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EPtalk by Dr. Jayne 4/18/19

April 18, 2019 Dr. Jayne No Comments

The largest US health insurer, UnitedHealth Group, has added its critique to the Medicare for All proposals currently being debated in Congress. We’re going to hear about this for the next year and a half, at least through the next presidential election, so I’m not surprised they’re putting their two cents in.

Medicare covers approximately 60 million people and UnitedHealth’s products cover nearly 50 million, so they conclude that Medicare for All would cause “wholesale disruption of American healthcare.” I’d like to remind the CEO making the statement that there’s more to the Americas than the US and we should be looking at many nations’ healthcare systems as we try to find a way out of our own mess. UnitedHealth posted revenues of $226.2 billion last year through insurance, physician practices, consulting, and pharmacy benefits operations. Medicare for All, or any universal coverage, plan would likely take a bite out of those revenues.

In the patient care trenches, I have a bird’s-eye view of the issues caused by employer-based health insurance. Patients staying at jobs they hate where they are abused because they are afraid of losing health coverage, particularly for pre-existing conditions? Check. Patients with complex medical conditions staying in abusive relationships because the spouse holds the coverage and they can’t afford it on their own? Check. Patients suddenly losing coverage due to downsizing, and not being able to afford individual plans? Check.

I saw all three of these this week. A discussion of the cost of care was part of the urgent care visit. Members of Congress need to walk a mile or two in their constituents’ shoes before making decisions on this complicated issue. Even the concept of Medicare for All means many different things depending on whose proposal you are looking at.

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Mr. H asked recently for comments on “Health System IT Providers vs. Would-Be Disruptors: Unfairly Dismissive or Appropriately Skeptical of Outsiders” and I wanted to throw in my two cents’ worth based on a recent client project. It’s not only the outside disruptors who that make those of us in the IT trenches skeptical. It’s also the other outsiders that our organizations bring in, because either they feel that input from another industry would be useful, or that as one director told me, “You don’t have to know healthcare to manage IT systems in healthcare.”

That’s how I found myself sitting across a conference table from a “lab interface team” who was supposed to be helping create some custom orders management content for a boutique practice. As we were in the Motor City, it seemed that my team was entirely populated by former auto industry programmers and technicians. Confident in their ability to use algorithms to free the physicians from mundane data management, they had designed a flow for laboratory orders and results management and wanted my sign-off.

Unfortunately, they had no idea of how laboratory flags work or any concept that a lab that is technically abnormal might be perfectly fine for a given patient, or that one that is normal range might be bad for a given patient. The idea that results need to be interpreted in context not just based on normal vs. abnormal was a new one to this team, which appeared hastily thrown together by the hospital, which had acquired said boutique practice without really thinking it through.

Did I mention that they also didn’t know their OBR from their OBX from the proverbial hole in the ground? The look in their eyes at having a physician school them on the nuances of being an actual lab interface team was priceless. I left the meeting suggesting that perhaps they should learn something about HL7 capabilities and scheduled a discussion with their director about the team’s ability to actually get this project done on any kind of useful timeline.

I don’t doubt that non-healthcare people can learn and become healthcare people, but you have to at least understand the problem and the business case before you try to create a technology solution. I’ll be earning my money with these folks, for sure.

From Jimmy the Greek: “RE: Hide the women and their uteri….” Jimmy shared a Washington Post article covering health-monitoring app Ovia, which sells intensely personal (although de-identified) data to employers that include the app in company benefits packages. We all know how easy it is to re-identify that data, so it caught my attention. The app collects information on user mood, bodily functions, sexual activity, and ultimately labor and delivery. The article mentions a woman who was using the app in the delivery room to upload data. Were I not a hypothetically swinging single, perpetually 29-year-old clinical informaticist, using an app when I should have been contemplating the perfectness of my baby and his amazing existence would be appalling.

Employers can see aggregated data on health risks, question searches, finances, and return-to-work plans. Depending on the size of the company it might be easy to figure out exactly what employees are documenting. Users are also exposed to targeted advertising for dubious products, including nutritional supplements and special cleaning products. Privacy experts are worried that employers could modify benefits based on projected costs or that discrimination may occur against women seeking pregnancy. Not to mention that some coercion may be involved when companies pay workers to use the app as mentioned in the article.

As someone who previously provided maternity care and delivered over 150 babies, I’m also concerned at the psychological ramifications of this level of tracking in pregnancy. It’s a scary enough time for mothers without having their every move quantified. There is one popular pregnancy guide out there that I actually recommended the mothers under my care should avoid. It included recommendations that shamed mothers who weren’t baking their own whole-grain muffins and said that pregnant women shouldn’t use microwave ovens because of unknown risks to their babies. The so-called “femtech” market is apparently big business, slated to hit $50 billion by 2025.

The Ovia terms of use give the company a “royalty-free, perpetual, and irrevocable license, throughout the universe” to clearly use information for marketing however they see fit. They can also sell the data to third parties and I doubt many of the users actually review the 6,000-word disclosure.

Ovia also claims reductions in premature births and other outcomes, but the data is from an internal return on investment calculator rather than from appropriately constructed peer-reviewed studies. The company makes no secret that it’s delivering content that helps reduce medical costs and encourages women back to the workplace. While researchers are tempted by the availability of large data sets, they’re concerned about the applicability of the data to actual research.

The article mentioned a number of other women’s health apps, including period trackers and fertility trackers. I must admit I was woefully unaware of the size of that market segment. I’d like to see women be better educated about their bodies, but I hate to see some of these apps positioning themselves as something to help “demystify” normal biological processes.

If you had a daughter, would you encourage or discourage her from using apps like these? Would you use them yourself? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 4/15/19

April 15, 2019 Dr. Jayne 3 Comments

I was out with a friend on Saturday, at least until he had to leave to go to a planned downtime event at work. He mentioned that in all the years he had been with his company, it was rare for a downtime or disaster-recovery prep event to go as planned.

Maybe his industry has less tolerance than we do in healthcare, but it got me thinking about the impact of downtime in the patient care environment. The Journal of the American Medical Informatics Association published an article on this recently: “Clinical impact of intraoperative electronic health record downtime on surgical patients.”

Many of us just read the abstracts, and a quick pass yielded some interesting information. Researchers looked at the impact of EHR downtime events lasting more than an hour over a six-year study window. Specifically, they looked at adult patients undergoing surgeries more than 60 minutes in length during an inpatient stay lasting longer than 24 hours. Since it’s hard to do certain kinds of controlled studies on events like this, they matched more than 4,000 patients exposed to one of 176 downtime episodes with 4,000 patients who weren’t similarly exposed.

Looking at the math superficially, this means that the facility was averaging more than 29 downtime episodes a year, each lasting more than an hour. That’s pretty striking – approximately one every 12 days. I’ve never worked in a facility that had that kind of downtime and I can’t imagine the anxiety that clinicians might feel in that situation.

The authors found that although the patients exposed to a downtime event had operating room times and postoperative length of stay that were slightly more than unexposed patients, the 30-day mortality rates weren’t any different. In short, there wasn’t an appreciable link between the length of the downtime event and significant adverse events.

I wondered whether the sheer volume of downtime episodes might have been protective in this facility and decided to dig deeper than the abstract to find out more about the study site. The devil is in the details in this scenario, especially since the data was gathered at the Mayo Clinic. The identified downtimes could have occurred in any of the seven applications considered core clinical systems in support of the operating room. These included the anesthesia information management system, PACS, CPOE, clinical documentation, an integrated clinical viewer, the surgical information recording system, and the surgical coordination system.

Researchers categorized the length of the downtime as well as its impact, whether limited functionality was available or whether it was a complete outage. Scheduled downtime events were excluded as were those less than 60 minutes long. When matching exposed and unexposed patients, the team looked at day of the week as well as time of day to control for any variation in staffing, facilities, and EHR load. The patients were also paired according to surgical specialty, emergency / non-emergent status, and physical status.

The typical downtime was on a weekday between 7 a.m. and noon and was not a complete outage. The most commonly impacted systems were the integrated clinical information viewer, PACS, and CPOE. Surgical subspecialties most commonly impacted included general surgery, orthopedic surgery, and cardiac surgery. The median age of patients was 61 years, with a range of 49 to 71.

Although 30-day mortality wasn’t impacted by downtimes, interoperative duration was about 10% longer for the procedures where there were outages or interruptions. Longer operative times have been linked to greater risks of complications and also can lead to higher costs to the facility. In my experience, this also impacts physician morale, with surgeons who feel their schedules have been delayed becoming irritated and at times agitated. The operating suite is one of the parts of the hospital where the adage about time being money is truly applicable. They also noted a 4% increase in length of stay, which also has cost implications. Both increases underscore the need to have strong plans in place to help staff contend with unplanned downtime.

The authors further conclude that there is a need for future studies looking at scheduled vs. unscheduled downtime and parsing it down to specific systems to determine impacts at a more granular level. They also note the need to look at data from different facilities and healthcare settings. They also identified a limitation in the matching, namely that procedures weren’t matched year by year. Since there are constant changes in surgical technique and significant changes in some procedures, the year could have been a confounder. They also noted that, “In this context, it is not possible to generalize the results of this study at our institution to the potential impact of resilience and specific contingency planning to other hospitals.”

I don’t see other facilities planning to line up to bare their downtime data. Additionally, investigators at other institutions may not have the robust longitudinal downtime data that these authors had access to and they may not have the full cooperation of information technology staffers. I still see hospitals where the culture of fear is alive and well and efforts to study incidents in order to improve processes may still be met with suspicion. There are also those where downtime processes are fairly disorganized and they wouldn’t be suitable candidates for study.

I got a surprise Saturday evening when my friend reappeared unexpectedly from his downtime event. His comment about his company’s events not going as planned was prophetic because they actually canceled the downtime before it even started. It was good for a chuckle, although the theoretical risk of downtime events in the patient care environment is no laughing matter.

I’d be interested to hear what readers think about this EHR downtime study and whether they believe their institutions would be willing to undertake that type of analysis of their own data.

Got downtime? Leave a comment or email me.

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EPtalk by Dr. Jayne 4/11/19

April 11, 2019 Dr. Jayne No Comments

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The World Health Organization (WHO) has released its draft strategy on global digital health. Their goal is to “improve health for everyone, everywhere by accelerating the adoption of appropriate digital health.” The strategy calls for a united approach to the awareness and understanding of the role of technology while tailoring solutions for each country. The strategy has two major components: the first outlines four strategic objectives while the second creates a four-part framework for action. WHO is accepting public comments through April 30.

I had the chance to meet up for lunch with a former residency colleague who has also gone through the looking glass to health information technology as a career. He was interested to discuss the dissolution of Google’s AI ethics board less than one week after it was formed. The external advisory board, dubbed the Advanced Technology External Advisory Council (ATEAC), was designed to monitor how Google uses artificial intelligence, but the selection of members became problematic. There is so much to keep up with in the tech world that I hadn’t realized Google had been criticized for its role in a Pentagon drone project and since has said it won’t work on AI-related weapons systems. Google plans reconsider the role of an advisory board entirely, stating it “will find different ways of getting outside opinions on these topics.”

Since he works for a major health system, we also had a chance to discuss our thoughts on accountable care organizations and the shift towards value-based care. He wasn’t aware of recent survey data that shows that more than one-third of participants in the Medicare Shared Savings Program (MSSP) are considering leaving the program. Our friends in governmental organizations love renaming programs, but I’m not sure calling it “Pathways to Success” isn’t going to make it any more palatable for organizations that are concerned about their ability to take on higher levels of financial risk. This year’s survey data represented approximately 40 of the 200 ACOs. Those that are more likely to consider leaving the program included hospital-led ACOs, which have tended to perform below their physician-led ACO peers.

We also had some good conversation around whether medicine is still a vocation or whether it’s becoming commoditized like many other industries. He’s no longer in clinical practice, and like many of our peers, attributes the decision to hang up his stethoscope to the moral injury that healthcare providers face on a daily basis. The reality of clinical informatics is that you don’t have to tell anyone that they have cancer and that their insurance won’t pay for treatment, or have to try to figure out how to help patients pay for their medications when they’re barely covering the rent. I think a string of practice and hospital mergers and acquisitions probably also contributed to his lack of zeal for the primary care trenches.

He hasn’t lost his sense of humor, though, and one of the funniest comments of the day was about trying to address governance and adoption issues while his health system’s physicians are spending a great deal of innovative energy finding new ways to try to say no to technology. We discussed what it would look like if people spent that time learning and mastering a system or re-engineering their practices rather than just raging against the machine. The bottom line is that even across the country and with a different physician population, many of us are facing the same issues every day.

Over the last several decades, the healthcare industry has been increasingly concerned about the role of government in healthcare, so I was excited to see an editorial in the Journal of the American Medical Association on “Building Trust Between the Government and Clinicians.” Co-authored by former CMS Administrator Donald Berwick, it notes that building such trust “requires understanding, empathy, and humility.” It encourages clinicians and policy-makers to walk the proverbial mile in the other’s shoes. The piece calls out several data points that are important – that the US spends nearly double what other similarly-developed nations spend on healthcare without significantly better outcomes or quality.

It goes on to note that some policy makers focus on clinicians who put self-interest above the needs of our society, resulting in the creation of systems to “guard the public from them.” It uses the example of Medicare recovery audit contractors who are paid based on the number of issues they find, putting all physicians on the defensive when only a few are committing fraud. The authors note that “out-of-control oversight and policing for the 1% who warrant this type of scrutiny burdens the daily work of the 99% who do not.” I think most of us in the trenches would agree. In 20+ years in practice, I’ve never had a prior authorization request or precertification request denied, yet I have to continue to jump through hoops to order medically necessary tests.

The editorial calls on clinicians and policy-makers to find common ground that supports both stewardship of resources and the patient care mission. This resonated with me. For policy-makers, achieving fewer and more efficient regulations would be more likely if they spent time understanding the position of the clinicians whom their policies affect. The realities clinicians actually face should provide a lens to view and judge new policies. Unless and until policy makers trust with their heads and feel in their hearts that the vast majority of physicians and other health professionals are well intentioned, they will continue to design policies around the exceptions rather than the rule. Policy-makers should regularly spend time visiting physicians’ offices and hospitals to better understand the ripple effects of policies on those providing care.

It’s similar to having software engineers actually visit clinician practices using the systems they design and create, so that they’re not operating in a vacuum. I’d love to see them observe the folly that my staff had trying to get a CT scan approved after the fact (emergencies don’t occur during normal business hours) when the payer was pushing back because my documentation of the patient’s abdominal pain did not use the word “severe.” I finally asked if anyone at the plan had actually looked at the scan results. Had they done so and seen the enormous and life-threatening pancreatic tumor that was found, maybe they would have toned it down a notch. Instead, they were arguing over semantics. Perhaps they would have preferred to care for a catastrophic event when it eroded through a blood vessel rather than the controlled hospital admission we provided.

They also call on clinicians to learn how the other half lives, understanding policy needs and learning about healthcare spending during medical school. In turn, “the vast majority of physicians who deserve to be trusted” would be rewarded with fast-track of pre-check systems like those used by the TSA. It remains to be seen whether legislators and other policy-makers will heed this advice, but we can be ever optimistic that perhaps someone will see through the money and special interests and give it a shot.

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I’m constantly re-engineering my home office and it’s easy for me to take a break because I can just wander to the sofa and put my feet up. Having spent entirely too much time in cubicles and small circulation-less conference rooms, I was intrigued by the idea of a nap desk. Naps are supposed to help improve mental awareness, but I’m not sure I would want to sack out under my desk even if it is made of stylish lacquered wood, metal, and leather. The desk is just a prototype for now, and unless you have your own office, I can’t imagine it would be terribly restful.

What’s your strategy for catching a couple ZZ’s during the work day? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 4/8/19

April 8, 2019 Dr. Jayne 4 Comments

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I recently attended my medical school class reunion. It was my first time attending, and since it was a “big year” for our class, I figured I should go. I didn’t know what to expect, but it turned out to be a great experience.

The way our school handles reunions is that it has a major reunion event every year, celebrating the classes every five years starting at the 10-year mark. This year was primarily for the classes of 2009, 2004, 1999, 1994, and so on. Once you hit a certain point (possibly 50 years?) they welcome you at every year. We had about 20% of my class attend, and according to the organizers, that was a pretty good turnout.

The festivities started on the hotel shuttle from the airport, where we got to see members of the class of 1969 figure out that they were sitting next to each other and had no idea they were in the same class. Watching their faces light up as they figured it out was hysterical. They immediately started swapping stories about what it was like to be in school 50 years ago. For us relative youngsters, a lot of it was the same, even though times have certainly changed.

We had a member of the class of 1954 on the bus. In her class were four women, and she was delighted to learn that our class was the first one to have more women than men (even if it was only “more” by one person.) Doing the math, we figured she had to be close to 90 years old, but you couldn’t tell. She had a walker, but was carrying it folded up rather than using it.

From there, it was on to a cocktail reception, where two members of the third-year medical school class plopped down at our table. One of my classmates started probing them on “what is it really like to be a millennial,” which was pretty funny. We learned that most of the class doesn’t actually go to class since all the sessions are preserved on video. Back in our day, we had a “note-taking service” that tape recorded every class. The class then took turns transcribing it and highlighting the key points, leaving you with a great set of notes. Although the new students don’t have to attend class, they miss out on the distillation done by their peers, so I’m not sure they’ve really built a better mousetrap.

We must not have scared them too much since they stuck around for most of the reception, although I think they were relieved to not have to attend any other reunion events after that one.

The next day was full of continuing education sessions and tours of the medical center, parts of which have become unrecognizable in a research grant-fueled construction boom. The medical library has very few actual printed materials any more, with the stacks having been replaced by individual study spaces and administrative offices. A new computer lab allows for computerized administration of the tests that have to be taken during third-year rotations, and student-focused spaces now include lounge areas, video games, and areas for extracurricular groups to meet. It’s definitely more student friendly, although there should be more student-friendly resources given the more than doubling of the tuition since I graduated.

Our tour guide,  a fourth-year student who will be graduating soon, seemed surprised by the state of medical education back in our day. We were thrown out into the world to learn our craft on “real patients,” but they have state-of-the-art simulator labs where they are put through a variety of proctored scenarios so they are better prepared for their internships. The latter half of the fourth year provides opportunities to complete life support and trauma certifications, where we had none of that exposure until we walked in the door at our internships.

I have to say I was a little envious about the preparation they are receiving, I think it will make internship a lot less shocking. Our guide was surprised to learn that as recently as we had graduated, we were not subject to duty hour limitations. Her eyes were wide at learning how often we took call and for how many weeks of the year. On most of her rotations she didn’t take call, and when she did, it was one day a week and the shift was limited to 18 hours.

There were presentations from various medical school leaders, where we learned about upcoming curricular changes that are aimed to better prepare students for the realities of medicine. My school has a strong track record for cranking out researchers and academicians, and I was interested to hear that they’re attacking precision / personalized medicine as a way to reduce costs. I had never really thought about it in the way it was presented, that even with the high cost of some of those treatments, the real savings is in patients you’re actually not treating with standard therapies that might not be effective. It will be interesting to see how that plays out in reality. There were also discussions about whether our school will join the club of schools that are providing full tuition scholarships for the entire student body.

Of course the highlight of the reunion was hanging out with classmates and learning what everyone has been up to in the new century. Some are wholly career-focused and driven, others have dropped out of medicine entirely, and there are several of us in-between. As much as physicians tend to talk about the importance of work-life balance, I was surprised to hear one of my classmates make a negative comment about women who had children during their residency training. Instead of celebrating their ability to juggle that level of complexity, he commented “what a strain that must have been on the residency program.” He backtracked a bit when one of the women mentioned that she only took four weeks off after childbirth, because that was the amount of vacation allotted to all residents each year and she didn’t strain the system any more than her counterparts who went to the beach.

Based on our interactions with current students, I suspect there is going to be a lot more tolerance for work-life balance concerns. There may be a steeper learning curve in residency due to the changes in work hour restrictions as students are exposed to scenarios they haven’t seen before because they simply weren’t in the hospital overnight. On the other hand, they may learn faster or better because their brains won’t be mush from working hellish schedules.

I had the privilege of talking with a 90-year-old urologist and getting his thoughts on how things have changed over time. Based on his family history and state of health, the odds are good that I’ll be seeing him again in five years.

Have you ever attended a class reunion? Would you do it again? Leave a comment or email me.

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EPtalk by Dr. Jayne 4/4/19

April 4, 2019 Dr. Jayne 4 Comments

CMS has launched an Artificial Intelligence Health Outcomes Challenge. The three-state competition is planned to “accelerate artificial intelligence solutions to better predict health outcomes such as unplanned hospital and skilled nursing facility admissions and adverse events.” The CMS Innovation Center plans to use the data “in testing innovative payment and service delivery models.” Partnering with the American Academy of Family Physicians and the Laura and John Arnold Foundation, CMS will award up to $1.65 million during the three stages.

CMS has decided to be confusing by naming the three stages “Launch,” “Stage 1,” and “Stage 2” rather than just numbering them. Launch is essentially an application phase, with 20 participants selected to advance to Stage 1, where challengers will design and test their solutions using Medicare claims data. Up to five participants will move to Stage 2 where they can refine their solutions using additional Medicare data sets. The grand prize winner will receive up to $1M with a $250,000 award to the runner up. Launch is already underway and the program will run through April 2020.

If you’re wondering how to further translate the CMS-speak, the goal is to build “explainable artificial intelligence solutions to help front-line clinicians understand and trust artificial intelligence-driven data feedback to target scarce resources and improve the quality of care.” CMS Administrator Seema Verma explained this further: “For artificial intelligence to be successful in healthcare, it must not only enhance the predictive ability of illnesses and diseases, but also enable providers to focus more time with patients. The power of artificial intelligence will truly be unleashed when providers understand and trust the data and predictions.”

I was talking about this with a colleague, particularly the focus on diseases rather than health and prevention. There are so many factors that could immediately impact both individual and population health parameters that don’t require a challenge or competition. We already know what needs to be done, but lack funding to do it. These not-so-sexy solutions involve things like public health education, social workers, and strategies to eliminate food deserts and improve healthy behaviors. AI is a pretty distraction from the difficult work that could (and should) be happening.

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Speaking of the challenges found in trying to improve healthy behaviors, there is much speculation on whether financial incentives make a difference. Many organizations including my own hospital have done this by increasing insurance rates for smokers or offering discounts for non-smokers or those who complete a biometric profile. Discounts for non-smokers seem to make sense because we know smokers have more illnesses thus higher healthcare costs; the benefits of a biometric screening, however, have not been proven. I know that for me personally, going for the biometric screening did nothing to change my behavior, but cost me a half day out of office.

A recent article in the Journal of the American Medical Association looks further at the effect of financial incentives on improving healthy behaviors. In a recent US-based randomized trial, lottery-based incentives tied to medication compliance didn’t lead to a significant reduction in cholesterol levels. Another study found lack of reduction of cardiac events or hospitalization even though patients could earn more than $1,000 for being compliant. Other studies including those looking at smoking cessation in pregnant patients do show some benefit for financial incentives.

The article looks at reasons why studies might not show successful incentive use, including bias created when patients self-select for a study, since those who self-select are more likely to be motivated to change behavior whether there is an incentive involved or not. These motivated patients “rarely represent the population most in need of support, yet they are most often targeted by trials.” There are also issues creating control groups and in timing study enrollment based on patients transitioning through “hot and cold states in which their motivation varies, potentially determining their response to incentives.” Another issue is offering an incentive that is too small for the desired behavior change, which can be a negative motivator when higher incentives may actually drive change.

The authors conclude that when incentive-based interventions are being designed, subtle factors need to be considered, including the size / frequency of the incentive, how it’s positioned, and whether the target population fully understands the incentive and the desired behavior.

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From Midwest Afficionado: “Re: pastry therapy. Here’s some for you, Dr. Jayne, in the form of an edible book festival.” Apparently, this is the third annual edible book festival at Washington University School of Medicine in St. Louis. Although submissions were welcome from any genre, there was a special award category for “Most Edible Medical Book.” Submissions will be eaten promptly at 2:30 p.m. Previous entries included a “Checklist Manifesto” Rice Krispy Treat and a tribute to “Grapes Anatomy.”

Data from a recent Kaiser Family Foundation tracking poll indicates that patients aged 18-29 believe EHR technology has led to increased quality of care and has improved provider communication. The age bracket caught my eye since if you consider the pre-MU era (pre-2009) to be solidly pre-EHR, most of these patients weren’t even adults, so it might be a difficult comparison. General public perception of the benefits of EHR has decreased – in 2009, 67% of patients believed EHR would improve care, but a decade later, only 45% believe it has actually happened.

Still, only 6% of respondents said they felt EHR has worsened quality of care and 7% felt communication has worsened. More than 20% of patients said they or a family member has found an error in their chart. More than half of respondents voiced concerns about unauthorized access to the medical record, although younger adults (that 18-29 year age group) are less likely to be concerned than other age groups. I suspect that group is used to having their data used or mined by third parties, or that perhaps they’re just so used to hearing about data breaches that it is less concerning.

The American Medical Association shares sound advice on the use of wearable health devices in practice. They note four main possible issues that should be considered when adding devices to the care plan. Patients might disengage before the benefit can be realized, either due to convenience or perceived lack of benefits. They might also ignore symptoms and rely too much on devices. Others may obsess over the data, resulting in anxiety. Last, they might try to interpret the data without physician help, leading to false-positives and additional intervention. It was a nice little review of what to think about, and should be helpful for physicians who don’t have a lot of experience with wearables.

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Curbside Consult with Dr. Jayne 4/1/19

April 1, 2019 Dr. Jayne No Comments

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It’s time for a trip through the reader mailbag. I apologize that I’m not able to respond to emails as often as I’d like, but sometimes it’s hard to manage not only a full-time job but my HIStalk gig and the volunteer work I do. I love hearing from readers and I feel like I’ve really gotten to know a handful of them even though we’ve never met or spoken. I’m always impressed by the thoughtful comments that people send my way.

Props to Epic’s MyChart team, who reached out to me in response to last week’s Curbside Consult detailing my experiences with Share Everywhere. They are concerned that it seems to not be working as designed and offered to troubleshoot it for me. I don’t want to risk de-anonymizing myself by revealing the institution, but they did have some good questions to help me further explain what I’m seeing so they can take a look. 

I also asked them to help me understand how patients are supposed to report issues since the hospital hasn’t seemed interested in the past at hearing about technical problems I was having with the billing side of MyChart. I would be interested in hearing from readers at other Big Health Systems on how they handle patient concerns about their patient-facing systems, whether Epic or not. It might make for a good post.

A reader sent some comments on my experiences with Share Everywhere vs. MyChart, further illustrating the issues with client-configurable features.

Like many tools made available by Epic, the healthcare organization makes choices and configuration decisions regarding MyChart, Care Everywhere, Share Everywhere, and Lucy. At our organization, problems, allergies, medications, test results and immunizations are all displayed with date information at the summary level as well as at the visit or encounter level. I had not looked at Share Everywhere for some time and was surprised that we do not display provider office notes in the Share Everywhere view. We do make office notes available to our patients, however. We need to explore whether this is an Epic limitation or a configuration option that we have not enabled. New functionality that we are almost ready to enable is sharing radiology images across the Care Everywhere network. Again, Epic provides the capability, we are responsible for configuring and enabling as is every other Epic customer that has chosen to participate in Care Everywhere. We also must choose to make incoming images available to our caregivers, just as other organization will need to decide if they choose to accept and make available images.

No props for the handful of emails I found in my box from people asking if I’m interested in guest posts from the people they represent or asking how they can contribute to HIStalk. It’s immediately obvious when I see those that they’ve never actually read the site or they would know about Readers Write.

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Props to the couple of people who reached out to wish me a happy Doctors Day. Although it’s celebrated on March 30 in the US, other days are used in other countries. For example, Iran commemorates it on Avicenna’s  birthday, at least according to Wikipedia. In the US, it recognizes the anniversary of the introduction of general anesthesia using ether in 1842. I’m truly glad we don’t have do bite-on sticks after a slug of whiskey and that we now have less-flammable options.

However, I’m giving negative props to the American Academy of Family Physicians, whose celebratory email offered a discount on AAFP products and conferences, but only for the day. Most physicians I know have AAFP communications routed to their work email addresses and it was a Saturday, so I wonder how many takers they had. I would think they’d have a better handle on how busy their members are and consider offering the discount for at least a couple of days to allow people to take advantage of it.

One of my favorite correspondents sent some thoughts on interoperability and mental health and substance abuse data. They also sent their comments around my mention of the Duke whistleblower settlement:

As to whistleblowing, I was much more idealistic in my youth and pointed out issues to people in authority at my institution that I thought were problematic (generally related to serious patient safety issues, occasionally compliance issues).  Suffice it to say, these minor attempts at whistleblowing never went well for me and never resulted in any significant changes either. I’ve been tempted to “drop a dime” on my hospital to Joint Commission or the department of health, but they always seem to eke through CMS visits with immediate jeopardy in the balance, so the likelihood of any action on a higher scale seems minimal.  It is clear that hospital and departmental leadership can be vindictive to people who throw shade on them despite touting a “just culture.” Without an airtight case, which is virtually impossible to get, whistleblowing seems like more trouble than it’s worth. For every person who gets a big cash payout for whistleblowing, I’m sure there are many more well-intentioned people who will struggle to find another job as a result of their efforts.  For these reasons I’m much more circumspect in my old age and focus on flying under the radar and not making waves.

I’ve had that experience as well, being branded as “frequently dissatisfied” in an evaluation by one member of my residency’s faculty because I used to bring suggestions for improving the program or making things better for the learning environment. I learned quickly that they didn’t see feedback as a gift and that any suggestion would be received as a criticism. Needless to say, when I was selected to be chief resident, my first order of business was to implement the majority of things I had been asking for since I was an intern. Rumor has it that the “New Intern Handbook” we created that year is still in circulation, providing information that no one tells you in medical school, such as how to pronounce a patient dead when you get that call in the middle of the night.

On the topic of EHRs being responsible for the downfall of the patient-physician relationship:

Not too long ago, our group surveyed members and only one person made any remarks about the computer and that was “the EMR sucks.” Everyone else mentioned low salaries, poor communication from leadership, deteriorations in workplace safety and increased staff injuries, excessive emphasis on RVUs, and lack of respect for clinicians by leadership. I really don’t believe EHRs are the root of all evil.

I didn’t have to worry about anonymizing the comment, since those are the same issues I heard at the last meeting I attended of my hospital’s emergency medicine attending physicians.

I’m going far into the wayback machine on this one, but I posted in February about my flashback on the Addressograph machine. Apparently extinct technology is a hot topic:

The addressograph brought back memories! One of my first tasks in healthcare was to write program for the machine that produced those cards. We reprinted those cards every other day for inpatients because the numbers and letters would wear out. Later when I was in management I worked to replace them with stickers. The ward clerks did not want to give up their addressograph machines!

Addressographs were definitely a lot of fun! (Though the smell wasn’t quite as good as freshly printed mimeograph,) They were also very practical in terms of quickly getting an index card with the key patient info at the top that could be used to keep signouts much more efficiently than our current electronic physician handoff page. A saved index card was also like gold when the patient bounced back, unlike the current physician handoff that gets deleted at discharge.

I had forgotten about those signout pages. For those of you who are not on the provider side, when the resident physicians leave for the day, they sign out to the on-call team, which is responsible for covering patients they may never have met. In the olden days, we would meet with the on-call resident before we left the hospital. We would pull those sheets from our white coat pockets and give a brief rundown on the patients we had been caring for. The sheets might have included med lists, labs, problem lists, and other tidbits of information that would help the on-call team know what to do if an issue came up with the patient. Some of us even got fancy and created templates for our sheets to ensure we wouldn’t forget important information. The size limitation forced you to be concise and only focus on the most important information, which is probably becoming a lost skill from the voluminous charting we have in the EHR.

Another reader waxed poetically about dial up modems:

I also found there was something satisfying about hearing the sounds that meant your modem had connected and the old acoustically coupled dialups (where your phone receiver went into the rubber connector) were very amazing at the time.  It definitely beat standing in line at the computer center with a giant stack of keypunched cards (praying that you didn’t drop them and have to put them back in the right sequence.)

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The “antique” technology that had the most mentions isn’t antique at all since it’s still in use at many hospitals — the beeper:

My favorite old technology has to be the old versions of beepers. When I was an intern, beepers just beeped. Nothing else. You called the paging operator and they gave you your message. These beepers had two advantages: you could cross your arms in a boring lecture and surreptitiously turn them off and back on again, which would make them beep. Then you could quickly escape to go outside to the hall phone and address your “page.”

The Motorola Adviser was my workhorse pager during residency, and according to one reader:

It has been granted eternal life. We still have them (and fax machines). Everyone has been saying for years that we should switch to cell phone “paging,” but there are cell phone dead zones and the beepers have much better coverage.

I’m closing up the mailbag for now. Keep those virtual cards and letters coming!

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EPtalk by Dr. Jayne 3/28/19

March 28, 2019 Dr. Jayne No Comments

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For your entertainment pleasure, ONC has released the public comment submissions received on the “Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs” document. More than 200 comments were received, with the majority being in the areas of HIT usability and clinical documentation. My personal favorites:

  • I believe that part of the reason that only 30 PERCENT of physicians practice independently and that most are now employed is the push for EMR usage and all the administrative burdens associated with it. Add the “click the button” game and more will leave. (Michael Richter MD)
  • Thank you for finally throwing a life to all physicians! One of the biggest blunders made when HER’s (sic) were approved was not mandating interoperability. This single mistake is costing the Health Care System in the United States billions of dollars every month. Please act now on this blatant oversight / mistake. The time to correct it is overdue. Also, it is time to spend some money on plane tickets to visit countries like Italy, France, Germany and Japan to name just a few, and learn how they have better outcomes at half the price we pay. Being ranked 37th in the world is not good. Our infant death mortality statistics and ranking is pathetic! (Joseph S. Testa MD)
  • i have not seen any reliable study that has concluded that the adoption of electronic health records in doctors’ private offices has led to improved health care or reduced costs of health care. As a frequent recipient of electronic health care records, I have found this mode of information retrieval is more often an impediment than an asset; as vital data is never highlighted and is usually either omitted or buried within a large file of irrelevant data. Within the hospital setting, I have found electronic health records to be a life threatening obstacle to patient care. When a computer monitor takes the place of a simple vital sign monitor, I’ve had to wait for as long as ten minutes for nurses to acquire the simplest of vital sign measurements. In my community, had the local hospital been motivated to spend the same money on health care that was wasted on an overly complex and inefficient computer system, our town would be enjoying the finest health care at no cost whatsoever. Instead, tens of millions of dollars leave the community to pay for a large computer service corporation. (Michael Steiner MD)
  • Our staff and physicians have nicknamed our system The PDS (practice-destroying software). (Howard Green MD)
  • The cost and complexity of EMR system maintenance and exponentially increasing regulatory requirements force doctors into large groups where we are relegated to data entry and coding tasks rather than the patient care we trained for. We are clearly expendable… End direct to consumer advertising for medications and durable medical equipment. (The author didn’t include his identifying information in his document, so once I downloaded it, I had no idea which submission it was.)
  • EHRs have been created for effective billing tools. CMS contractors are NOT following the CPT coding guidelines agreed to by all other stakeholders creating tremendous chaos and dissatisfaction. So adding EXTRA work to a process that was already stressed expecting a different result is insane. So payments should include costs for scribes to input the data in order to reduce physician burn out as we have aging population and will need MORE physicians to care for them. AI will not do it. (Another one that became de-identified when I downloaded it.)
  • The EMR was not designed with the end user in mind. It was designed with government and insurers in mind. It was never designed to help improve “quality” but rather make it easy to mine data and make insurance companies look good. I have opted not to participate in obtaining such a system because there is no compelling reason to do so. (see above) If you want physician buy in, you would have to scrap the current systems and start with the physician in mind. You would need to make the physicians job easier, not harder. You would have to be honest about the motivation to pursue an EMR. It should be made optional, and let it be bought on its own merits. If it has no merit; it won’t be bought. Remember that physicians are not stupid. Any attempt to market an EMR with hidden agendas will be discovered, and the reception lukewarm at best. Good luck. (Also de-identified on download – learn to sign your documents, folks!)
  • In healthcare, focus not on cure. but care. Ailing patients need care and it can even be provided by 3rd, 4th, 5th, or even any one person outside the family. Exceptional cases are there that at times like Tom Hanks in Cast Away was being motivated by a basketball which he perceives as a man talking to but its rare and it needs a healthy young man to do so but A Patient is a Patient. (Anonymized by download.)
  • However, the draft Strategy does not appear to recognize the investment that providers must make to train staff, procure and implement new systems, migrate and secure data, and respond to patient requests for assistance with healthcare data. For example, for the past several years my PCP requires an annual fee of $150 to help offset the cost of compliance with insurer and regulator IT standards. We just received a letter notifying us that his annual fee will raise to $1,800.00 per patient in 2019. My family of six cannot afford to spend $10,800 to be his patients. Neither can my elderly family members who were patients of the same PCP but who now struggle to find local providers who accept Medicare patients. HHS can begin to address these issues with a recognition of the costs and challenges faced by providers– and ultimately their patients. For example, the CMS fee schedules should be revised to reflect the costs of training, IT infrastructure maintenance, and patient educaton. The cost of annual IT Security training should included as directly attributable to the cost of care. (Martin O’Connor)

Most of the vendor submissions were lengthy, but I commend Epic for their two-page submission that calls out two key elements, one of which is the fact that “the electronic patient access timelines for Medicaid Promoting Interoperability are not aligned with Medicare Promoting Interoperability or MIPS, causing additional complexity for provider organizations and software developers, despite previous indications that the programs are intended to be aligned.” Whoops!

Healthfinch included the adorable Charlie on their submission as they championed the need for ONC to include delegation of routine tasks into strategic goals. They also ask for recommendations that state boards “address inconsistent and unclear “scope of practice” guidelines.” Can I have an amen from the congregation?

Intelligent Medical Objects (IMO) sent a very organized submission with a table of contents. The fact that they cited the original text then followed with their comments for each point they were making helped tremendously compared to other submissions. I was also interested to learn about an organization called the “Partnership to Amend 42 CFR Part 2” whose goal is to align various privacy rules to allow appropriate sharing of health information around substance use disorders.

One community hospital quality coordinator sent a submission that had at least seven fonts in it, which forced me to stop reading since it felt like a ransom note. I was surprised by the number of typos and grammar errors in some of the submissions, as if spelling and grammar checks weren’t run. It’s hard to take comments from a Top 3 EHR vendor seriously when the author hasn’t edited properly for its vs. it’s. Another submission was clearly written in Notepad, which is always entertaining for us IT folks.

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The only other exciting conversation this week was around the Duke University whistleblower settlement. Lung researchers were caught faking data for inclusion in grant applications to the National Institutes of Health, resulting in a $112.5 million False Claims Act settlement. The whistleblower is a former staffer in the department. He’ll receive 30 percent of the settlement, which is a good amount since his career as a research biologist is likely to be over. The US government will receive the balance. There was a fair amount of misconduct in the involved labs, with the need for retraction of 17 scientific articles to date as lab technicians either falsified data to document a desired result or sometimes failed to even conduct experiments where data was recorded.

Would you ever risk it all to be a whistleblower? How serious would the situation have to be? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 3/25/19

March 25, 2019 Dr. Jayne 15 Comments

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Back in November 2017, the Epic-using world was abuzz about Share Everywhere, which was supposed to let the rest of us who are using other systems have one-time access to key patient information such as medication lists, problem lists, test results, allergies, and possibly physician notes. I remember from the announcements that the feature was version-dependent and figured it would take some time for the most current general release version to roll out to the various health systems that surround our independent urgent care.

Share Everywhere allows patients to generate an access code that allows the patient to give access to a provider, home health worker, therapist, or other member of the care team who doesn’t already have access to the patient’s Epic chart. It’s supposed to be accessible through MyChart. Since anyone in my city who has been hospitalized in the last year has been cared for on an Epic system, I figured a year would be enough for the hospitals to roll out the latest and greatest so that patients could let our urgent care providers peek behind the curtain at their records.

Now that flu season is starting to abate and I have a little more time to breathe while I’m talking with patients, I decided to make a concerted effort to ask patients about their use of MyChart in general and Share Everywhere in particular.

Patients frequently pull up information on medications, whether it’s from MyChart, the Walgreens app, or their CVS profiles. Some even access their pharmacy benefit manager, such as LDI or Express Scripts. Many patients still carry a paper copy of their medication list in their wallet, often with strike-outs and additions.

Today, I had four patients offer to pull up their account in MyChart. None of them had any knowledge about Share Everywhere or how to access it. I decided to go digging for it myself once I got home, accessing my account at Big University Hospital. Once I found the link at the bottom of a little-used tools menu, I generated a code for myself.

Despite having an accurate problem list in my patient-side account, the “share” version of my chart was lacking a problem list of any kind. It’s basically blank. The medication list contained a list of items that didn’t show any date of prescription or the name of the prescribing provider, only the person documenting it whose name I didn’t recognize. Only the items documented pre-Epic that came in with a conversion had start dates. Allergies were up to date (fortunately) but immunizations were blank. I found some useless test results that all said “see scanned report.” The family history information was clearly entered by the clinical geneticist I saw a while back, based on its specificity. There wasn’t any kind of a list of providers, which might be useful for patients that see a few more providers than the two I see each year.

Going back to MyChart, I also found a “Wallet Card” feature I had never seen before, which was supposed to have a “convenient, printable summary” of my medical information. The diagnosis list was blank, the medication list was blank, the allergies were blank, and it included a work phone number where I was last seen in 2007. I’m not sure how it’s even in the chart since I make sure to review the updates every time I’m seen at a practice, but it’s in there nevertheless. I found a handy way to print my eyeglasses and contact lens prescriptions, but unfortunately it doesn’t have my name on it or the name of the provider, so it’s not useful to try to get lenses dispensed. Good idea, poorly executed.

I’m a curious person and I was on a mission, but I wonder how many other people know these features are available to them or how to use them? Certainly Big University isn’t sending out an email telling patients that if they wind up at another place’s emergency department or an outside urgent care, here’s the best way for that competitor to access their records.

Now that I know how to tell patients how to find the Share Everywhere code generator, I’m at least able to go back to my desk and peruse their records without having to try to read them on a phone in the exam room. I’m not due to go back to Big University as a patient until at least July, so I’ll have to try to clean up the phone number issue at that point. I’ve learned from battling the billing team through the patient portal that it’s not worth trying to deal with it remotely. It hasn’t been effective in the past and I ultimately have to call a physical office.

We’re still a long was from patients being able to truly hold their records in the palms of their hands, but at least we’re taking baby steps. Maybe I’ll start a grassroots movement to have patients actually review their records and inundate the health systems with correction requests where needed. Depending on the volume, it might spur some changes in documentation habits or help providers understand that there are people outside their own system that are seeing what they are putting into charts. I’ll have to follow up with some of the more senior members of my family that have more extensive records and see what resemblance theirs bear to reality.

I’d be interested to hear from non-Epic providers whether they’ve had much utility with Share Everywhere and whether other hospitals and health systems are doing a better job keeping it accurate than mine is apparently doing. And from patients, are you aware how to generate a token for your providers to access your information? It’s only good for five minutes, so you have to do it right there, but in the right circumstances it would be useful. I’m also curious whether the other major software players have similar access for outside providers. If you can point me in the right direction, I’ll start polling patients. It’s got to be easier than watching people try to populate an intake form from memory.

When’s the last time you shared your record? Leave a comment or email me.

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EPtalk by Dr. Jayne 3/21/19

March 21, 2019 Dr. Jayne 2 Comments

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Several people texted or emailed links to the recent Fortune /Kaiser Health News investigative article on electronic health records. I enjoyed the video sound bites at the beginning, where various members of the US government were extolling the benefits of electronic records. The piece hooks the reader by opening with a story that details a patient’s death from a brain aneurysm, with the lack of diagnosis being influenced by failure of the head scan order to be transmitted by her physician’s EClinicalWorks EHR.

The article goes on to detail a stunning array of patient safety issues and medical errors tied to EHR use, noting the gag clauses that vendors use to keep their clients quiet. eCW isn’t the only vendor called out in the article – Epic, NextGen Healthcare, Allscripts, and Greenway Health were noted as having been the target of lawsuits and complaints.

It’s a long article, but worth the read. It reminded me of some of the industry’s antics during the push for EHR adoption that I had forgotten: the availability of eClinicalWorks systems at Walmart’s Sam’s Club and various vendors holding nationwide “stimulus tours” and “cash for clunkers” roadshow dinners that offered physicians an opportunity to switch to a new EHR.

Although there wasn’t anything truly shocking in the article, I wonder what non-industry people would think about its content and how the events unfolding in the EHR industry parallel (or don’t parallel) what might be going on in other industries. I’d be interested to hear what any non-health IT folks who read the piece think about our little slice of the economy.

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The National Resident Matching Program, a.k.a. “The Match,” was held last week. This year’s process was the largest on record, with 44,600 applicants vying for more than 35,000 residency training positions. Not surprisingly, newly-minted physicians voted with their feet and their pocketbooks. Competitive specialties that filled all available positions included interventional radiology, otolaryngology, plastic surgery, and thoracic surgery. Many of those filled more than 90 percent of their slots with graduating US allopathic (MD) seniors.

Despite the fact that primary care physicians are supposedly in demand, specialties that filled fewer than 45 percent of their slots with US MD seniors included family medicine, internal medicine, and pediatrics. The remaining primary care slots are being filled by osteopathic (DO) seniors and international medical graduates. Until things change dramatically, we’re going to continue to see medical students shy away from the parts of the workforce where they’re needed the most.

I ran across an interesting piece on how working long hours and weekends might affect men and women differently. The underlying study looked at workers in the United Kingdom and found that women are more negatively impacted by long hours. Working on the weekend impacts both subgroups, but in different ways. Women working long hours were more apt to show depressive symptoms than those who worked fewer full-time hours or part-time. Men working long hours didn’t show a significant rise in depressive symptoms.

My family lives in an “opt in” state for data sharing on the state’s health information exchange. Fortunately, the big players in their town all participate. When my uncle was recently hospitalized at Big Health System, my dad was excited to find a pamphlet on the value of opting-in to HIE sharing while going through the admissions documents. Since he understands the value of having multiple clinicians be able to share data, he went to the nursing station to obtain the appropriate forms to opt his brother in. The person he talked to seemed surprised to learn about the pamphlet and didn’t have any idea what forms were needed. He was redirected to the medical records department deep in the bowels of the hospital, and they didn’t have any idea either. He was forced to call the number on the pamphlet to try to get information, which wasn’t terribly fruitful. Documentation 1, Patient 0.

Walmart is taking advantage of domestic medical tourism by sending patients across state lines for consultations and second opinions. The company’s Centers of Excellence Program matches patients with a short list of hospitals, including Mayo Clinic and Geisinger Medical Center, for certain surgeries and treatments. While it was optional for the first six years it was in existence, participation has been required since 2018. Geisinger plans to expand similar programs to other companies besides Walmart. This approach is quite a change from what many of my patients experience, where they can’t find specialists who even accept their insurance.

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Maybe your mom was right: going out and getting some fresh air can be a game-changer. A study recently published in the International Journal of Environmental Health Research shows that spending 20 minutes in a park can improve wellbeing. Participants visited urban parks in Birmingham, Alabama during the summer and fall. From experience, being outside in the summer in Alabama can be a challenging mélange of heat and humidity, so I’m glad they included another season. Subjects weren’t told what to do in the park or how long to be there, but were monitored with fitness trackers and questionnaires. Wellbeing scores rose in park attendees.

Washington DC-area pediatrician Robert Zarr has been a fan of sending patients outdoors for a long time, founding ParkRxAmerica to help providers “prescribe Nature” as a way to decrease their patients’ burden of chronic disease and increase health and happiness. Zarr believes that writing the prescription in the EHR just like a medication makes it more specific and motivates patients to actually follow the instructions. This has also been done by National Health Service GPs with good outcomes. The US National Park Service has a Health Parks Healthy People program to advance the idea that “all parks – urban and wildland are cornerstones of people’s mental, physical, and spiritual health, and social well-being and sustainability of the planet.” People who know me know I’m a huge fan of the US National Park Service, and after paying my recent tax bill, I’ve decided to visualize 100 percent of my federal taxes going to support it. I made it to Redwood National Park last summer and would be happy to write a script for anyone who’s interested.

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

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Curbside Consult with Dr. Jayne 3/18/19

March 18, 2019 Dr. Jayne 5 Comments

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There was another big story about telemedicine in the news this week, this time about a young man who had to undergo what sounds like a competency evaluation via video prior to signing a “do not resuscitate” document. Regardless of the telemedicine situation, the story is heartbreaking. A young man with testicular cancer is dying. His wife did not have power of attorney, and it sounds like the hospital was concerned about his ability to legally sign the document.

The focus of the story is the telemedicine angle, whether it’s poor connectivity, level of compassion, etc. I haven’t seen a news piece, however, that addresses the other issues that are brought to light by the situation. Namely, how it got to that point in the first place.

This was a patient with a recurrence of testicular cancer, which is a serious situation. Of course, we don’t have all the medical details of the case, but there are some non-medical issues at play here. For an oncology patient with a young family, we should hope that a comprehensive advance care planning session should include not only discussion of end-of-life wishes, but also the need to have the appropriate legal documents in place. These discussions need to happen early in treatment, while the patient can discuss with their family and make good decisions and before events unfold that put decision-making capacity in question.

Seeing the pictures of his young daughter made me wonder if he had a will, and if so, did the attorney involved (if there was one) also advise on advance directives and power of attorney documents? We always think about healthcare organizations supporting patients in these situations, but what about legal organizations? Are there channels for attorneys to volunteer services to families like this to ensure they have the supports they need? Why is it always the physicians and hospitals that bear the brunt of responsibility for failure in these heart-wrenching situations?

I know I’ve covered this topic before, but everyone needs to have these conversations, whether you’re sick or well. We never know what is going to happen, what illness or speeding car might strike us down. However, in the situation where someone potentially has a terminal illness, it should be happening without fail.

I don’t know about the laws in the jurisdiction where this story occurred, whether a psychiatrist specifically was needed for the determination of capacity or whether anyone else in the hospital could have done it. We don’t know if this was the middle of the night or the middle of the day. Perhaps the video consult was offered up as a way to speed things, if it would have taken longer to bring the appropriate clinician into the hospital. There aren’t a lot of facilities that keep psychiatrists in-house at all times, so maybe the choice that was made was the best one at the time even if it didn’t play out as the family expected. Approaching end of life is challenging enough even when all the paperwork is in place and the family is supportive of the patient’s wishes. 

My thoughts go out to everyone involved. I encourage everyone out there, young or old, healthy or not, to have these conversations with your family members and to make sure you have the right paperwork in order to make the best of a terrible situation when the time comes. Eventually, death comes for us all.

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Another situation I ran across this week that demonizes technology without addressing other “comorbid conditions” was an interview with Eric Topol. This time, EHRs are the bad guy, but artificial intelligence is going “make healthcare human again,” at least according to his newest book. I don’t know Dr. Topol other than by what I have ready in his books and in various interviews, but I’m awfully tired of people who seem to have all the answers to what are undoubtedly very complex problems.

Topol lists EHRs as “the single worst part of the deteriorating doctor-patient relationship.” Although I agree they’re a factor, I personally think the worst part of the deteriorating relationship is the devaluation of the relationship itself. Because our medical system in the US is so broken, people no longer value the concept of a lifelong primary care physician who is going to know you as a patient and understand what optimal health means for you. We’ve sacrificed it on the altars of cost and convenience because those elements are more important for many of the people in our society. We’ve decided that it’s more important to treat populations (numbers) than people (outliers) and have incented people to behave in a way that supports that. Providing clinical expertise has become transactional and commoditized.

I feel this acutely every day that I see patients, especially on those days when I am part of a story that starts with a seemingly minor medical problem and ends with, “I went to the urgent care and now I have cancer.” I never dreamed that as an urgent care physician I would diagnose the number of life-threatening conditions that I see on a regular basis. It falls to us because people don’t have primary care physicians, they can’t get in to see them, or they can’t afford to get medical care. Once I diagnose people and refer them to the appropriate subspecialists, they’re generally lost to me unless they follow up with a card or a note. However, they don’t leave my mind and their stories haunt me every time I see a patient with a similar presentation.

Fixing EHRs isn’t going to fix the fragmentation in care. First, we have to decide as a society that unfragmented care is important. We have to decide that primary care and public health are important and we have to support those decisions with our pocketbooks.

I have a friend at a large health system that just spent half-billion (with a “b”) dollars on an EHR rip-and-replace. How much was she able to get as a grant for a school-based health clinic to serve children who never see a physician or other clinician? Zero. She had to pull together a coalition of community organizations to fund it despite her non-profit employer sitting on one of the largest cash reserves in the nation.

Topol says EHRs are “uniformly hated” and that’s just not the case. Sure, we dislike clunky interfaces and click-happy screens, but we sure love being able to process a drug recall in 90 seconds and notify 10,000 patients with a dozen clicks. We never loved our paper charts (and some of us hated them), but in reality, how many people “love” the tools they use for their work? Do mechanics love their tools? Do bankers love their tools? Do teachers love smartboards more than they loved chalkboards or whiteboards? Talking about the dynamics of love/hate just raises emotions and makes it harder for us to rationally evaluate what we’re really working with and how we are able to use it well vs. struggle with it.

Topol does at least give a passing mention to the healthcare disparities in the US, noting that increased use of AI and data “could make things much worse if these tools are only provided for affluent people.” We’re already at that point, where people struggle to pay for basic healthcare. If we can’t universally deliver vaccines (proven cost effective) to all people, are we really going to be able to afford gathering and analyzing all their data (not yet proven to be as spectacular as some people think)?

Fixing the EHR might make the day smoother, but it’s not going to fix the major underlying issues in healthcare. It’s not going to fix a hospital system that lowballs physician salaries in the name of value-based care, but turns around and builds a multi-million-dollar imaging center. It’s not going to fix an insurer that will pay $30,000 for a gastric bypass for a teenager after it wouldn’t pay $2,000 for an intensive weight management program that might have prevented or delayed the need for bariatric surgery. It’s not going to fix nursing ratios on patient care floors that are inhumane, not to mention unsafe.

I don’t have all the answers, but I’m pretty good at stirring up a discussion. What do you think is the worst part of the deteriorating patient-physician relationship? Leave a comment or email me.

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EPtalk by Dr. Jayne 3/14/19

March 14, 2019 Dr. Jayne 1 Comment

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Today was a Google Cloud kind of sock day, and I have to say these made me smile with their stethoscopes, microscopes, and miniature DNA. These beauties (along with many of the other socks given out at HIMSS) are from Sock Club, which designs their socks in Austin, Texas and manufactures them in North Carolina using cotton sourced from the southeastern US. Perhaps I see some locally-sourced HIStalk socks in my future.

CMS has released an updated version of its Security Risk Assessment tool. Many organizations I’ve encountered fail to appreciate the importance of the Security Risk Assessment, which is required under HIPAA. Some clients think that SRA is something their EHR vendor does for them and don’t understand that it’s not just about the technology, but also about compliance with physical, administrative, and technical safeguards. CMS has always had free tools, but they hadn’t been updated in a while. This one was release in October 2018.

Speaking of CMS, there is less than one month remaining for eligible clinicians to submit their MIPS Year 2 data for the Quality Payment Program. The system closes at 8 p.m. ET on April 2, 2019. CMS Web Interface users must report their Quality performance category data by 8 p.m. ET on March 22, so that deadline is even shorter. Good luck to everyone who is making the final push before submission.

It’s also time for the annual Call for MIPS Quality Measures. CMS is looking for measures to consider for future years of the Merit-based Incentive Payment System (MIPS). Recommendations can come from the domains of: patient safety, person / caregiver-centered experience and outcomes, communication / care coordination, effective clinical care, community / population health, and efficiency / cost reduction. Measures can be submitted through the ONC-JIRA system. You can learn more about the measure selection process here.

Congratulations to the 178 physicians who recently became board certified in clinical informatics, bringing our overall number to more than 1,800. There are yet more physician practicing in our field who are unable to be certified because they may have let their primary board certifications lapse. I’m looking forward to the day when we can be either primarily certified in clinical informatics or when we will be allowed to recertify without a current primary board certification.

As a former family medicine physician with a traditional practice, I realized all too quickly in practice that a good portion of my job was sales – trying to convince patients to “buy” something they didn’t want, such as healthier behaviors or medication compliance. Even in the urgent care setting, I’m constantly trying to sell patients on the benefits of symptomatic treatment for their viral illnesses rather than throwing antibiotics at anything that sneezes, runs, or coughs. I enjoyed this Health Affairs article  that looked at the idea of rewarding patients financially when they choose lower-cost alternatives.

The study looked at more than two dozen employers with almost 270,000 eligible employees and dependents. It was in play for more than 100 elective procedures, including advanced imaging (MRI, CT) and joint replacement surgeries. Patients who chose lower-cost alternatives received between $25 and $500 cash depending on the nature of the procedure and the relative cost of the provider. Although the savings only translated to a 2.1 percent reduction ($8 per patient), it resulted in an overall $2.3 million in savings annually. The largest effects were in MRI and ultrasound imaging. There was no savings seen with surgical procedures. The authors note that “this structure is appealing to employers, because compared to alternative programs such as high-deductible health plans or reference pricing, it encourages patients to price shop without exposing them to increased out-of-pocket spending.”

Until recently, I received my mammograms at an independent physician-owned imaging center that delivered high-quality services at a fraction of the cost of the local hospitals. Some quirky genes led me to enroll in a local medical center’s high-risk breast cancer surveillance program, which includes alternating mammograms and MRIs with increased frequency along with input from genetic counselors, surgeons, and other members of the support team. The cost is certainly higher than the independent imaging center and I’m able to understand the risk/benefit equation better than the average patient, for whom this could be challenging. Data is evolving so quickly it’s difficult at times to make these choices. I’m still not sure about the risk of gadolinium contrast deposition in my brain and whether it’s making me wacky, so if anyone is a neuroradiologist and has an opinion, let me know.

A team from Harvard University is partnering with the US Department of Health and Human Services to better understand attitudes towards health data, accessing it, and what patients know about their rights. Take a minute to complete their survey. Thanks to Amy Gleason @ThePatientsSide for sharing.

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Not all tech is good: The US Food and Drug Administration issues an alert that patients and providers should be cautious regarding robotically-assisted surgeries for mastectomy and other cancer-related surgeries. The FDA has not granted marketing authorization for any cancer-related surgeries and states that “survival benefits to patients when compared to traditional surgery have not been established.” Robotically-assisted surgeries use small surgical site incisions and can reduce pain, blood loss, and recovery time compared to open surgeries. The FDA goes on to say it “is aware of scientific literature and media publications reporting poor outcomes for patients, including one limited report that describes a potentially lower rate of long-term survival when surgeons and hospital systems use robotically-assisted surgical devices instead of traditional surgery for hysterectomy in cases of cervical cancer.”

Hospitals love to use the robotic devices for marketing campaigns because being high tech is sexy. As a physician, it’s more important to me to make sure I have a surgeon who has a high-volume practice in a particular procedure and performs that procedure at a facility which also has a high volume of those procedures. Those two factors have been shown to improve outcomes compared to lower-volume surgeons and facilities. The amount of training that providers receive on robotically-assisted procedures can be highly variable and is an important question for patients to ask as well.

Medscape released its 2019 “Family Medicine Physician Lifestyle, Happiness, & Burnout Report” last month. Here are the takeaways that caught my attention:

  • Plastic surgeons are the happiest, at 41 percent
  • Family physicians are nearly twice as happy (52 percent) outside of work than they are at work (23 percent)
  • We cope with burnout by eating junk food (35 percent), drinking alcohol (22 percent), and binge eating (19 percent) but we’re not using marijuana (0 percent)
  • We drive reliable, economical cars: 23 percent Toyota, 18 percent Honda
  • Nearly one-fifth of us don’t have spiritual or religious beliefs
  • 17 percent of us have had suicidal thoughts and 1 percent have attempted suicide

The last item is particularly sobering and weighs heavy on me as I approach a milestone reunion for my medical school class. We lost one of our dear classmates during the last semester of our fourth year. The American Foundation for Suicide Prevention has resources specifically for health professionals. If you are in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or text the Crisis Text Line by texting TALK to 741741.

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Curbside Consult with Dr. Jayne 3/11/19

March 11, 2019 Dr. Jayne 6 Comments

My HIStalk team mates have already mentioned the sensational news item about a patient being told about a poor prognosis through telemedicine. It was a hot topic in both professional and personal circles this weekend, with reactions from outrage to understanding, so I wanted to weigh in.

Depending on which version of the story you read and who was writing it, the story ranged from “a robot told him he was going to die and they didn’t have any idea before that” to a much better explanation of what actually happened. I’ve seen the video clip, and although certain aspects of it aren’t ideal, it’s often challenging to have these kinds of conversations regardless of how they are held. Some of the challenges we face are unique to current attitudes in the US about technology, medical care, and death.

We’re so used to seeing miraculous recoveries on TV and in the media, whether fictional or not, that we’ve become detached to the realities of what can happen when you go into the hospital. For those of us on the inside, there’s less of a mystery. I’ve seen a healthy, 30-something physician roll onto the labor and delivery unit with her advance directive and healthcare power of attorney in hand, making sure that we understood her wishes because she knew what could happen. The nurses joked about it, but I knew she was serious. It’s not something the average expectant mother thinks about, but it’s a statistical reality, and some of us see the horrors that can happen every day.

I wish more people understood that the hospital is not an episode of “Grey’s Anatomy.” If you wind up in the intensive care unit, there’s a good chance you won’t make it out. And if you do improve, there’s a chance you might not be the same.

We are so focused on being able to do everything and overcome anything that we forget about the realities of age and that fact that you just can’t outrun the statistics no matter how hard you want to. A person of a certain age with underlying chronic conditions who goes into the hospital in respiratory distress has a significant chance of not going home. Our culture is so engrained in “battling” diseases and “the fight” that we push realities to the side. Physicians struggle with being the bearers of bad news, but we don’t do any service to our patients when we are overly optimistic.

For those on the receiving end of bad news, everything is colored by experience. If this is your first time experiencing the impending loss of a family member, you may receive it differently than someone who has been through it before. Whether you’re religious or spiritual and your own beliefs about death influence what you hear. It’s difficult for the care team to know where anyone is in this particular journey, especially with the fragmentation in healthcare today. Often the realities of today don’t include a patient being cared for by their family physician of 30 years at the bedside. There may be emergency physicians, a hospitalist, an intensivist, and multiple specialists. Maybe the patient has that family physician, but they’re hundreds of miles away from home when the unexpected happens. Maybe the patient has a nearby support system, maybe they don’t.

In the first half of the 1900s, people knew what death looked like in real life and they expected it. As an infant, my grandmother almost died of pertussis (whooping cough) and the neighbors who came to give their condolences were shocked that she was still alive. Families often cared for the sick at home and knew what was involved at the end.

In our high-tech age, we’ve medicalized the end of life so much that we forget it’s natural. Atul Gawande’s “Being Mortal: Medicine and What Matters in the End” is a great read in this regard. Different cultures have different feelings about end of life and I have enjoyed learning about different practices. In some communities, the process of dying is addressed with great self-awareness and attention to detail. It’s important for us in the healthcare trenches to remember that no matter how many times we’ve been involved in someone passing, there might not be an easy or obvious way to relate to every patient or family.

I’ve watched dozens of physicians have a similar conversation to what occurred on the video. Essentially, the physician is trying to talk to them about the level of care the patient is receiving and whether they want to focus more on comfort-focused care and symptom relief. Depending on the news account, some family members admit that they “knew this was coming and that he was very sick.” Another said they were just learning that he was gravely ill. One objection was to the technology itself, including the volume of the speaker and its proximity to the patient who had difficulty hearing.

We don’t know the full extent of the situation, whether the family had experience with a video-based consult before, or how the telehealth process was explained to them. We can’t see who else is in the room or at the bedside, but it’s easy for many to pass judgment on it. Even in person there are difficult conversations around this topic, where physicians struggle to find the balance between recommending care that can help and care that might hurt. Families struggle with feelings of giving up versus fighting for life.

This situation creates a tremendous opportunity to have conversations around technology on both professional and personal levels. As someone in healthcare, how did this story make you feel? How does it relate to what your institution might be doing? Are there ways you could be doing things better or otherwise differently? On a personal level, have you talked with family members about their wishes should something happen, whether expected or unexpected? How would you react if a loved one was being cared for by virtual members of the team? How do members of the family value quality vs. quantity of life and how do those beliefs influence medical care choices?

We always talk about assuming positive intent and I don’t think anyone involved in this video consult program intended for a family to be hurt or upset. Sometimes things occur that are out of our control or sometimes mistakes are made, and we can use those experiences to change how we approach things in the future. As “insiders,” we can help educate our families and friends about the realities of what we see day in and day out and how it’s not at all like you see on TV or in the movies. We can start a discussion that will perhaps lead to other conversations that might make it easier on some other family down the line. We can learn about other approaches to death, dying, and intensive medical care and decide whether we want to think about situations in new ways.

As a society, let’s temper our outrage and figure out how we want to do things better.

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EPtalk by Dr. Jayne 3/7/19

March 7, 2019 Dr. Jayne 2 Comments

My sci-fi nerd flag was flying high when I heard that the Amazon, Berkshire Hathaway, and JPMorgan Chase venture will be called Haven. That was also the name of a planet featured in “Star Trek: The Next Generation” and one where the Enterprise crew was supposed to have some well-earned rest and relaxation. I’ve perused the website and appreciate the way they’ve spelled out their mission clearly and in a way that most people can understand. It looks like most of the open positions are in their Boston and New York offices. It will be interesting to see what kind of people gravitate there.

Researchers are seeking to use artificial intelligence to help design better vaccines against the influenza virus. Flu is a virus that mutates rapidly. Researchers from two pharmaceutical companies are taking biochemical data from samples of exposed patients and running them through an algorithm in an attempt to understand how an effective immune response forms. Other teams are using machine learning to predict the spread of influenza using training data sets from physician offices, hospitals, and social media. The Centers for Disease Control maps flu trends, but being able to truly forecast flu activity would be an asset. I hope they hurry up and get it right. I’ve avoided flu for most of my medical career, but it hit me this week and with a vengeance.

In Mr. H’s annual reader survey, there were some responses that indicated a desire to see more focus on less-traditional areas of healthcare IT, including telehealth. Since I’ve been doing some of my own explorations in the telehealth realm, I’ll share my observations and findings.

One of the first things I’m finding is that it’s important to understand what you mean when you start talking about telehealth. Is this provider-to-provider, institution-to-institution, or direct-to-consumer? The differences involved in the various approaches are vast.

In talking with physicians, there is good acceptance of the provider to provider offerings, which can help serve rural areas or places that don’t have the specialists needed to care for patients with certain conditions. This typically involves a patient coming in to see their provider, then joining with a subspecialist or other clinician via video call. The provider who is actually with the patient can assist with physical exam findings and vital signs. It doesn’t have to be a physician, but can also be a nurse or other trained member of the care team.

This approach can be huge as far as saving time and money for patients to travel to see subspecialists, understanding that some patients just wouldn’t go because of the burden. I’m seeing this more as academic medical centers partner with outlying organizations and it seems to really be taking flight in the pediatric subspecialist world.

There is also good acceptance of institution to institution telehealth, such as remote ICU monitoring or telestroke management services. This can allow specialists to weigh in on the care of patients at institutions that might not have the level of expertise needed to care for certain conditions. It can also just serve as an extra set of eyes for an already-skilled facility, making sure that nothing is missed in the care of critically ill patients. There are typically deep linkages between the organizations from both contractual and philosophical perspectives, so the level of trust is high.

Telehealth services that are delivered directly to the consumer have variable uptake. Some healthcare organizations have already built robust telehealth programs, allowing their providers to work directly with patients who may have challenges traveling to the office. Devices can be used to report patient-generated data in order to provide better care, such as daily weights for heart failure patients or blood glucose readings for diabetic patients.

Other organizations may be using telehealth strictly for acute visits, allowing physicians to extend their hours, access, and productivity without having staff in the office for an extended session. They may be using a telehealth platform within their EHR or licensing with one of the nationally-known telehealth companies to get this done.

Then there are the independent telehealth organizations that may contract with employers or payers, or may market directly to patients as consumers.

I think providers are skeptical of the independent telehealth organizations. There was recently a raging editorial from one of the leaders of the American Academy of Family Physicians on the topic. However, there’s no question that these services are filling a gap in services that aren’t being provided by brick and mortar clinics or traditional primary care practices. Although there are some direct-to-consumer organizations that seem fairly profit motivated, others have significant interest in measuring clinical quality and patient outcomes along with patient satisfaction and efficiency metrics, just like an in-person practice would. These organizations are doing work to explore how they can fill gaps in care while maintaining antibiotic stewardship and clinical quality. They’re also working to ensure that the loop is closed with reports to primary care physicians so that there is continuity of care.

The challenge for these organizations is the lack of data looking at telehealth care of various conditions. There simply isn’t a body of research (yet) that looks at the effectiveness of a telehealth history and examination vs. an in-person examination. We know that physicians have treated certain conditions over the phone for decades, yet there are challenges when it is a brand-new patient-physician relationship rather than an existing one. Smart organizations are gathering data on their outcomes and their approaches and using it to drive future care pathways.

I think we’re going to see a continued boom in telehealth including expansion into the primary care and chronic care space. There will also be plenty of room for specialized telehealth organizations to flourish. Patients are voting with their pocketbooks on convenience and access and I hope traditional organizations are making note.

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The Epic campus has made it into Atlas Obscura,one of my favorite sites for internet time-wasting. I had heard about many of the features, but not the medieval drawbridge, which caught my attention. I’ve never been, but I hear it is something to behold.

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Curbside Consult with Dr. Jayne 3/4/19

March 4, 2019 Dr. Jayne 1 Comment

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Due to bad weather, I was gifted a fairly quiet and unremarkable urgent care shift today. I definitely appreciated the time to allow my brain to play catch-up. Word of advice: if you get blackout drunk at a Mardi Gras party and wind up with a visibly deformed leg, I hope you have sober friends who can take you to the emergency department immediately. Waiting until the next day and then going to urgent care for your nine-way fracture isn’t going to be as helpful.

I’m working on a couple of projects, one involving creation of some new educational resources for an organization that is pursuing EHR optimization. It’s often difficult to figure out the best way to train people, and successful organizations will use multiple methods to ensure that everyone is receiving information in the way that best suits them. Those organizations also use frequent retraining to ensure the information is retained.

Out of all the organizations I’ve worked with over the years, only two had individuals with advanced training in adult education involved in the creation and upkeep of the training process. Too often, training is done “like we did it last time” and doesn’t take advantage of different types of media and experiences.

Some people are visual learners who are going to respond best to well-delivered presentations and written materials, often taking notes on the content. These folks may do well with classroom presentations as long as they’re organized and concise and have dynamic presenters that don’t bore the audience to death. Others are auditory learners who may also do well with a classroom format. Still others are kinesthetic learners – they need to touch, feel, and do to absorb workflows they are trying to learn. They do best in a lab setting. There are also variations on the various learning styles, including whether people learn better individually or in a group setting.

Too often leaders make assumptions about how their people should learn,  limiting the options that are offered and potentially to negatively impacting a subset of their users. Savvy organizations poll their users and see what kinds of training materials they would like to have.

LOINC recently surveyed their core users and the breakdown was interesting. Of nearly 500 users:

  • 48 percent preferred a published guide available as a PDF
  • 25 percent wanted written documentation as a web page
  • 6 percent preferred slide presentations
  • 17 percent wanted video presentations with audio
  • 3 percent wanted in-person training

It would be useful for leaders to survey their users to see what kind of training is preferred.

Leadership should also be aware of the corporate culture and how different types of training will be received in the field. For example, one large health system I worked for decided that they didn’t want to expend the resources to bring everyone together for training. They decided to train via web meeting with people at their desks. Participants were not aware that the training team had attentiveness tools, including being able to see whether the window in which the presentation was occurring was the primary focus on the desktop.

Within 15 minutes of the start of the webinar, hardly anyone still had the session in primary focus, and of those who did, they were most likely multi-tasking based on the lag in their responses to interactive polling questions. Others never even signed in to the webinar because they were sidetracked in the office with the urgent issues that occur on a minute-by-minute basis. Had they been allowed to leave the office and attend classroom training, those interruptions and distractions would have been minimized. Needless to say, the training was a flop, and for our next upgrade, we returned to classroom-based training.

One of the things that bugs me the most is training sessions that lack of materials for the participants. Back in the days after the demise of the Kodak slide carousel and following the rise of PowerPoint, lecturers often handed out copies of their slides for attendees to take notes on. As we became more environmentally conscious, people stopped handing out copies, but this left students frantically scribbling and trying to capture concepts and ideas. Some presenters balk at handing out the slides before a lecture for fear that it will make the audience inattentive. This completely ignores the subset of learners that benefit from seeing an overview of material before they’re confronted with a deep dive.

For this new project, I’m working on the scripting that will be used to retrain physicians, including a compilation of the clinical scenarios that are the most relevant to each physician who will attend an in-person session. They will be experiencing a classroom portion followed by a lab, followed by time for individual questions and interaction with the trainers. All of the sessions will be recorded and we’re distributing the materials, both before the class and after. The slides that are sent before the class will allow people to bring a printed copy if they want to, and those distributed after the class will contain notes and annotations from questions and discussion held during the session. Not everyone wants a big shelf full of binders and manuals, but the reality is that some people still like hard copies.

The other project I’m working on is more creative in nature, a communication and marketing plan for a practice that is planning to launch virtual visits. They have decided to try to do them in-house using their EHR, which doesn’t have great telehealth functionality, but at least they’re willing to dip their toes in the water to see whether patients are interested in it. We’re putting together communications to make sure everyone in the office is aware of the project and the plan to launch it as well as the questions they will need to be able to answer when patients ask.

Figuring out the best way to market it to the patient population is also a challenge. The majority of them are tech-savvy, but will need some education on why they will be billed for a virtual visit that in the past would have been handled as an unreimbursed phone call. It’s been fun to come up with the flyers illustrating the difference as well as doing some role-play with the leadership to make sure they can articulate all the goals and objectives before we roll the materials out to the front-line staff. I’m enjoying working with people who are willing to lead by example and to roll up their sleeves instead of just delegating something this major to someone down the line.

A nice creative project helps get my brain working again after this long awful winter. Even though snow is still on the ground, I’m starting to feel like spring might finally be around the corner.

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EPtalk by Dr. Jayne 2/28/19

February 28, 2019 Dr. Jayne No Comments

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I’ve been rationing my fun socks post-HIMSS. Today was the day to show off these polka dot doozies from the amazing CoverMyMeds sock machine. I have to give them props for the best swag-dispensing system on the show floor. If you were willing to hit Twitter and follow some basic instructions, you got a great pair of socks.

I checked in on the company’s statistics. They have helped complete 128 million medication prior authorizations. More than 700,000 providers have used it and they are connected to 96 percent of pharmacies. The service remains free for providers and partners, with health plans, PBMs, and drug companies footing the bill. I don’t run across many prior authorizations for medications in the urgent care space, but if I was back in traditional practice, I think it would be a must-have.

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I needed my great socks to boost my mood since I’ve been having adventures in collaborative software this week following an organization rollout of Microsoft Teams. It seems like nothing lasts for more than a year or two here and we’ve been through an entire progression of applications, from Windows Live Messenger to Skype to Slack to Yammer and now to Teams. At one point we also had HipChat in the mix, which created confusion since people were expected to collaborate on multiple platforms depending on who we were working with.

Although use of the actual Teams platform has been seamless, I’ve been struggling because since we went live I can’t use my OneDrive documents offline and no one can explain why it’s not working. I discovered this not-so-little issue when I was on a flight with no Wi-Fi service and couldn’t even edit documents, despite them being stored “on” my laptop within OneDrive. There’s a ticket open on my behalf with Microsoft, but it’s already been a couple of days and I’m not hopeful about a resolution. If anyone has seen this and has any ideas, let me know.

I was pleased to see that the HIMSS Electronic Health Record Association (EHRA) is working to make it easier for physicians to effectively use data to avoid opioid misuse. The US has a patchwork of Prescription Drug Monitoring Program (PDMP) systems by state (except for Missouri, which still can’t seem to get its act together). The systems function differently depending on state laws, which can be challenging for providers practicing on state borders. It’s also challenging for EHR developers who have to try to figure out how to create solutions that work across the country.

EHRA has put together a compendium of state-specific policies and standards, including what data is being collected and who can access it. EHRA’s Opioid Crisis Task Force has also created an “ideal minimum data set” detailing the information needed to best support clinicians who are making decisions around opioid prescriptions. The ultimate goal is to be able to create a standard for PDMP data that would be consumable by EHRs and useful to clinicians. EHRA notes that they’d like to work with ONC and other stakeholders in this effort. I agree it would give the effort some teeth since it’s often hard to herd the states in a common direction.

CMS is holding a listening session on March 5 covering the Interoperability and Patient Access Proposed Rule. Registration is open for the session, which will include opening comments by CMS Administrator Seema Verma followed by an overview of the proposed rule. Participants will also be able to submit questions and get clarifications that are needed prior to submitting formal comments to CMS.

Many physicians have concerns about the impact of patient satisfaction scores on their overall performance including how they play into compensation and insurance rating issues. An article published this week gives credence to some of those concerns. The investigators set out to specifically investigate whether Asian physicians received lower patient satisfaction scores compared to non-Hispanic white physicians. Researchers surveyed nearly 150,000 patients and found that those who self-identified as Asian were less likely than other patients to give their physicians the highest ratings for patient satisfaction. Overall, Asian physicians had lower patient satisfaction scores due to the higher proportion of Asian patients treated by those physicians.

There were other subtle differences in the data depending on the characteristics of the patient and physician populations. The authors encourage organizations that use patient satisfaction scores to drive provider compensation to look at the possible need to adjust their numbers based on patient race and ethnicity.

As physicians try to be more responsive to the cultural preferences and practices of patients, this type of research is going to be more important and brings up many questions. What defines a particular race or ethnicity? What if you are Asian but were raised by a Midwestern Caucasian family with no connection to your birth culture? What if you are Caucasian but grew up deeply immersed in the Latino community? How do you grade a physician based on true cultural competency vs. their ancestry or genetics?

The study looked at data gathered from 2010 to 2014 from a community health clinic in northern California. What would the data look like if it were gathered from a practice in another part of the country or with a different socioeconomic makeup? What about a more recent timeframe given the speed of change regarding cultural practices?

These are important factors to consider, but they aid in exposing how difficult it is to measure patient satisfaction and the various factors that might go into it. How do you control for compassion and communication when looking at clinician behavior? I’ve heard some interesting physician comments on the study, but would be curious to hear what others in the healthcare community think and also what people think as patients.

I’m waiting for the HIMSS session recordings to come out so I can finish “attending” sessions and claiming continuing medical education (CME) credits. It seemed like many of the sessions I wanted to attend were at the same time, so I’ve got some catching up to do. Despite the availability of on-demand recordings, we’re still limited to only claiming credit for one session per real-world time slot. In the age of electronic media, it would make more sense to allow participants to claim the credits that best meet their professional development needs rather than limiting them by their inability to be two places at once (which used to be reality before recordings).

I’d be fine with still capping the overall number of hours if granting too many hours is part of the concern, but I think this is one of those situations where we’ve simply added technology to an old-school process without revisiting how it might best serve the end users. For the hours to count for the CME needed for Clinical Informatics you have to also complete questions on the learning objectives so it’s not like a bunch of us are trying to game the system.

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Curbside Consult with Dr. Jayne 2/25/19

February 25, 2019 Dr. Jayne 2 Comments

I spent the weekend with one of my healthcare IT mentors. He’s been around the industry for several decades and I’ve been the fortunate recipient of some of his knowledge as he’s shared it with me over the years. He taught me much of what I know about building relationships with clients and constituents, along with how to cut through the noise that some in the industry constantly generate.

Over time I’ve been his customer, later his co-worker, and even did a brief stint as CMIO at an organization he led. Most of all, I’m grateful for his friendship as I’ve moved through this wild and crazy industry. He’s helped me weigh the pros and cons of various opportunities and reminded me to be true to myself, because the industry and the people in it can change with not even a moment’s notice.

Following the whirlwind of HIMSS, it was good to be able to sit by the pool and do nothing. When the most major item on your agenda is determining which movie you’re going to watch after dinner, life is good. (Note to readers: “A Quiet Place” is not so quiet of a film.)

It was nice to have a glimpse of retired life, although I can tell he misses the industry at least a little bit. He spent the majority of his career on the vendor side. We played the “who did you see at HIMSS” game and it was a trip down memory lane talking about everyone we’ve known or worked with over the last 15 or so years. Very few of our mutual friends are in the same places in the industry, with many having made the rounds among multiple EHR vendors over time. Certain executives seem to bring their entourages with them as they move, which leads to an exodus when they ultimately leave. It seems like some people just follow each other around the industry.

The people we’ve worked with have ranged far and wide, landing full-time gigs at academic medical centers, health systems, and with cross-industry vendors such as Salesforce or AWS. Some work in lobbying or the healthcare policy arena. Others have left the healthcare IT world altogether – one raises pygmy goats and another owns a hot yoga studio.

It’s always fun to hear about their exploits and to wonder where various people landed in later phases of their careers while pondering one’s own future. I’ve been a bit restless the last several months. Running your own business is challenging and making sure that the people who work on your behalf are meeting client expectations can be exhausting even with a small group of people.

I’ve explored a couple of opportunities to return to life with a Big Health System, along with one to move into the vendor space. None of them were particularly conducive to staying in practice, which ultimately led me to cross them off the list. I’ve had a couple of periods during my career where I didn’t see patients and I did miss patient car,e although I didn’t miss dealing with insurance companies or landlords.

In reviewing my recent foray into job hunting, I was frankly surprised by the inability of the provider organizations to come up with a clinical situation that would work. Often the emergency department or urgent care work has been contracted out to a staffing company that is reluctant to take on a part time physician.

One offered to add me part time to an existing internal medicine group. Trying to work as a primary care physician but only be in the office half a day a week is very challenging. I did it when I first moved into the CMIO trenches and there was much patient dissatisfaction with the arrangement, as patients were used to having advanced access scheduling with me as their physician. Not to mention that my partner constantly grumbled about having to cover for me even though he was being compensated for the extra work.

I can’t imagine trying to be a new physician to a practice but only be in the office half a day a week unless you were just seeing acute or overflow visits, and none of the organizations I talked to were offering that kind of arrangement. I don’t think that seeing patients is essential to being a good clinical informaticist or physician leader, but I do enjoy it and think it provides valuable context for being able to serve the organization.

The vendor role was reluctant to let me stay in practice at all, for fear that I wouldn’t devote my full efforts to the job. I think that was short sighted and they shouldn’t care what I do on my weekends. It turns out they have a “no moonlighting” policy for all employees, which was a bit of a red flag anyway. I don’t think employers should try to dictate what people do in their off hours unless it reflects badly on the company or interferes with the employee’s ability to complete their responsibilities successfully. It seems like many people have a “side hustle” these days, probably due to the uncertain aspects of the healthcare IT economy.

I’ve been looking into some telemedicine opportunities because they seem to be flexible and might be a bit more easily worked around a full-time informatics role. However, it’s not anything I have ever done, so it’s hard to gauge whether it would be a good fit. My friends who have done telehealth either really liked it or didn’t. I’m used to being adaptable, so we’ll have to see how things unfold.

I’ve got a major volunteer commitment this summer that I need to schedule around, so I don’t want to upset the proverbial apple cart too much unless an amazing opportunity comes along. A wise man once advised me to always keep my mind open to new opportunities and his advice has been spot on so far. Until the universe drops something spectacular in my lap, however, I’m perfectly content to sit by the pool, contemplate a nice glass of wine, and be grateful for the life I’m living.

If you could re-engineer your career, what would you do differently? Leave a comment or email me.

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EPtalk by Dr. Jayne 2/21/19

February 21, 2019 Dr. Jayne 9 Comments

We’re officially post-HIMSS, because the emails have started arriving thanking me for my interest in various vendors’ products after I stopped by their booths at the show. Folks have had time to decompress and begin sorting through various business cards that were traded and notes that were made about follow up. 

I have my own stack of cards to go through, following up on new connections and seeing what opportunities might arise from the conference. As summer approaches, I tend to start putting together my strategic plan for the upcoming year. I’ve had some tempting offers to go back into the hospital trenches as well as some interest from the vendor side, so this might be a year full of change.

Normally I don’t spend a lot of time reading things from Healthcare IT News, but their interview with Judy Faulkner caught my eye. Part of the conversation was around physician burnout and relative happiness (or unhappiness) with EHRs. She brought up some good points that many of us in the trenches already know, but that large organizations seem to tune out at times. One of those points is that although EHR use can be associated with physician burnout, it’s not necessarily causal. There are burned out physicians that are happy with their EHRs, and EHR-haters that aren’t burned out. Other factors influence burnout including administrative burden, leadership issues, patient load, and work-life balance issues.

She also notes that clients need to stay current with their EHRs, installing the latest versions so they can benefit from usability enhancements that followed the post-Meaningful Use programming era. I’ve found that to be true with nearly all the vendors I’ve worked with, not just Epic. Once they cleared the certification hurdles, vendors often went back to customer enhancement request lists and started making good on old promises.

Another point she made was around training. Physicians that tend to do better with EHR adoption are likely to have had better training. That doesn’t always mean more hours of training, but it could mean more focused training or role-specific training, using the physicians’ time wisely and training them on the tasks they are most likely to perform in their work.

She calls for physician subspecialists to train their peers. That’s great in theory, but it’s not very easy to find physicians who want to dedicate themselves to learning how to train other physicians how to use the EHR. I’ve worked to mentor multiple CMIOs in this regard and not everyone has the aptitude or personality to be a trainer even if they want to do it, even when the hospital is willing to compensate them appropriately. In too many cases the compensation, isn’t remotely adequate, so it becomes a non-issue.

Faulkner does mention the idea of EHR personalization as a positive factor towards EHR happiness. She notes that it’s a challenge to convince health systems to do that for their physicians. My take on it is that it’s not just an Epic issue, but happens with most vendors and most health systems. It can also vary based on the degree of autonomy held by physicians outside the EHR.

One hospital I work with keeps its employed physicians on what many would consider a short leash. They’re fanatical about quality and reducing unnecessary variation, so physicians are expected to use order sets and standardized workflows. They’re incented on following the rules. Generally, people comply or they leave. The users tend to be satisfied with the EHR because they know what to expect and they know the rules of the game they’re playing.

At other organizations where there may be lots of competition for attending physicians’ patient volumes, I’ve seen hospitals bend over backwards to customize the EHR on an individual physician basis for fear that someone will take their surgical business elsewhere. This can lead to redundancy and confusion in order sets and workflows and costs more to maintain, but the organization feels it’s worth it. There’s definitely a need for vendors to make their systems easier to personalize and to allow user-level configuration rather than having to have IT teams involved in making small adjustments.

She goes on to note some data from KLAS that looks at EHR happiness and whether the health system is “agile,” meaning “If a physician wants a change made and talks to an IT person, how many committees does it have to go through? And if the answer is zero, that’s good.”

I understand the sentiment, but for those who haven’t waded into the muck that is EHR or IT governance, it’s an oversimplification. I’ve done hundreds of hours of work for hospitals and health systems “undoing” various changes that were made without any level of approval (and often without any documentation). Oversight isn’t a bad thing, but has to be crafted carefully to support the needs of the user and the goals of the organization. There should be a decision matrix that shows what kind of changes need what kinds of approval, and from whom. Simple things that don’t have downstream ramifications should happen quickly, where more complex issues that might have far-reaching consequences might need multi-level oversight.

Assuming the interview is a relatively straight transcription and didn’t go through much editing, it shows the level of understanding and insight that Judy Faulkner has into some of the issues her clients are facing. I’ve interacted with C-levels at many vendors and some of them don’t seem to have as much understanding of the challenges their clients are facing and how it impacts the end users. Many of them are good at using sound bites, but when it comes to getting into the details, they become quiet.

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I’m approaching a milestone reunion for my medical school class, and one can’t help but think about how much it cost to get here. Some of my classmates are still paying off their loans. A recent planning committee get-together led to some conversation about free tuition being offered at some medical schools. The brand new Kaiser Permanente School of Medicine in California has announced that it will waive tuition for all years for the school’s first five classes of students.

This led to quite a bit of discussion on the fact that Kaiser Permanente is opening its own medical school, unaffiliated with any university. Depending on how much influence Kaiser Permanente has on the students and what facilities they rotate through, there may be significant difference from the educational opportunities received at other schools. The first class will be relatively small (48 students) and the school names three academic pillars: foundational science, clinical science, and health systems science (which they describe as focusing on care delivery including population health, quality improvement, and social inequality). Students will participate in longitudinal clerkships starting in year one, hosted in Kaiser Permanente hospitals and clinics along with community health centers. It will certainly be interesting to see how this plays out.

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I was in the office yesterday treating lots of folks with influenza. At one point, all nine of our exam rooms were occupied by people receiving IV fluids. The flu is hitting people hard. I had a great team working with me. However, at one point, I noticed that probably all of them were young enough to be my children.

This thought came back to me later in the day, when one of them was using the EHR to print a label for a blood draw and asked aloud, “What did we do before we had Dymo printers?” They looked at me like I was from Mars when I started to tell them about the Addressograph machine, with which we used to print headers on patient chart pages and various labels. One of my jobs as a Candy Striper on the mother-baby unit was to stamp new chart pages for all of the patients on the floor. It’s funny the things you forget as technology moves on, but I think I can still smell the ink when I think hard enough.

What’s your favorite piece of extinct technology? Leave a comment or email me.

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