest, I didn’t know how far First Databank had gotten into the world of genomics. I always enjoy stopping by the FDB booth at HIMSS and remember vaguely hearing about them moving into pharmacogenomics. Certainly, some specialties are going to be more drawn to the value of integrating genomics than others. Many of my primary care colleagues are concerned about being able to keep up with the basics of making sure all their patients are receiving preventive screenings and that diagnoses are managed optimally, let alone being able to manage the impact of genomics on precision medicine.

I was particularly excited to hear about the Expanse solution being able to import genomic data and integrate it into the patient record in what sounds like a discrete fashion. My own recent genomic results are sitting in a PDF within the chart and aren’t even accessible to me as a patient through the patient portal. My physician was supposed to mail me a copy (snail mail – shocking, I know) but the results never arrived, so they did send me a PDF version. Good thing, since when I look in the patient portal, it just says “see outside report.” If my physician’s EHR can’t even display the results, there’s no way it can use them to tell me how often I should get a colonoscopy or how my risk changes depending on what is found during the procedure.

It will be interesting to see how long it takes other EHR vendors to get on board with a similar solution, as well as how long it will take existing Meditech clients to embrace the new content.

How is your system currently handling genomics? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/26/21

Even though I’m a relative insider, I read HIStalk regularly so I can keep up. The recent Monday Morning Update contained a couple of reader comments that really got me thinking. The first was a mention of healthcare costs and the technologies that promise to lower them. Mr. H noted that “healthcare savings rarely trickle down to the actual patients – they just swell the profits and executive payroll of billion-dollar health systems, insurers, and employers…” Based on my experiences over the last few years, I have to say I agree.

Payers and patients alike are drawn in by the convenience and relative cost savings of certain care venues, such as urgent care centers. The marketing around this usually involves the fact that they are “cheaper than the emergency room,” which although true, doesn’t necessarily make them the most economical venue. My soon-to-be-former urgent care employer posts charges that are typically one-sixth that of what you would see for similar services delivered in a hospital emergency department. That seems like a good deal until you realize that the services are still significantly more expensive than they would be if they were delivered by a primary care physician.

Due to the care setting and the need to practice more defensive medicine than that practiced by primary physicians, patients are likely to receive more services than they would in a lower-acuity environment. As an independent facility, we don’t have access to patients’ recent labs or tests unless they want to hand us their phones so we can access the patient-side MyChart accounts. We also don’t know the patients as well as their primary physicians, so we don’t know how likely they are to follow up as we recommend, so we might recommend subspecialty follow up as a backup plan when there might be more cost-effective options. Patients certainly have higher up-front costs with co-pays when they visit urgent care rather than a primary physician, and although it’s cheaper than the emergency department, it costs more than it needs to.

Although we hoped price transparency would help drive patients to more economical care settings, we failed to fully understand how patients value convenience. There are certain conditions that need to be managed immediately, such as lacerations or serious injuries, but the vast majority of patients seen in our urgent care could be managed within a day or two by a primary physician with no difference in outcome for the patients. However, patients typically don’t want to wait. Patients are also concerned about access issues and even getting in to see their primary physician since there’s not only a shortage of appointments, but of providers in general. Our culture is one of instant gratification and patients want their problems addressed right away. Sometimes it seems strange, though, because they often haven’t even tried over-the-counter remedies that might have helped them before making the decision to seek care.

That ties nicely to the second reader comment, about the US Food and Drug Administration requiring prescriptions for many items despite the fact that they’re fairly straightforward or even available without a prescription in other countries. I agree with Mr. H that the need for prescriptions has driven growth in telehealth and online pharmacies, who end up becoming de facto prescription mills because they rarely deny the patient’s request. Even as a face-to-face physician, taking a solid history and performing a thorough physical exam doesn’t typically change the outcome when a patient with sporadic bladder infections and early minimal symptoms comes in asking for antibiotics or when a parent brings in a symptom-free child with a COVID-19 exposure. Now that we’re more than a year into the pandemic, we are just getting to the point where patients can buy testing kits over the counter without a prescription. It remains to be seen whether that will make any difference in how the pandemic rolls forward.

Especially at the beginning of the pandemic, and through the first couple of peaks, in the absence of over-the-counter testing, it made sense to have large-scale clinics that would test patients based on a standing order rather than having patients see their own physicians. Now that most of those clinics are closed, at least in my area, patients are forced into the urgent care system due to lack of options. A friend shared her husband’s Explanation of Benefits with me for a recent COVID-19 test. The charge was $1,900, which is absurd. This included the physician visit, the facility fee tacked on by the hospital since it owns the urgent care, and the cost of testing for not only COVID-19, but also influenza. Due to having a fever in the office and not having taken any medications for it, the patient was also charged an exorbitant amount for a couple of ibuprofen tablets. To add insult to injury, her husband went to the “wrong” urgent care and it was out of network, so they’re on the hook for the full amount of the charges without any payer-negotiated discount.

It certainly would be a lot cheaper if we had a viable public health infrastructure and could channel these patients appropriately, not only to reduce their costs, but the overall cost to the nation. Or in the absence of that, if we could start to manage people using less-costly resources, such as over-the-counter testing. But as long as the big healthcare systems and for-profit organizations stand to lose out on what they perceive as their piece of the pie, it will be difficult to truly drive change no matter what technologies we create. Even though many of us think disruptive technologies are cool, they scare the living daylights out of good portions of the healthcare industry.

Still, I’ll keep plying the clinical informatics trade in the patient engagement sector and in the telehealth trenches. Even if we’re making incremental change, it’s still movement in the right direction. I’ll also keep lobbying to address some of the fundamental issues, such as the shortage of primary care physicians and lack of support for their efforts. I’ll also continue to advocate for increased funding for public health infrastructure and the technology needed to support population-based health.

What are your thoughts on healthcare savings being pushed to the patients, or on increased availability of over the counter products? Leave a comment or email me.

Email Dr. Jayne.