EPtalk by Dr. Jayne 12/23/21

I haven’t been anywhere near the physician water cooler this week, but around the healthcare IT water cooler, the hot news (as expected) is the Oracle acquisition of Cerner.

I haven’t heard any optimism around it. Most of the comments are of the “lots of organizations have tried to succeed in healthcare and they all fail” variety. Many see it simply as a way for Oracle to increase its customer base as well as it being a win for Epic since customers who might have debated between it and Cerner choose the path that isn’t about to undergo changes to leadership and strategy.

I’ve been involved in a couple of EHR replacement evaluations where Cerner was a contender, but failed to win the deal despite being less costly than the alternative. Primary care physicians tend to find it underwhelming for high-volume ambulatory practices. It will be interesting to see if Oracle does any better at winning those hearts and minds with their promises of voice recognition-based workflows and automation of care delivery.

As far as the virtual hospital hallways are concerned, I’ve been in contact with several friends who are nurses, one of whom is currently infected with COVID-19. They’re irate at suggestions that infected healthcare workers should be subject to shorter isolation periods to avoid straining the US healthcare system. Especially with many healthcare organizations continuing to fail at providing adequate personal protective equipment, including N95 masks, asking those who have shouldered the burden of care to put themselves at additional risk working alongside COVID-positive colleagues is something we never imagined would be suggested at this stage of the game.

My COVID-positive friend, who happens to be an ICU nurse, commented on how beneficial it has been for her to actually sleep for as long as her body needs. She has found her isolation to be somewhat restorative even though she is having mild coronavirus-related symptoms. Asking for additional sacrifice from those workers to care for what truly has become a pandemic of the unvaccinated just rubs salt on existing wounds and will not bolster the morale of healthcare workers. I would propose that if anything, it makes them feel that people think they are expendable.

Another hot topic among healthcare policy friends is the jump in US health spending. The number topped $4.1 trillion for 2020 as we attempted to fight COVID-19 in our dysfunctional and misaligned way. Case in point: COVID testing. My county testing with no direct cost to patients through multiple drive-through clinics. Results are generally delivered same day via email. Appointments are readily available on its website, with dozens of unclaimed appointments each day. Despite this, I see dozens of posts every week in various community-focused Facebook groups and other forums where patients are looking for open slots at CVS, Walgreens, and other pharmacies because they are booked solid.

My former clinical employer is running four testing sites that do several hundred visits each day, but with a twist – they require each patient to be seen by a licensed provider (MD, DO, NP, PA), which results in a full visit billed to the insurance company. Since patients don’t incur that cost up front, they don’t understand that what could have been a relatively cost-effective testing visit has been inflated by a factor of 10. Even if they don’t pay the cost out of pocket, they’re going to pay it down the road through increased insurance premiums and shifts to cost sharing.

These processes are why spending has jumped nearly 10%, double its usual rate, with no corresponding improvement in outcomes. I don’t think people realize that $1 of every $5 in the economy is going to healthcare. Even if people did, I’m not sure it would have much meaning to them.

Other interesting tidbits in the report, since it’s hiding behind a paywall:

• Health spending works out to approximately $12,500 per person.
• The count of uninsured individuals held steady, although there was a shift in those covered from workplace-based policies to Medicaid and Affordable Care Act marketplaces.
• Medicare beneficiary counts grew more slowly due to significant numbers of deaths in those aged 65 and older.
• Individual out-of-pocket spending decreased due to deferred care, such as postponed surgeries and screening procedures.

The latter two are certainly negatives in my book. Where senior citizens accounted for roughly 15% of all COVID-19 cases, they represented 80% of the deaths. The loss of so many family members and loved ones is tragic. I’m fortunate that the elders in our family are extremely healthy and their living situations allowed them to be protected thus far, but plenty of my friends and colleagues have lost an entire generation to the virus.

I’m hearing a lot more this year about people planning to test prior to family gatherings. Hopefully that will help prevent at least a small amount of transmission and reduce the strain on our overwhelmed healthcare workers. I’ve been generally pre-quarantining just to be on the safe side, but not everyone has the luxury of working from home.

I enjoyed attending the Consumer Electronics Show last year, even though it was virtual. There were plenty of products to check out and many of the companies did a great job trying to engage the virtual audience. Obtaining a media registration last year was easy, but they made things trickier this year for me since a photo is required even for digital attendees. My credentials are still pending approval, so there’s no guarantee I’ll be on prowl in the virtual exhibit hall this year. I’ve lived a full year without the $16,000 bathtub I was eyeing last year, so I guess if I can’t attend, I will survive. One of my colleagues is attending in person and I’m a bit jealous, but I’ll be holding down the fort while he’s gone and will have to rely on him for the in-person buzz.

What conferences are you looking forward to attending this year, or do you think COVID-19 will keep us all close to home again? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/20/21

The news this week has been dominated by surges in COVID-19 cases across the country. Epidemiologists are predicting a January peak and hospitals in many parts of the country are becoming overwhelmed. Staff members at those hospitals, as well as at urgent cares, community health centers, ambulatory offices, etc. are beyond overwhelmed, as they have been fighting this pandemic for nearly two years.

Most of the colleagues who I talk to regularly are beyond stressed as their organizations try to figure out how they’re going to staff another surge. The nursing shortage continues, with some of that work being shifted to physicians, which is increasing their levels of burnout. The thing that bothers them the most is not the hours or the work, but the feeling that they community no longer supports them but instead takes them for granted, or worse, sees them as expendable.

There’s a tremendous push for people to “live their lives,” but the reality is that we would all be better served by dialing it down a notch and sticking close to home for a while. None of us want to be constrained. We’re all tired of it, but it’s a necessity for many families right now as they struggle to protect vulnerable individuals in their households.

Seeing JP Morgan Chase cancel its healthcare conference was bittersweet. Everyone is so desperate for “the old normal,” but cramming people in hotels and restaurants isn’t the right answer. There’s a shortage of home testing kits across the country at the moment and people in some cities are facing long waits for clinic-based testing, so it doesn’t seem right to burden those systems with pre-travel testing. The same goes for people planning to travel out of the country for the holidays, which can generate multiple tests per traveler on their return, depending on workplace and school policies. I’m glad people have the money to travel to the Caribbean, but I feel for the healthcare workers who will grimly trudge through the lines of tanned, happy travelers seeking testing as they wonder when they will be able to take a break. One of my urgent care clients is routinely testing more than 100 patients per day at a single location, which is an unsustainable pace.

Mr. H noted that HIMSS is reviewing its Right of Entry Protocols for HIMSS22 to see how they’ll play in Florida, which has blocked vaccine mandates for workers and won’t allow businesses to require proof of vaccination. I have to say I hadn’t thought of that before registering for the conference, but now it’s giving me pause. We’ll have to see what the case rates look like as the conference is closer. We know that vaccination doesn’t necessarily prevent transmission, but data is good as far as there being less viral shedding and a shorter duration of symptoms. As we get more data about the Omicron variant, that may change, but right now I’m definitely more comfortable being around people who are fully vaccinated as well as masked versus the unmasked people at the supermarket who are talking on the phone as they shop, aerosolizing as they go. Influenza A is starting to rip through our community as well, so if the COVID-19 doesn’t get you, there’s a chance the flu will.

From a healthcare IT standpoint, I’m starting to see hospitals and health systems put projects on hold again as they cite the need to be all hands on deck for patient care issues. Organizations that haven’t already been tuning up their telehealth strategies have probably missed the window of opportunity while utilization was relatively low. Those who have robust telehealth programs are seeing greater demand, and most of the physicians I’ve spoken with are considering retooling their schedules to create dedicated blocks for telehealth visits so that they can minimize disruption to their days. With hospitals canceling elective cases again, patients are left in the lurch, and I feel bad for those who have been waiting for procedures that are again being pushed back.

As we approach the third year of the pandemic, I’m also starting to see physicians look for part-time opportunities due to childcare issues, especially in dual-physician households. As higher wage earners, these couples have historically had greater ability to afford full-time household caregivers such as nannies, but the long hours and unpredictably lengthened days have caused some caregivers to leave their physician employers. There is also some degree of mismatch between COVID-sensitive physician families and caregivers who might not want to be vaccinated or mask at work, just like there is in any other part of the workforce. Parents of young children who were hopeful for a vaccine to be available soon for their children are crushed by the recent Pfizer announcement that they’d be amending the clinical trial for children 6 months to under 5 years of age. This could delay the vaccine by an additional six months as boosters are studied. For those families, it will be a long winter, indeed.

There are so many terrible things that have come with the COVID-19 pandemic that when you come across something good that has come from it, you just have to celebrate it. Partway through the pandemic, I was introduced to what was then called The Covid Cello Project. It started as a group of 17 professional cellists who couldn’t work due to the initial lockdowns and decided to do a virtual collaboration. Since then, it’s grown to over 500 cellists who submit individual recordings that are then compiled and mixed into a group performance. It was rebranded some time ago as The Global Cello Project to reflect its worldwide reach as well as the easing of the pandemic, but now many of us are staying close to home again, so it’s hard not to refer to it by its original name.

The founder challenged us to put our most recent piece together in only nine days (usually we have several weeks) and I spent the first three of those days in the woods, so I’ve really had to work to get my part ready. Tonight was the recording deadline, and with the support of my in-house production crew, I was able to nail it in one take. Now the team gets to work editing all the videos and mixing all the recordings and we all get to be surprised by the finished product. It’s been great to have something to think about and work on that brings people together, even though my fingers have had the most exhausting week of their lives.

What good things have you encountered as a result of the pandemic? Have you taken up a new hobby or found a new passion? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/16/21

The healthcare IT world seems to be going into hibernation for the winter. I don’t expect too many big news stories between here and HIMSS. I’ve started to see some buzz around the Consumer Electronics Show and plan to attend virtually if they ever approve my request for press credentials. I enjoyed the virtual approach last year, although some day I’d like to go in person – they say the atmosphere of the show is really something, although I’ll be interested to see what in-person attendees think of it this year compared to its pre-COVID-19 vibe.

There’s minimal buzz around HIMSS, but I’ve gotten a lot of questions about ViVE. Everyone loves an excuse to go to Miami Beach in March, but the price tag is steep and requesting media credentials would require me to reveal my true identity, so I guess I’ll have to take a pass.

Regardless of the lack of vendor or industry news, academic channels continue to put out good articles. I enjoyed this recent item in the Journal of the American Medical Informatics Association. Titled “Assessing the impact of the COVID-19 pandemic on clinician ambulatory electronic health record use,” it does just that, by looking at data from ambulatory care physicians in over 360 health systems in the US that use the Epic EHR. They looked at data from December 2019 to December 2020, capturing the full timeline of the onset of the pandemic. They used data for active use of the EHR, after-hours use, and messaging. I wasn’t surprised that they saw a decrease in EHR use at the beginning of the pandemic. However, utilization not only ramped back up to baseline but increased by July 2020. This was consistent for both in-office and after-hours use.

In-Basket messages increased, largely due to the category of patient messages, which grew to 157% of its pre-pandemic average. Most of my colleagues hate the inbox regardless of the EHR platform. It usually contains not only messages from patients but also refill requests, correspondence from other providers, requests for referrals, preauthorization paperwork, lab results, diagnostic study results, and reminders to complete documentation in a timely fashion.

Some organizations do well at allowing physicians to delegate a large amount of this work to appropriately trained staff members, which allows team-based handling of many patient messages, refill requests, and referral / authorization requests. However, others refuse to let anyone other than the physician do this work, which not only leads to burnout, but can delay care. The savviest organizations report on their inbox workload and monitor how much work is being done by which members of the staff and adjust coverage accordingly. I wish this approach would be more commonly adopted, but as long as physicians continue to do the work without pushing back, there’s not a significant incentive for those organizations to change.

I wrote recently about challenges faced by the US Food and Drug Administration’s Risk Evaluation and Mitigation Strategies (REMS) programs to help mitigate the risks of serious side effects with certain medications. I used the program for the drug Accutane as an example. Little did I know that the IPLEDGE program for Accutane and its generics would implode this week. A colleague wrote in response to a patient complaint about refill delays: “Since Monday, there has been a nationwide issue regarding IPLEDGE and the FDA’s system for controlling isotretinoin prescriptions. They decided to change several things with the system and use a new website without first ensuring the website actually works. It is *literally* a sh*tshow with the nationwide program being shut down, hold times more than six hours for their tech support, and no one able to renew their prescriptions. I would give the office a break as currently no dermatologist in the country can send isotretinoin prescriptions until the FDA fixes the website.”

Sounds like the FDA didn’t learn much from the clozapine website debacle. These are exactly the kind of technology nightmares that physician offices fear, and which can bring even a well-oiled refill process to a screeching halt. Unfortunately, there’s no mitigation for the losses and frustration caused by this type of systems failure for either the providers or the patients. There are enough experienced healthcare IT people out there who know how to plan a project and how to run a go live that this should not be happening. Sounds like there were gaps in end-user testing, help desk support, and a potential reversion plan. Now that this has happened twice, I’d be interested to hear from anyone with FDA connections on what they plan to do to keep it from happening again.

Despite the news we’ve heard in the past that chocolate is good for you, new information shows that boring old multivitamins are more likely to slow brain aging. Preliminary information from the COcoa Supplement and Multivitamin Outcomes Study for the Mind (COSMOS-Mind) showed that taking a multivitamin each day for three years was associated with a 60% slowing of cognitive aging, most notably in patients with pre-existing cardiovascular disease. The findings were presented at the 14th Clinical Trials on Alzheimer’s Disease conference. The impact of vitamin use peaked after two years then remained stable; the reported 60% slowing is equivalent to 1.8 years. I usually treat myself to some dark chocolate around the holidays, and despite the evidence, I won’t be changing that habit.

I was commiserating with a friend recently about the American Medical Association’s monopoly on Current Procedural Terminology codes. Most of the provider-side organizations I have worked with dread the AMA’s license process, which is challenging for smaller organizations that have a lot of part-time users. Some EHR vendors include AMA licensure in their own license fees, but others make you work directly with the AMA to arrange licenses. My friend must know someone with some good AMA connections, because he later sent me a picture of this AMA-branded cheese board set. I’m not sure what exactly it’s trying to convey, since it’s somewhat evocative of what you see in movies when the character who is going to torture someone opens a case with various knives and picks. From a cheese board standpoint, the recessed AMA logo looks like a great place to harbor bacteria.

The holidays always bring out some interesting corporate gifts, although lately I’ve seen more companies making donations on behalf of their workers rather than sending gifts. What’s the most unusual corporate gift you’ve seen? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/13/21

The hot gossip around the physician lounge towards the end of the week centered on CVS Health’s plans to enter the world of primary care delivery. For anyone that missed it, their plan is to use telehealth, new clinics, and teams of physicians, nurses, and pharmacists to help solve the primary care problem. CVS Health believes that because it owns resources across many of the touch points of the healthcare system, it is uniquely positioned to enter the market.

If you are not in the US or are less familiar with the company, it not only owns thousands of retail pharmacy locations (some of which offer urgent care-type services), but also a pharmacy benefit manager (Caremark). Additionally, CVS owns a health insurance company (Aetna), so I don’t disagree that it has a pretty broad portfolio.

Not too long ago, CVS Health began rebranding some of its stores as HealthHub locations. I could never figure out what that differentiator really meant. My local store was rebranded, but nothing changed – still the same products, still the same square footage, and no increase in the number of exam rooms or appointments for its retail clinic. The company plans to keep adding these HealthHub stores (including 1,000 this year) and they are supposed to host a physician-led care team that includes dieticians, mental health professionals, and social workers. At the same time, the company is planning to close several hundred other retail locations as populations shift.

Digging deeper into the company’s press releases, it sounds like the company plans to further shift store formats, stating “Three distinct models will serve as community health destinations,” including sites that are dedicated to primary care, sites that are an enhanced HealthHub “with products and services designed for everyday health and wellness needs,” and traditional CVS Pharmacy stores “that provide prescription services and health, wellness, personal care, and other convenient retail offerings.” I couldn’t find mention of any changes to the CVS relationships with Target stores or the regional grocery chains with which it has also partnered.

I don’t disagree with their goal of providing a resource to better coordinate care or manage chronic conditions. The company is well aware of what we in primary care have known for a long time – primary care services are relative cheap in the grand scheme of healthcare spending (about 10% of annual spend in the US) and can actually help prevent disease and slow the progression of chronic diseases. This can lead to overall savings in healthcare spending.

However, there simply aren’t enough primary care physicians to go around, and in our culture, the perceived value of having a primary care physician is low. People seem to prefer transactional care that happens on their schedule, and I understand that as well.

Knowing that there aren’t enough physicians, many of my physician colleagues were speculating on how CVS plans to do this. CVS apparently plans to acquire physician practices, which should be interesting. Nearly 70% of physicians in the US are employed by hospitals or corporations, which have been on a buying spree during 2019 and 2020. The hospital/health system-employed portion of that number is about 50%. The remaining corporate entities include insurers and private equity firms. When they haven’t been purchased outright, independent physicians are consolidating into larger networks.

When you stratify the data by physician specialty, it becomes more interesting. The specialties with the highest rates of being physician-owned or independent are surgical subspecialties, anesthesiology, and radiology. Among the bottom five: pediatrics, family medicine, and internal medicine – in other words, primary care. I’d be interested to learn more about the CVS Health acquisition strategy because frankly I’m not sure where they’re going to find the headcount. Just because you purchase a practice doesn’t mean a patient will stay with it. Patients may not like how the new practice runs, and I can pretty much bet that a CVS-owned location will run differently than the average private practice.

Physicians may not stay with the practice. Perhaps they are closer to retirement than advertised and decide to leave immediately following any earn-out or guarantee period. Even if you can convince a subset of physicians to join a new practice with CVS Health, they’re likely to be hampered by non-compete clauses or other negative incentives that will make recruiting their patients a challenge. Additionally, folks who have remained independent for this long, in the face of ongoing market consolidation, might not be terribly well suited for the corporate medicine life.

Being cared for by a physician affiliated with a hospital or health system is a powerful idea. Patients, especially those who are medically complex, often feel a sense of security about having all their subspecialists and consulting physicians within the same system. Even with interoperability, there’s a sense that outsiders might not have access to all the records or might not provide the same level of care. There’s also backlash against corporate entities in some communities, with concerns that profit-oriented organizations will use patient medical records for marketing or other purposes.

One of the largest challenges I see for CVS Health acquiring these primary care practices is the matter of electronic health records. Many of the independent practices that they might acquire have EHRs that support that independence, like those from Athenahealth, NextGen Healthcare,EClinicalWorks, Greenway Health, etc. Having been through countless EHR conversions, I know that getting data out of those systems is usually easier said than done. I hope CVS Health has a substantial EHR conversion budget and is right-sizing their staff to handle it because patients expect their records to move with the physician, especially if the whole practice makes a transition.

Additionally, from a human resources standpoint, the altruistic physician candidates who are causing medical school admissions to surge won’t be ready to hang out their shingles for another seven or eight years. There’s no guarantee that they will find primary care attractive unless there are major changes. On the other side, there are a lot of burned-out physicians in the world right now who might just see working for CVS Health as a good thing. Time will tell how well their recruiting efforts will pay off as well as how challenging the technical pieces will be.

What do you think of the CVS Health move into primary care? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/9/21

Many physicians are closely watching several cases that are working their way through the US court system, especially those being heard by the US Supreme Court. For anyone who has ever seen oral arguments or read the transcripts, you may have noticed that the justices tend to say what they want to say, and often there is some interesting humor involved. The transcript of Becerra v. Empire Health Foundation did not disappoint. The case questions whether the Department of Health and Human Services followed correct procedures as it created a rule that changed the way Medicare reimbursement rates for hospitals are calculated. Justice Kagan pointed out an issue with the public comment portion of the rulemaking process, asking whether it was “unclear what the commenters thought they were being asked to comment on? In other words, a commenter who said I approve of the status quo, it was unclear whether that was the real status quo or the status quo as mis-described by the agency?”

Justice Breyer tried to reframe the issue, stating “I mean, do I understand this correctly? And the changes I understand it correctly are near zero, okay?” ultimately concluding that “people are exhausted, just like me after reading this case.” Justice Thomas referred to the “indecipherable language,” differentiating the concepts of “entitled to” and “eligible for” while pushing the attorney to explain it in “ordinary language.” Justice Kavanaugh jumped on the bandwagon, explaining the perils of trying to use two different meanings of “entitled” in the same sentence as he illustrated five different problems with the rule. Kavanaugh concludes that “we’ve whacked agency rules for much less than that,” which I found pretty amusing, imagining the members of the Supreme Court as hit people. Trench coats, fedoras, and dark sunglasses, anyone?

I always keep an eye out for articles that look at how companies and individuals are faring with the new normal of working from home. Lenovo has an interesting project in the works that will allow employees to work from one of the most remote locations on Earth. The Work for Humankind Initiative will support volunteers willing to work remotely from an island that is 400 miles of the coast of Chile. Lenovo has been upgrading the technology infrastructure on Robinson Crusoe Island and has built a shared workspace that will be come a community hub once the project is over. Project organizers are looking for volunteers with diverse skill sets who can help support the local community and volunteer 20 hours per week while on the island.

Successful applicants will spend four weeks on the island, from March 1, 2022 through April 10, 2022, and the dates include a 10-day quarantine on arrival. They must be fully vaccinated and willing to undergo COVID-19 testing three times weekly if selected. Finalists will undergo health, background, and psychiatric checks. Of course, the project will feature all the latest and greatest technology from Lenovo, so dedicated Apple users might want to think twice about applying. Interested parties can apply prior to December 30. It sounds intriguing – I’ll have to see if my current consulting gig would consider letting me head south.

From Job Hunter: “Re: sex work. It’s not the kind of healthcare technology piece we usually talk about, but did you see this article about healthcare workers who are leaving the industry for online sex work?” The Medscape article talks about healthcare workers who are struggling to make ends meet and turn to sites such as OnlyFans to supplement their income, or who give up their healthcare careers entirely. One featured UK-based worker made the equivalent of his annual healthcare salary in 22 days using OnlyFans. A featured New York-based emergency medical services worker turned to the site to supplement her income during the pandemic, leading to friction when her co-workers found out. The article goes on to point out the potential of encountering medical students who engage in sex work, which reminded me of the fictional Izzy Stevens in the TV hit “Grey’s Anatomy,” who paid for school by working as a lingerie model. The idea seemed vaguely scandalous at the time, but these days nothing is shocking.

Speaking of burnout and stressed clinicians, a new KLAS report finds that electronic health records might not be the top cause of clinician burnout any more. Nearly 20% of burned-out clinicians list COVID-19 as a top reason. Physicians most commonly list chaotic work environment as a central cause, where nurses cite after-hours workloads. I’m not surprised by the latter based on conversations with my nurse friends, who never get out of work on time and almost universally are looking for new jobs. This matches the KLAS data that shows that since the pandemic started, the percentage of nurses who are likely to leave their organizations in the next 24 months has increased.

My close nurse colleagues have grown tired of having to provide float coverage to patient care units where they might not be fully trained or experienced to care for the patients they’re assigned. I’ll never forget the first night my bestie had to float from the mother/baby unit to an assignment of mostly male medical/surgical patients. There were lots of questions coming my way all night long since the nursing pool was so scarce that she barely had colleagues to ask. I’m always happy to be the phone-a-friend, but the float situation went on for months until enough nurses quit over it that the administration had to reconsider. It’s a shame they didn’t make a better decision earlier before they lost a good chunk of their staff and had to pay exorbitant rates for travel nurses to provide coverage.

COVID-19 cases are rising in my community, and I’ve decided to head back into the clinical trenches on a very part-time basis, providing some cross-coverage for a Direct Primary Care physician while she takes some much-needed time off. It’s a different model than I’ve ever practiced in, and I can’t wait to see what the charts look like when a physician gets to write their notes purely for the sake of patient care and not for billing or any other reason. She uses an EHR I hadn’t heard of before now, and I always love to see how other systems work so I’m looking forward to it.

This weekend was spent doing a lot of administrative tasks, so I figured I’d go ahead and sign up for HIMSS22. The system needs to verify your membership status and I thought the glitch that created this screenshot was pretty funny. I came back later, and the system worked correctly, but it was still worth a chuckle. Will I see you in Orlando in a couple of months? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/6/21

One of the best parts of being a HIStalk sidekick is hearing from readers. I’ve got a handful of folks who correspond regularly, sometimes with comments on recent pieces, but other times giving me a heads-up on happenings that I otherwise would have missed. I’ve been way behind on my email due to the amount of work I’ve been doing for one of my new projects and was glad to see something from one of my regular correspondents as I reached deep into the abyss that is my inbox.

Most of us in clinical informatics tend to subspecialize, depending on where we work and how many other clinical informatics professionals are on a project. When I was starting out as a relatively new CMIO, I was a generalist as far as having to work with a lot of different clinical specialties, but was relatively specialized in that 90% of my work was in the ambulatory space. I only had to know about inpatient as much as was needed to address interoperability and the flow of data from health information exchanges and clinical repositories.

From there, I moved to the health system side and had to know a lot more about hospital-based medicine, but still worked with a broad swath of specialties. I became an expert in things like Meaningful Use and clinical quality reporting more out of necessity than anything else.

As a consultant, I run into all kinds of different informatics situations and have to think on my feet. Most of the time I’m fairly well-versed in the topics that get thrown at me, but occasionally I run into something I know very little about. This particular email illustrated one of those situations and was a good lesson on how essential change control really is, along with understanding the downstream impacts of systems changes. My reader was happy to provide some background to get me up to speed.

Over the last 15 years, the US Food and Drug Administration (FDA) has been implementing Risk Evaluation and Mitigation Strategies (REMS) for various medications with serious safety concerns. The goal is to reinforce appropriate use and to help reduce the risks of those medications. One of the most well-known REMS is the program for Accutane, which can cause serious fetal anomalies. As a precursor to REMS, one antipsychotic medication, clozapine, has had FDA-imposed monitoring requirements since its approval in the late 1980s. Clozapine is an antipsychotic drug that can sometimes cause low white blood cell counts, leading to a patient being unable to fight infections. In rare instances, those cell counts can get dangerously low. These effects were seen in the initial clinical trials and frequent laboratory testing was needed before patients could pick up their prescriptions from the pharmacy.

Initially, this was managed using a paper process to submit data to the registry, but for some time, the FDA has had a website where prescribers could enter laboratory results and pharmacists could query whether patients were current. My reader states it worked pretty well, including notifications to providers when a patient was late in having a lab result entered.

However, this changed during the initial months of the COVID-19 pandemic. They note, “FDA left the monitoring up to clinical judgment as patients who were stable on the drug for years really didn’t need monthly labs. But before the pandemic and currently, the rules have been quite clear – no lab test recorded, no dispensing of drug.” This made sense in the context of an emerging healthcare crisis when there may have been barriers to patients obtaining blood work, since having people miss medication doses aren’t good for patients, particularly when missed doses could cause relapse of a serious mental health condition. Additionally, when patients are off this particular medication more than 48 hours, they have to be brought slowly back up to their steady-state dose, which creates a window of suboptimal treatment.

Fast forward to the present, where FDA had an issue with the REMS website vendor that resulted in vendor and process changes. It wasn’t clear to the reader which process changes were supposed to be beneficial as opposed to which ones were caused by limitations of the new website contractor. Regardless, the transition has been described as “an unmitigated disaster.” They note that “the new process is hard to understand, even after taking the mandatory training to register for the new website.” There are PDF forms for submission as well as an electronic process, but the new process is more cumbersome with additional fields, poor layout, and suboptimal usability. Additionally, physicians had to re-enter the results for the most recent blood draw in the new system even though they were in the old system.

To cap it off, the website locked out users even though they had pre-enrolled for the new site, and the help line was overwhelmed, leaving many clinicians, pharmacists, and patients worried that patients wouldn’t be able to get their clozapine. Ultimately, following urgent meetings with stakeholders, the FDA temporarily suspended the documentation requirements. In FDA parlance, “Tthe FDA does not intend to object if pharmacists dispense clozapine without a REMS dispense authorization (RDA).” My reader closes out with this thought — even though the FDA has been focused on pandemic-related matters, they could have handled this transition better.

Putting on my “after-action” reporter hat, it sounds like some key steps were missed, things like stakeholder alignment on business requirements, clinical usability review and sign-off on development requirements, user acceptance testing, go-live support planning, and a contingency plan for reversion or emergent intervention if things were not going well. These are all things that many of us deal with on a daily basis and it’s always baffling how these big projects miss the mark. (Case in point: the VA and Cerner, but that’s a much longer topic and I don’t have enough wine in the house to start tackling that one.)

I hope FDA is able to work swiftly with its vendors to get this sorted out so that patient care can take precedence, and that the learnings from this one will allow them to do better in the future. It’s a good reminder for all of us that work with systems that directly impact patients – we need to be vigilant and make sure that corners aren’t cut so that patient’s aren’t harmed.

What’s the most egregious example of poor change management that you’ve seen in your healthcare IT career? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/2/21

Last May, the Office of the National Coordinator for Health Information Technology (ONC) launched its Health Interoperability Outcomes 2030 initiative with a goal of engaging the public around the future of interoperability. It received over 700 submissions of “Interoperability Outcome Statements” during the comment period and has created summary statements to reflect what the future should look like. Several of the summary statements resonated with me based on current projects and recent patient experiences:

• Individuals will be able to seek and receive care (e.g., telehealth, specialty) without needing to gather and provide their health information themselves.
• Individuals will no longer fill out paper forms for any healthcare encounter or process.
• Health professionals will be able to search for and access electronic health information within their workflow and have it presented in ways that intelligently synthesize relevant data.
• Reporting for public health, quality measurement, and safety will all be completed automatically and electronically.
• Duplicate diagnostic tests and procedures will be reduced.
• Health professionals will spend less time on administrative tasks and more time caring for their patients.

If you’re interested in some bedtime reading, individual submissions are also available. Some of the more high-profile submitters have their names listed and a few have videos. Repeat themes from the bulk of the comments include the desire to stop using fax machines, the desire to have end of life or advance directives universally available without being provided by the patient, and the need for a unique patient identifier to support interoperability.

In other government health news, the Centers for Medicare & Medicaid Services (CMS) announced this week that it is ending part of the Primary Care First innovation model, specifically the Seriously Ill Population component. The initiative targeted Medicare clinicians who provided care for high-need, seriously ill Medicare beneficiaries. The patients would be attributed to a specific clinician who would receive additional payments for coordinating and delivering care. CMS determined that the outreach methods planned to identify patients would most likely not result in a sufficient number of participants, making evaluation of the model impossible. The CMS Innovation Center plans to look for other ways to best serve these patients either through new models or enhancement of existing programs.

Zoom announced this week that it is accepting beta customers for its new integration with Cerner’s EHR. The integration will allow for EHR-based provider notifications when patients are in the virtual waiting room as well as sharing of test results during the Zoom meeting. There’s been a Zoom integration with Epic since the pre-COVID days. I wonder how many development hours it took for Cerner to play catch up?

Physicians who rapidly embraced telehealth visits last year have been struggling with lack of integration over the past year often resulting in clunky workarounds as well as patient and clinician frustration. When you look at smaller EHR vendors as well as some of the larger ones, the pace of integration has been slow. I know of quite a few physicians still using completely freestanding telehealth systems or just using conferencing software because their organization claims it doesn’t have the time or resources to work on existing integrations, not to mention the number of folks using systems where they haven’t been released yet. Even when organizations have homegrown solutions to provide integration, they’re still often clunky.

It’s not every day that we see an article about a good old HIPAA violation. HHS settled with five providers who violated the law’s Right of Access Rule, which states that providers have to give patients copies of their medical records in a timely fashion at a reasonable cost. As someone who used to enjoy reading her state’s Provider Discipline Newsletter, I wonder what these organizations did to receive such disparate penalties. Where one pain management clinic received a $32,000 fine and two years of monitoring, one internal medicine physician will pay a $100,000 penalty. A medical group settled for a $10,000 fine and performance of corrective actions. There has been a total of 25 actions since this particular enforcement started in September 2019. Based on the number of health systems I see behaving badly in this regard, I’m surprised there aren’t more actions.

I’m no stranger to wandering through the woods, so I was interested in this “News & Perspectives” piece in the Journal of the American Medical Association. In response to seeing patient take toxic but ineffective drugs during the pandemic, they applied to the US Food and Drug Administration (FDA) for approval to perform clinical trials using medicinal mushrooms and traditional Chinese herbs. The double-blind, placebo-controlled study (known as MACH-19) looks at treatment of mild to moderate COVID-19 with the agents and is ongoing at UCLA and UCSD. Recruitment has been challenging due to declining pandemic cases, however. Another trial is looking at whether medicinal mushrooms can be used alongside COVID-19 vaccines for better protection. The theory is that mushrooms can alter the behavior of immune cells. Unfortunately, robust science takes time, and results might not be available until well into 2022. Hopefully, the pandemic will be greatly reduced by then, but the findings could be helpful for other viral infections. If nothing else, the effort demonstrates the need to actually test proposed therapeutics, rather than encouraging patients to take unstudied drugs or those not meant for humans.

One of my clients offered to add me to their Grammarly subscription, so I thought I’d give it a try. With the various hats I’m wearing and roles I’m juggling, I can use all the help I can get a times. I like how it works with social media and various apps, not only highlighting any potential issues as they occur, but allowing one-click corrections. Apparently, it is impressed that I have a 12-week writing streak and today announced, “You’ve surely earned some ambrosia for your efforts.” I don’t know about ambrosia, but I’d settle for some dark chocolate.

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/29/21

The holidays are often a time for families to catch up and share recent happenings. Especially in the ongoing COVID-19 era, there is often a lot of catching up to do if people haven’t been seeing each other as recently as they did in the past, and if they haven’t been keeping up by other means. Although most of my older relatives are on social media (including one who has a Facebook account for each device she owns, because our attempts to explain how accounts work have not been well received), others spent the time catching up on their grandkids’ exploits. I always find it interesting to see how people in the same age bracket embrace technology differently.

In the early days of Facebook, I had avoided joining because I was super busy with a multi-hospital EHR conversion project and didn’t need one more thing to suck up excess time. I remember the night I finally signed up, sitting in a hotel room in the middle of nowhere during a hospital site visit. When it searched my contacts to try to find “friends,” the first person that came up was my then 88-year-old grandmother. It turns out that was the best way for her to see pictures of my cousin’s children, since they lived across the country. Even though she used a computer for little else, she saw the value in trying something new. She was also the kind of lady who spent part of her retirement auditing classes at the community college so she could learn new things, so I think that had a lot to do with it.

Fast forward to this year, and one of our relatives is struggling with a new iPhone that her son bought for her, seemingly without talking to her about it. She had been an Android user for years but her base model phone was low on memory and speed. Since she was on her son’s plan, he volunteered to help her pick out a new device, but it turned into him buying her what she thought she needed versus what she actually needed. Now she’s stuck with an expensive phone she doesn’t like, and the family dynamics make her not want to speak up about getting something else. The grandkids worked with her to do basic things such as connecting her phone to her house’s wi-fi network and doing some minor adjustments to voice-to-text settings, but I suspect she’s still going to struggle with it.

Most of my relatives don’t really understand what I do since I “gave up being a doctor,” so of course there were some conversations about that. I’ve given up on explaining how you can still be a doctor and not necessarily see patients. In the interests of simplifying the explanation, I’ve tried to explain that what I do is kind of like being a medical school professor who helps a resident learn a new surgical technique or a better way to treat a patient, and that sometimes I also work to help create the tools that doctors use to do their jobs. They still don’t get it, but that’s OK. I’m still the one they come to with all their medical questions, even in disciplines I know absolutely nothing about, so I guess I’m still a doctor after all.

There were of course the usual conversations about everyone’s chronic health conditions and the woes of choosing the wrong Medicare secondary policy. Since I’m working on a project that involves heavy use of a health system’s patient portal, I tried to get some information about whether and how my relatives might be using the ones they have access to. Use was all over the map, partly due to limitations in what their providers allow patients to access and partly due to lack of knowledge. It seemed like using it to send messages to the doctor was the most common, followed by prescription requests. No one was using it to read their visit notes, and none of them were aware of the ability to grant proxy access to a family member or caregiver.

The latter would be great for the other members of the family that are doing a lot of caretaking, so I hope they’re able to set this up in the near future. I’m not sure I would push them to read their visit notes since they would probably become aggravated by any inaccuracies or jargon. I recently had a visit at a large academic health system and there were at least five small errors in my note. I’m not going to get excited about it because it doesn’t change the treatment plan but I’m sure they would be less sympathetic if they saw something like that in their notes.

As with any technology, it takes time for adoption to occur, and I see wide variation in how different health systems are encouraging people to use their patient portals as well as in the support that they provide to users. Those that understand how much a well-configured patient portal can help office efficiency promote it more and are willing to spend more resources on development and configuration. Those that instead view it as something they have to provide and don’t want to cultivate likely have a lower return on investment as well as a less-fulfilling patient experience. This phenomenon shouldn’t be a surprise to anyone who has worked in healthcare IT, but I think sometimes people forget it as they’re planning projects.

Since I’m working on a project that assumes heavy use on the part of both patient and provider, I’m trying to learn everything I can about what works and what doesn’t work so I can help create the best solution for my client. In addition to talking to other CMIOs who have maximally leveraged their solutions, I’m taking some classes to really learn the details about what the system I’m working with can and can’t do. I’m working with some great analysts, but there’s always a chance they missed something or didn’t think about it in a way that a physician would, and my client is supportive of the approach.

In talking with a friend who does some clinical informatics work for his university, his institution restricts him from attending vendor classes. I think that’s absurd, especially if he planned to use his own continuing education funds to cover the cost of training. I get that they don’t want random people going to classes and demanding that they make changes that are problematic, but there’s a thing called “discussion” when people have ideas, and preventing staff from learning isn’t a good look for those in higher education. It’s also not a great recipe for stakeholder engagement, but I’ve known that his employer hasn’t cared about that for a very long time, so I’m not surprised.

I hope readers were able to at least get some down time this weekend, and that all the games of “refrigerator Tetris” were successful. What was the best thing you did over the holiday? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/22/21

As health systems continue to refine strategic planning for a potential upcoming influenza season or yet another wave of COVID-19 infections, telehealth is undoubtedly part of nearly everyone’s strategy. As a consultant, it’s interesting to see how different organizations have decided to use it.

For some, it’s strictly for acute visits and urgent-care type services that they can’t accommodate due to packed office schedules. For others, it’s an adjunct to their offerings for chronic care visits, which depending on the condition may be less likely to require a physical exam. Others are using it to grow their business by reaching out to previously untapped patient populations. A small number are using it as an option for physicians and other providers who may not be able to work in-person due to a personal health issue that precludes face-to-face contact with patients, or potentially having a family member at home who is at risk for infection.

I know a number of physicians who are going through cancer treatments or who are otherwise immune compromised and being able to practice virtually has kept them from going on disability or leaving medicine altogether. It’s an option that few physicians had previously and might be one of only a handful of good things that have come out of enduring a global pandemic. Not only is the option good for those individuals, but it’s good for care delivery organizations who would have otherwise lost capacity. When those physicians can keep their own panels it’s ideal since there can still be continuity, but I know that’s not always the situation, such as in the case of physicians who are in procedure-based subspecialties.

Still, there are growing concerns about how telehealth fits into the care landscape. Concerns with the cost of telehealth compared to in-person visits have been fairly straightforward, but questions about the clinical care provided have been less well defined. A recent report from Quest Diagnostics reviewed one of the concerns in more detail. The report, titled “Drug Misuse in America 2021: Physician Perspectives and Diagnostic Insights on the Drug Crisis and COVID-19,” found that almost 70% of physicians worried that signs of drug misuse were missed during pandemic-related care disruptions. The drugs in question include both prescribed substances as well as those obtained illegally.

Researchers looked at some 5 million test results performed by Quest Diagnostics, including 475,000 from the year 2020. They combined that data with survey results from the Harris Poll, which queried more than 500 primary care physicians. The report concluded that physicians are concerned about their ability to manage patients given the risks of drug misuse. In addition to worrying that they missed warning signs of drug misuse during the pandemic, 94% of primary care physicians state they are seeing an increased number of patients with mental health issues during the pandemic and “fear a correlation between rising mental health issues and prescription drug misuse.” Additionally, 98% of physicians are concerned about issues with controlled substances as a whole, compared to 75% who are concerned about opioid medications.

Specific to telehealth, 75% of physicians are concerned that telehealth visits limit their ability to identify whether patients are at risk for or already having issues with prescription drug misuse. Where 91% of physicians feel they can recognize warning signs during in-person visits, only 50% feel they can recognize issues during a telehealth visit. In my experience as a physician, most of the warning signs I’ve identified come from the patient’s history and discussion of their current situation rather than from the physical exam, so I find this phenomenon interesting. Beyond the information gathered from the patient’s story, I’ve used data such as refill patterns or information from prescription drug monitoring program records to identify potential misuse. Although I don’t question how some physicians feel, I’d be interested to understand more deeply why they feel this way and what they find lacking in a telehealth visit.

Another angle that was brought up was the idea that physicians are less willing to prescribe opioids during the pandemic, as well as the lack of alternatives for treatment for chronic pain. Nearly 80% of them are concerned that patients will turn to illicit fentanyl if they can’t get prescription medications, with 86% of them being concerned that illicit fentanyl will lead to higher death rates than prescription opioids. I totally understand not wanting to prescribe controlled substances during a non-face-to-face visit, especially since I was fairly strict in traditional practice as far as random drug testing during visits, and agree that we need better options for treating chronic non-cancer pain. The illegal drug crisis is real and it’s important for physicians to have strategies to identify such drug use, but I don’t think that a telehealth visit rules out that ability.

The report went on to look at drug testing as a component of treatment, with 81% of physicians seeing it as critical to prevent overdose deaths. However, more than half of physicians aren’t following up when presumptive drug tests are positive, and it’s not clear why. Given the capabilities of EHRs to include flowsheets for medication management as well as trackers and prompts for drug surveillance testing, I wish more of my peers would take advantage of those features so that they could more confidently care for patients. Additionally, only a third of physicians felt confident in prescribing naloxone to treat potential opioid overdose. It’s pretty easy to configure order sets that include both opioid pain medications and naloxone, so failing to do so is another missed opportunity to leverage technology. Existing clinical guidelines can be built into the EHR to help with clinical decision making and screening for changes in prescribing patterns.

I think it’s important to not overlook telehealth as a potential adjunct to pharmaceutical pain management. There are many providers out there who offer psychotherapy via telehealth, which could help as part of team-based care to identify patients who might not have their needs met with current pain management regimens. With the potential of using lower-cost resources such telehealth therapy versus in-person physician visits, patients could have more frequent check-ins about their needs as well as the ability to learn additional techniques to better manage their pain. Other options like telehealth-enabled physical therapy could be added for patients who might not be able to participate in traditional physical therapy appointments due to time or logistical limitations.

I polled a few primary care colleagues about the report, and their consensus opinion was that identifying drug misuse was more about having a relationship with the patient and ongoing contacts than it was about being in-person versus virtual. They were significantly more concerned about fragmented care as a risk factor for drug misuse as opposed to telehealth. I’d be interested to hear if any reader institutions are looking further at this issue, and whether they’re reaching different conclusions.

Have any thoughts on the connection between telehealth and prescription pain medication abuse? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/18/21

Road warriors, get ready. United Airlines has resumed sales of hard liquor on flights after resuming sales of beer and wine in June. Other airlines continue to hold off on serving alcoholic beverages as incidents involving disruptive passengers continue to rise. American Airlines plans to suspend alcohol service in the main cabin until at least January 18. There is still plenty of alcohol for sale in the nation’s airports, and several where I’ve recently traveled now allow passengers to drink the gate area instead of just within specified areas. I’m one of those people who keeps my mask on the entire flight and doesn’t snack or drink except for an occasional sip of water. Hopefully, the changes won’t bring an uptick in bad behavior, but only time will tell.

HIMSS continues to try to push its Accelerate platform through email blasts. Honestly, I have absolutely no desire to join another social media platform, let alone one that is controlled by HIMSS. I was in the beta group for Accelerate and didn’t find the content to be useful. As for joining the groups they’re pushing now, I already participate in groups through my medical specialty society and through the American Medical Informatics Association, so I sort of feel like I have all the connections I need unless something really crazy happens. If readers have found value in Accelerate, drop me a line – I’d love to hear about your experiences.

From Jimmy the Greek: “Re: monitoring. I recently worked with an organization that was planning to roll out a software package that was embracing its Big Brother tendencies. It monitors how much time you spend in each application on your laptop, how much active typing/mouse time you have, etc. and provides a dashboard to your manager.” The system in question was advertised as allowing employees to “understand your personal work habits allowing you to maximize your workday and reach your potential.” For employees who are in roles that involve a certain amount of throughput, such as medical billing specialists, coders, claims processors, etc. this kind of solution might make sense if people are struggling with meeting their goals and need tools to understand their productivity.

In other roles, I question the need for it unless people aren’t getting their work done. Solutions like that that score people on how much they are “doing” don’t give any credit for the cognitive time preparing to do something or for analysis or strategic thinking. It doesn’t reflect any work done that doesn’t involve the laptop, such as diagramming on the white board, having non-electronic meetings with co-workers, or all the fabulous things that process improvement folks do with Post-It Notes and flipcharts. It’s one more way in which employers can devalue the actual thinking that people do for their jobs.

In medicine, we’re used to it since the cognitive specialties typically get paid far less than the procedural ones, but I don’t think such a focus on “doing” at the expense of “thinking” or “planning” is necessarily a good thing. Of course, it’s all about how the manager uses it, but as an employee, I’d be pretty annoyed by the concept.

I attended a small gathering this evening with some former co-workers from my last clinical position. Except for me, everyone is still working full time, pulling 12- to 14-hour shifts as COVID-19 cases start to rise again in our community. It was a departure from our usual sessions since most of the attendees brought their children for some s’more making around the fire pit as well as photos with a 10-foot-tall inflatable turkey. It was quite a spectacle, but it was good to see people getting away from the office and doing some normal things with their children (at least until bedtime approached and the meltdowns started).

I daresay none of us at the bonfire think that COVID-19 is “no big deal” or “fake” or any of the things clinicians continue to hear from patients on a daily basis. Most of us are glad we haven’t been infected, and if we have, that our cases have been mild because that’s not always the case with our patients. After I returned home, I was scanning through email and came across an article in the Journal of the American Medical Association that put things in perspective and made me want to tell the moms and dads to hug their children tighter. The piece is titled “Thousands of US Youths Cope With the Trauma of Losing Parents to COVID-19.” It’s something people don’t like to talk about but that those of us in the trenches have seen. In our area, we’ve had several situations where children lost both parents to the pandemic, which is for most of us an unimaginable tragedy.

The article details some of the COVID-19 specific factors that make the situations even more tragic, such as children only being able to interact with dying parents via video calls and inability to hold memorial gatherings. Recent data indicate that more than 142,000 children have lost a parent, custodial grandparent, or grandparent caregiver due to the pandemic, looking at dates from April 2020 through June 2021. The worldwide estimate counts more than 1.1 million children losing a parent or custodial grandparent.

The piece goes on to contrast the losses due to COVID-19 with those from natural disasters or mass tragedies, where intense mental health services are available and where the causative incident is limited. The authors note that surviving children may be “extremely fearful that the virus will kill a surviving parent or siblings or claim their own lives.” They also describe feelings of “intense anger or shame” that may be felt by children mourning the loss of a parent who was unvaccinated or who refused to mask or distance.

As we move into the holiday season, it’s important to pause and think about those families whose holidays will be different this year due to the loss of loved ones. Unfortunately, the death toll continues to climb, mostly among unvaccinated individuals. For those on the fence about vaccination, I would offer the suggestion that becoming vaccinated might be the best gift you can give your family and yourself. I’m looking forward to spending time with my vaccinated and boosted family members who are in their 70s, 80s, and 90s as well as doing the traditional holiday things we usually do, some of which are a bit kooky, but that’s what family is all about.

What are your plans for the holiday season? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/15/21

Big news this week, as CMS announced that it would automatically apply the “extreme and uncontrollable circumstances” exception to the 2021 Merit-based Incentive Payment System (MIPS) performance year. Previously, clinicians would have been required to specifically apply for the exception. The automatic exception will be applied for the 2021 performance year and only to those clinicians who are participating as individuals. Those participating as groups, virtual groups, or alternative payment model entities will instead have to apply for performance category reweighting. This can be done on the Quality Payment Program website prior to December 31.

Those who are carefully following how MIPS works will note that the exception reweights the MIPS performance categories to zero, which means that there will be a “neutral payment adjustment” (aka no penalty) for the 2023 payment year. Given inflation, even a neutral adjustment is still a reduction in payments, which adds to physician unhappiness. CMS also reopened the exception application for the 2020 performance year; participants can apply prior to November 29 by submitting a targeted review form.

As physicians consider the ongoing calculus of how they are paid, how they deliver services, and what their patients want them to offer, I’m starting to see more of my primary colleagues considering direct primary care practices. In that model, patients pay a monthly membership fee to see their physician. There is no third-party billing, and the model is designed to delivery quality care at a reasonable cost. The Direct Primary Care Coalition notes that “most DPC memberships / subscriptions cost less than the average cell phone bill” and that patients typically have greater access, shorter waits, and longer appointments with their physician. In addition to reducing administrative burden and costs, the model has the goal of building back the old-school physician-patient relationship and a mutually trusting therapeutic environment.

Many patients are demanding telehealth, especially during hours that aren’t considered traditional office hours. Those practices that remain part of traditional fee-for-service arrangements are continuing to advocate for payment parity for telehealth services so they can be reimbursed at the same rate for virtual visits as they would for in-person ones. On the physician side, the thought is that the visits require the same level of cognitive expertise and also the same amount of time as in-person visits. Opponents of payment parity argue that those visits should be less expensive due to reduced resources, but the reality for most physicians is that they’re still paying rent, they’re still paying staff to assist them and manage patient data, and they’re also paying additional fees for either freestanding video conferencing software or telehealth modules / content from their EHR vendors.

In New Jersey, Governor Phil Murphy recently rejected parts of a bill that would have required payment parity for telehealth services. He noted that the cost to state taxpayers may be “substantial” and that in-person care should be prioritized except when telehealth would increase access and improve patient outcomes. Murphy reinforces the idea that providers should have long-term cost savings with telehealth due to decreased clinical space and support staff. It didn’t sound like he spends a lot of time talking to physicians who are running low-margin practices and working hard to keep the lights on while they are struggling to retain staff in a market where solid clinical personnel are commanding premium salaries. I’ve performed telehealth visits with no support staff as well as those in a model where staff did all the same pre-visit prep as they would in a brick-and-mortar office, and I have to say the latter is much preferred.

Murphy also notes a concern that over the long haul, “pay parity could over-incentivize telehealth, further limiting in-person options” and that it might be “especially detrimental for those in underserved communities.” On the other hand, pay parity might allow those in underserved communities to have consultations with distant primary care physicians without an untenable wait, which is already the case in many rural and underserved communities. It could also provide opportunities to consult with previously inaccessible subspecialists when patients are unable to travel the distance to tertiary care centers. I agree that Murphy has a valid concern that CMS hasn’t fully made up its mind on payment parity, which could create confusion for Medicare and Medicaid beneficiaries.

Murphy goes on to make it clear that he believes that telehealth “was intended as a stopgap to preserve public health during an unprecedented emergency” rather than something that patients and physicians have decided serves both of them well. It’s unfortunate that he sees it as a way to deliver care of last resort as opposed to a rapid evolution in healthcare delivery. The bill received a conditional veto, which allows the senate to potentially incorporate his recommended changes and amendments. Those include a requirement that the state health department would revisit payment parity over the next 18 months and make a subsequent recommendation. In the mean time, payment parity would be in place through the end of 2023 if the recommendations are followed.

As a patient, I enjoy having options. I have two physicians who I see who really need to be seen in person due to the nature of the examinations involved. I see each of those physicians annually, which between the two of them, results in a comprehensive physical examination with a fair amount of overlap every six months. They’re part of the same medical group as my internal medicine physician, who has full access to both their records. When I see my internist in person, 90% of the visit is a discussion – what’s working for me health-wise, what’s not, and a review of laboratory results, my goals, and how I feel. Very little of it is dedicated to the physical exam and that’s OK given my current state of health. In reality, I’m seeing him for his brain much more than I’m seeing him for his exam skills, especially since I monitor the most important indicators of my health at home. As a patient, it would be much better for my schedule to be able to see him virtually and have him compensated fully for his expertise, which is why I value his care.

Time will tell how much cost reduction can really happen with virtual care. I think a lot of it has to do with how integrated various platforms are and how well physicians can learn to work with patients virtually. Will we have it all figured out by 2023? I’m not sure, but I’m committed to trying.

What’s your preference in the virtual versus in-person care debate? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/11/21

I had dinner with one of my friends from residency tonight. She’s considering leaving practice even though she’s not even 50. She had two unvaccinated patients die from COVID this week, one of whom was only 46 years old and who died after being in the intensive care unit and on a ventilator for over two months. Her late patient left behind several children, and apparently their father spent the last several days harassing my colleague because she had refused to treat the patient with ivermectin. The harassment included threatening comments and a visit to my friend’s house, resulting in a call to the police and my friend bundling her own children off to their grandparents’ just in case. Physicians have been fighting this pandemic for more than a year and a half and they certainly didn’t sign up for what she experienced.

On top of that, her partner quit and the health system she works for has been unable to hire a replacement who is willing to join a rural practice, leaving her to care for more than 6,000 patients on her own. She has also developed a severe skin reaction from the soap and sanitizer used in the office, resulting in a worker’s compensation claim after multiple product changes failed to yield results. She’s had to miss work due to numerous physician visits, including second and third opinions from dermatologists at the local medical schools. Every time she takes off for a physician visit, it negatively impacts her office productivity, and the medical group’s newly appointed administrator asked her why she can’t schedule her visits after hours. As she was telling me the story, I wondered if the administrator had ever been a patient or caregiver, because that’s just an asinine suggestion.

She had a lot of questions about telehealth and whether that might be an option for her if she isn’t able to find a solution to her allergic skin reactions. Her only experience with telehealth was during the height of the pandemic, when the health system encouraged physicians to embrace virtual visits because patients didn’t want to come in. However, in her particular community, many patients didn’t think COVID-19 was a big deal and thought that dealing with a computer was a bigger nuisance than risking infection, so telehealth never really took off. From a technology standpoint, they were using a solution that was completely cobbled together and had no integration with their EHR, so I encouraged her not to judge her options based on that experience.

We talked about some trends in telehealth, including insurance plans that have a virtual-first focus. I would propose that such plans would be most effective if continuity could be preserved, either with the same care team providing both in-person and virtual care, or if dedicated virtualists had full access to the patient’s medical records. There are concerns about physicians providing virtual-only care as far as not being able to perform a physical exam. The new plans are designed to have networks of in-person physicians that can perform hands-on services when required, and who can coordinate with the virtual physicians. Although payer-sponsored plans might have their own patient records, they might have difficulty coordinating when patients receive services from non-network physicians or other care providers. Some of the plans have high deductibles for in-person care, which may serve as a deterrent. Additionally, they may not be compliant with the Affordable Care Act.

We also talked about the challenges of practicing telehealth, including technology issues. A recent piece in JAMA Network Open looked at factors influencing whether patients and physicians were able to successfully complete telehealth visits. The authors looked at over 137,000 video visits and found an overall success rate of 90%. Patient factors were “more systematically associated with successful completion of video visits” where “clinician comfort with technology was associated with successful video visits or conversion to telephone visits.” Certain factors were associated with conversion to telephone visits, including lower clinician comfort with technology, greater patient age, lower patient socioeconomic status (including low availability of high-speed internet), and racial/ethnic minority status.

The study has some limitations, including having been conducted at the height of the COVID-19 pandemic when most of us were still getting used to the idea of video visits and many providers were using substandard technology platforms to try to connect with patients. Visits at that time were often sporadic and urgent, and there was little lead time to help patients with technology or their comfort level with video encounters. The study also was conducted in the Midwest and at a single healthcare organization. Longer duration studies with a broader cross section of patients would be beneficial.

Our conversation crossed into a lot of different elements of practice, and she was interested to hear about my recent experiences in EHR training. We’re both veterans of multiple EHR conversions and implementations, and she asked if I had seen the story about the US Department of Veterans Affairs being ordered to pay $160 million to clinicians for extra work hours spent updating EHR data. I hadn’t seen it until she mentioned it, but the short version is that 3,200 nurse practitioners and physician assistants who were employed by the VA at the time worked overtime doing various EHR functions and weren’t compensated appropriately. The court ruled that employees should have had received overtime pay any time they worked more than eight hours in a day. In the class action suit, each member will receive about $50,000 in compensation.

The last thing we talked about as our bottle of pinot noir became depleted was an article that looked at whether physicians could accurately predict the out-of-pocket costs for medications they were prescribing. The authors found that only 21% of physicians could do so, which sounds like what I might expect given the craziness of medication pricing and the challenges in figuring out various formulary coverage, deductibles, co-pays, and annual caps. We’ve both used EHRs that were supposed to display formulary and eligibility data in a way that should help physicians figure this out, but have found that none of them were particularly effective, especially since different payers use different formulary levels that resulted in confusing EHR displays and data that just didn’t make sense.

The evening ended with a discussion of her children and their career plans and the fact that she’s completely baffled her children want to pursue careers in medicine despite her obvious dissatisfaction with it and eagerness to leave it. They’re still relatively young, in middle and early high school, so of course things can change. Given the way things are now, I know quite a few physicians who wouldn’t choose the career again, or if they did, would choose a different specialty. It’s a sad commentary on what healthcare has become for a lot of physicians.

If you had it to do over again, would you still choose healthcare? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/8/21

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/4/21

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

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

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

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

Other interesting tidbits:

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/1/21

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/28/21

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/25/21

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.