Home » Dr. Jayne » Recent Articles:

Curbside Consult with Dr. Jayne 12/16/19

December 16, 2019 Dr. Jayne No Comments


Winter has arrived in the Midwest, and with it the end-of-year slowdown in healthcare IT news. While sales-focused teams are scurrying to complete end-of-quarter sales to bolster their final financials, marketing folks seem to be holding anything remotely interesting until we get closer to HIMSS. That leaves us with a smattering of governmental and regulatory news items.

I admit sometimes I miss these kinds of items because of the noise of all the other things going on in the industry, so maybe it’s a good thing that we’re headed into a less-frantic time (at least until March, that is).

Sneaking into the news on Friday was the FDA approval of Tandem Diabetes Care’s predictive software that bridges the gap between continuous glucose monitors and the company’s insulin pump. Why is this a big deal? It’s the first insulin dosing software approved under a new FDA interoperability pathway, which gets interesting because different companies make components of the so-called “artificial pancreas” systems that result. You could be using one company’s glucose sensor, another’s pump, and a third-party algorithm between the two.

Tandem is already working with Dexcom Inc. and Abbott Laboratories to coordinate. This is great for patients whose insurance may only cover certain brands of one device or another, and who otherwise might not be able to take advantage of the newest technology. Typically payers only cover insulin pumps every four years, so being able to update a control algorithm rather than having to obtain a completely new device is a pretty cool thing.

Also in the news this week: glitches in the Healthcare.gov system where many people have to sign up for insurance coverage. It’s possible that up to 100,000 users were impacted by technical issues on the first day of open enrollment. CMS had to add a “waiting room” to the site to help manage traffic flow, and as of December 7, there have been 6 percent fewer enrollments compared to last year.

Patient advocates were concerned about the typical last-minute surge of enrollments and whether the site would be able to handle the traffic before the deadline. I haven’t seen any updated numbers this morning, but I’m sure there will be a lot of spin placed on whatever data becomes available this week.

A recent approval by the Federal Communications Commission is raising concerns. The group voted last week to create 988 as a nationwide suicide prevention hotline telephone number, much like 911 for emergency services. It would replace the existing number for the National Suicide Prevention Lifeline. The thought is that a shorter number would enable more people to call, but there are anticipated downsides: an increased number of callers would also increase the costs for crisis centers staffing those phones and many centers are struggling to make ends meet as it is.

The hotline is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA). Theoretically more people would be calling 988 rather than 911, so that’s a cost savings since fire and emergency services won’t be dispatched for a potential suicide attempt. It could also lead to significant societal savings by preventing loss of life, but those savings aren’t immediately passed to those institutions bearing the cost, based on the calculus of healthcare math. Another example that healthcare is complicated, y’all.

Other government news includes the impending release of millions of dollars in disputed Medicare hospital payments that were withheld due to a payment policy that was struck down in court. The American Hospital Association estimates that $380 million will begin flowing as Medicare Administrative Contractors start reprocessing claims that were paid at reduced rates. Reprocessing begins January 1, so get your data and claims engines running!

Just when I thought I was out of government news, I came across news about the recent report by the US Department of Health and Human Services, Office of the Inspector General, regarding concerns around chart reviews looking at Medicare Advantage payments. Not surprisingly since billing is such a game, claims were reflecting sicker patients and more comorbid conditions than patients might actually have. Apparently payers are adding diagnosis codes for conditions that aren’t documented in physician or hospital records and this occurred in 99.3% of chart reviews.

Medicare Advantage is a big piece of the Medicare spending pie — approximately $210 billion of the $711 billion spent last year went to Medicare Advantage plans. There are concerns not only about overbilling, but that plans are functioning like the HMOs of the past to deny care as a means of increasing profits. There are also concerns that if the patients actually have the conditions added by payers (which aren’t reflected in the medical records) that patients aren’t receiving adequate care.

The audit looked at data from 2016 to assess the financial impact in 2017. As payers get more creative, it’s possible the problem could be even more rampant now. A particularly damning sentence from the report: “Although limited to a small number of beneficiaries, almost half of all Medicare Advantage organizations reviewed had payments from unlinked chart reviews where there was not a single record of a service being provided to the beneficiary in all of 2016.” At least fee-for-service payment models require the patient to be in front of you before you bill for services.

HHS recommends that CMS provide oversight of organizations that had payments resulting from chart reviews where beneficiaries received no services; conduct audits to validate diagnoses; and reassess the practice of allowing unlinked chart reviews being used as a source of diagnoses for determining risk. CMS accepted these recommendations.

There’s one piece of governmental news that’s front and center right now, although patients aren’t talking about it. Influenza is on the rise, with 2.6 million illnesses, 23,000 hospitalizations, and 1,300 deaths so far. I can’t count the number of patients who said “I never get the flu shot” a couple of months ago who are now showing up at the office sick and miserable. There’s not a lot we can do for influenza, other than providing supportive care and symptomatic relief. For small children, there’s even less we can do. Please do your part – wash those hands and stay home if you are sick. And next year, consider a flu shot.


Email Dr. Jayne.

EPtalk by Dr. Jayne 12/12/19

December 12, 2019 Dr. Jayne No Comments

My bedtime routine includes checking HIStalk for comments and doing some light Web surfing on my phone, so my attention was captured by yesterday’s JAMA article entitled “Matters of the Mind – Bedtime Procrastination, Relation-Induced Anxiety, Lonely Tweeters.” No surprise, studies linked smartphone use with bedtime procrastination. The piece also looks at how relaxation can be stressful for individuals with anxiety and depression, as well as how Twitter posts could help identify loneliness. These are areas of research many of us wouldn’t have dreamed of a decade ago. I’ve thought frequently about consumer technology (particularly smartphones) and how it’s collectively one huge experiment, albeit one without an Institutional Review Board to make sure the participants aren’t harmed. I think we’re just scratching the surface at learning what technology does (or doesn’t) do for or to us.


Jenn clued me in to this article about startups focusing on nurses as a target audience. There are 3.8 million nurses in the US, so it makes sense that companies would start designing around their needs. Clove is one of them, and their name is an inside joke as well – the C with a line over it is medical shorthand for “with” so their products are “with love.” The name is subtle but the medically-inspired design of its shoes aren’t – although they’re a running style, they have a solid smooth surface over the toe area which is great to protect from the spills and goo of the job. Ventilation holes are relocated to the sides, where splashes and drips are less likely.

The company is savvy in other ways, showing that they understand healthcare folks by shipping a three-pack of pens with every pair of shoes. The pens are marked “For Borrowing Only.” Anyone who keeps a spare (and usually crummy) pen in their pocket to deal with people who ask to use your pen and who are unlikely to give it back knows what I’m talking about. Nike also recently launched a healthcare shoe, but it’s not nearly as cool. I was a little put off by their unisex sizing as well as their use of the “star of life” logo most commonly used by emergency medical services. In contrast, Clove has both women’s and men’s sizing as well as color names that make clinicians smile: Grey Matter, Night Shift, and Pink Up.

Public health informatics is a big part of clinical informatics, and I was shocked to learn about a measles outbreak on Samoa, where measles is running rampant. The country has a population of around 200,000 and nearly 4,900 people have become ill with 71 dying. Similar outbreaks are also occurring in Tonga, Fiji, and American Samoa. Several of the Pacific island nations have vaccine rates below World Health Organization recommendations. There are numerous reasons for the low vaccination rates, but my thoughts go out to those who are sickened and their caretakers. Hopefully the outbreak is a brief one.

In other news, analytics folks must be cheering at the possibility that flu season could peak early this year. The Centers for Disease Control and Prevention’s FluSight Forecasting initiative gives it a 40% chance of peaking this month, as flu levels have been at or above the national baseline for several weeks. The chance it will peak in January is 30% and February is 20%. I’ve significantly reduced my clinical work for January and February because I loathe driving in icy conditions, so we’ll see if I played the odds right or not.


Intelligent Medical Objects has launched IMO Precision Sets, which are designed to allow clients to quickly define various value sets needed for quality work and value-based care. Based on IMO’s solid terminology and maintained by their dedicated clinical terminologists, they are available in various sets – Oncology, Reporting, Behavioral Health, Chronic Conditions, Perioperative, and Acute Conditions. I spent way too much time in a past life trying to maintain those groupings for reporting, through ICD codes and SNOMED codes. IMO’s original Problem IT product was the only solution I ever deployed as a CMIO where my providers proactively reached out to say thank you, so I’m a big fan of their work.

Congress is looking for feedback on a new bill nicknamed “Cures 2.0,” which is designed to go beyond the content of the original 21st Century Cures Act to address topics like digital and connected health platforms. They also plan to focus on real-world evidence in the FDA’s approval process, and to speed up coverage of FDA-approved drugs by payers. Feedback is requested by December 16 at cures2@mail.house.gov if you’re interested in sharing your thoughts.

As we approach the end of the year, it’s a time for many to reflect on the months that have passed and our hopes for the coming year. Since we work in healthcare technology, we’re not immune to the influence of various trends and fads, especially where health-related tech is concerned. Like many, I’ve had my adventures with wearable tech, startups, and various apps that proposed to make my life better. Lots of people have stories to tell about how we can live our “best lives,” from tech gurus to TV personalities. In a fit of decluttering I had my Marie Kondo moment, so I giggled when I came across this article about “The life-changing magic of making do.” I’m a frugal person (as evidenced by writing this wearing 20-year old pajamas on a 20-year old sofa, watching Netflix on a TV smaller than some computer monitors), but was shocked by some of the statistics in the article as far as sheer consumption in North America.

The piece’s comments on the lack of fixability with technology resonated with me – it’s one of the reasons I hope my geriatric washer and dryer never fully give up the ghost – I don’t need something with a motherboard to control how my clothes are cleaned. (I’ve had enough of that drama with the refrigerator to last a lifetime). I’ve rehabilitated both the washer and the dryer courtesy of Repair Clinic and its videos. (Have you ever seen inside a gas dryer? It’s pretty crazy in there.) It gives me hope for what I want to do professionally in the next year – to help healthcare organizations get the most out of the resources they’ve already paid good money for and that they might not be using to the fullest. It’s a good goal, but difficult for some organizations because it often involves hard work. It’s much easier to throw out a “problem” technology when the real problem is the people or processes that govern its use. We’ll see how that plays in the New Year.

What are your reflections on the past year and hopes for the coming one? Leave a comment or email me.


Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/9/19

December 9, 2019 Dr. Jayne No Comments

As part of the Maintenance of Certification process for my clinical informatics board certification, I have to complete a quality improvement project related to practice. Although there is quite a bit of flexibility in these projects, it’s been challenging for me to come up with something because I don’t have what many would consider a “typical” informatics practice. Many of my peers are either part of academic institutions where they have clear roles and/or titles. Others are part of healthcare delivery organizations where they have the ability to use data and processes for quality improvement. As an independent CMIO for hire, I often have a seemingly random mix of employers, ranging from startup technology vendors to large healthcare systems.

In these situations, I have contractor status. It’s a strange limbo where often you are treated like an employee but you’re actually not – you have many of the same responsibilities and are subject to the same rules as employees, but at the end of the day you don’t have the ability to direct your own work or propose new initiatives that would make sense for a straightforward project for board certification. My clinical situation is unique in that I’m employed, but very much part time and with no formal informatics role these days. My informatics influence is limited to cranky emails to our IT team asking why the system is suddenly allowing us to e-prescribe controlled substances when we do not have legitimate EPCS technology in place. My employer is reluctant to allow me to do anything with our data, since I’m essentially just an hourly physician.

I have another year or two before I have to finish this project, but I still feel somewhat adrift with it. Still, I am always on the lookout for ideas. One recently came across my desk, and I wonder if the practice would be willing to let me use their data if I could find some “what’s in it for me” for them. As an urgent care, we certainly see our fair share of trauma. Recently, JAMA Otolaryngology-Head & Neck Surgery published a study investigating a surge in cellphone-related facial trauma. Reported injuries range from being injured by a dropped or thrown phone to distraction-related falls.

The authors looked at 20 years of data from the US Consumer Product Safety Commission database looking at ER visits. They found 2,500 patients with phone-related head and neck injuries between 1998 and 2017, with a surge beginning in 2007, coinciding with the advent of smartphones. Approximately 40% of the subjects were between the ages of 13 and 29, and they were generally injured while walking, driving, or texting. Although cell phone use has also been linked to repetitive motion injuries, these were excluded from the study. The most common injuries were facial and head lacerations, followed by contusions, abrasions, and injuries to internal organs. The majority of patients were treated and released. Apparently there are more than six million patients treated for lacerations every year, with an estimated cost of $3 billion.

I’d be curious to find out how cell phones compare with other sources of trauma in our urgent care practice. We see over 300,000 patients a year so there should be a reasonable amount of data. Anecdotally, I think that sports-related injuries likely make up the lion’s share of our head trauma, followed by motor vehicle accidents, and falls. I’m betting that the causes would have to be determined by a chart audit, because many of my partners aren’t as specific with their coding as they could be. My quality intervention could be to assess whether visits were documented more accurately when physicians or scribes were doing the work, and to develop a curriculum to try to increase the specificity of coding. It’s kind of a soft project, but it at least addresses something that is clinically relevant in my practice. Still, it’s unlikely that I could talk my employers into it, since there’s not a clear return on investment for the time that would need to be spent educating clinicians and staff.

Another option for the quality project is for informaticists to conduct a 360-degree evaluation project. We did a 360-degree evaluation in residency and I’ve done it with a previous employer, and also with one of the community service organizations I work with. All three times I found it to be useful, although the episodic nature of some of my work might make this challenging. Some of my projects only last a month or two, which makes it hard for someone to get to know how you work, critique it, and then re-evaluate after you’ve completed some kind of intervention or change in how you work.

These are all part of the hoops that we have to jump through to maintain our board certification status. It’s particularly challenging in clinical informatics, since there can be such breadth in the type of work that we do. Our practice environments can be very different, and we may spend anywhere between 1% and 100% of our time doing informatics work depending on how much our employer wants to fund. I am glad that the American Board of Preventive Medicine, which is my certification body, recently approved a proposed Longitudinal Assessment Pilot as an alternative to the one-day board certification exam. It is supposed to launch in early 2021 and run for 24 months. Participants will answer 24 questions a year. This differs significantly from the longitudinal assessment pilot in my primary board, where we have to answer 100 questions a year for four years in order to replace the exam. It’s hard to imagine how the scope of clinical informatics can be distilled down to 24 questions a year, but unlike my primary board, it doesn’t seem that we have the opportunity to opt-out of this pilot.

I’m curious whether non-physicians are aware of the clinical informatics quality projects and whether your board-certified colleagues have pulled you in to help them get across the finish line. How are the projects perceived? Have there been positive outcomes? Or are they just a nuisance? On the physician side, is anyone else dreading their project? Leave a comment or email me.


Email Dr. Jayne.

EPtalk by Dr. Jayne 12/5/19

December 5, 2019 Dr. Jayne 1 Comment

A recent NEJM Catalyst piece looks at the role of physician gender when looking at EHR usability and clinician burnout. Researchers at the University of California San Francisco found that female physicians created longer notes, addressed a higher percentage of patient contacts within 24 hours, and spent more after-hours time using the EHR than their male counterparts. Female users were also more likely to use copy/paste and other tools to make documentation more efficient, but spent more time in the EHR. These factors may explain a higher rate of female physician burnout when looking specifically at EHR use. The study was fairly broad, looking at over 1,300 physicians across nearly 90 specialties. It looked at various six-week time periods over the course of a year.

The authors suggested that healthcare organizations could do a better job reducing EHR burden overall, including creating clear expectations for EHR use and timeliness of patient contacts. I’d go further to suggest that they look at the FTE support staff in various practices and whether the physician to staff ratios are equal.

I’ve seen several practices in my recent travels that relatively understaffed some physicians (both male and female) despite equal productivity. Staffing ratios there depended more on physician personality and the fact that some providers demanded more support staff, where others were more likely to pitch in and do staff-level work or didn’t want to rock the boat asking for more help. Although the study controlled for staffing, my experience in non-research environments is that staffing can be highly variable.

Other teams have also looked at this issue. A recent JAMIA article looked at usability and gender, along with age, professional role, and years of experience. Among intensive care physicians, they identified “significant gender-based differences in perceived EHR workload stress, satisfaction, and usability – corresponding to objective patterns in EHR efficiency.” Drawing conclusions based on gender can often create friction among clinicians, but I’m glad they’re looking at the problem.

I’ve been on several vendor webinars this week and have experienced sessions spanning the range of good, bad, and downright ugly. For those of you who have to deliver webinars, I have some tips.

First, make sure you have your content fleshed out ahead of time. You don’t have to write a full word-by-word script, but you need to know what you are planning to say. On the other hand, if you struggle with impromptu speaking or have a tendency to go off track, write a script. Whatever you do, please do not simply read the slides to the audience. You’ll lose them in a flash. If you use a script, practice reading it in a conversational way, not like a robot.

Second, check your slides for visual appeal. Text should not be too bulky in content or too small in font. Use visuals to convey your ideas along with your word track and it will be more memorable to the audience. If you’re including polls for the audience, please show the results as you go – don’t just grab the data for your own marketing purposes. Attendees often want to understand how they compare to others on the call – whether they’re ahead of the game or trending the same as other organizations.

Last, make sure any photos used during introductions are professional or appropriate to the audience. Your hair should be combed, at a minimum, and it would be nice if the background was uncluttered and the lighting was good. Under no circumstances should you crop yourself out of a group wedding photo (yes, I saw this).

Mr. H already mentioned this article about physicians and tech staff clashing at digital health companies. Having been a physician working in digital health including with vendors, I wanted to add my two cents.

The article makes the point that clinical and product teams are “at odds,” which I have definitely seen. I’ve also seen teams where everyone works well together and drives the solution forward because they have a mutual understanding of each other’s experience, goals, and priorities. One of the biggest barriers to successful collaboration is the presence of preconceived notions about the members of the team. If tech team members have had previous negative experiences with physicians, they’re likely to make assumptions based on those experiences. Similarly, physicians may not understand the roles and processes of various tech team members or how an agile process works. Getting everyone in the same room to learn about each other and how they need to work together is a start.

Another barrier I’ve seen is lack of structure – inconsistent sign-off processes that may not fully explain how requirements or other work product should be flowing through the organization and lack of defined processes for clinical and other subject matter experts to provide their feedback. That can result in unpleasant shocks at the end of the process when clinical folks are presented with workflows that aren’t going to work, but could have been better engineered if the clinician input was at a better place in the process.

Physicians also need to have a common framework for how they’re going to make decisions around clinical content. Is the company striving to be evidence-based, or is customer satisfaction or sales the lead driving factor? These elements aren’t mutually exclusive, but there has to be a common goal or physicians may be in conflict with each other. This goes back to governance, including team charters and product charters that make sure everyone is working towards common goals and there is clarity about how decisions need to be made, or how to handle when physicians or other clinical SMEs are not in agreement.

This isn’t just a clinical issue. I’ve seen the same problems in other areas of the healthcare IT industry, whether it’s revenue cycle, billing, patient engagement, etc. Everyone needs to understand the role that team members play and needs to respect the roles and knowledge of others on the team or there is going to be conflict. This goes back to leadership. If the individuals in charge don’t buy into this concept of mutual respect, and either team feels like it’s being marginalized or attacked, the effort is not going to be successful.

Do you have clinicians who are part of your development organization? What advice can you offer? Leave a comment or email me.


Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/2/19

December 2, 2019 Dr. Jayne No Comments

I’m happy to report that I’ve survived the Thanksgiving holiday despite the intersection of bizarre karmic forces that had me working in the clinic most of the week as well as hosting Thanksgiving Dinner. I worked Black Friday and the weekend as well, so I haven’t fully recovered. Next, I’ll have nearly two weeks free of clinical care, then some scattered shifts before the scheduling gods smack me down again with a five day streak of 12+ hour days before we head into 2020.

I don’t know what our schedulers are thinking at times, but I suspect they’re scheduling around the day-off requests of the full time and higher-ranking physicians. I’ve asked for fewer shifts in the new year, so hopefully I can regain my sanity.

Truthfully, I don’t mind working Black Friday and it’s become a bit of a tradition for me. I’m not much of a shopper and value my sleep too much to be getting up at the crack of dawn to hunt for bargains. Most of the patients who come in are actually sick and it’s a privilege to help them. Many of them put off care because of holiday preparations and having family in town and now they’re in bad shape.

Most of the primary care offices in the area were closed, so their choices were limited. One cardiology office I called had a message that they would be closed until January 2, so either something funny is going on with the practice or they accidentally recycled their Christmas out-of-office message from last year.

We started the day with more than a little trepidation. The team that was on for Thanksgiving noted they had issues with our EHR communicating with our drug dispensing system. They were not able to get it resolved due to lack of holiday support from the tech teams. Fortunately for us it was working, and by noon, we had seen more than twice our usual volume of patients. As soon as we would empty the waiting room, another batch of patients would arrive. It was well after 3 p.m. before any of us were able to sneak off to the kitchen to eat the previous day’s catered leftovers.

I have to say that our leadership understands that well-fueled staffers are happy staffers. They had pizza delivered the day prior to Thanksgiving, a full holiday spread on the day itself, and the random arrival of dozens of tacos and burritos on Black Friday.

The holiday patient mix is always an interesting one. We had several hospital transfers for influenza, pneumonia, and out-of-control diabetes. We saw kidney stones, raging urinary tract infections, and a couple of lacerations that should have been taken care of the day before, except people didn’t know we were open. There were even a couple of people who had a little too much holiday merriment and came in for IV hydration. Strep throat, sinus infections, and plenty of lingering colds rounded out the day.

I was glad to see the severity of illness dropping as the day went on since we were all getting pretty worn out by dinner time. We had a brief surge of people who came in after their shopping was done, which always makes me a little aggravated since they were out spreading germs when they should have been at home with some soup and a vaporizer. The rest of the weekend was a different story, with moments of calm punctuated by anxiety-provoking stroke symptoms, head trauma, and a myocardial infarction that was smoothly transferred to the hospital.

On days like these, I’m grateful for the EHR and the ability to have default documentation that works for patients with similar symptoms. We tweak them as we need to, but it’s still fast, and as long as you’ve personalized your defaults, the notes are of good quality.

Of course, there are always providers who don’t personalize their options, which is how you wind up with visit notes that have exam findings that you’re sure the physician in question didn’t do. Or they don’t use the defaults at all, which leads to slow documentation and plenty of physician frustration. I definitely couldn’t document this fast on paper, even when I worked in an emergency department that used paper templates designed for rapid documentation based on the patient’s presenting issue.

People often ask me why I continue to do as much clinical work as I do. The real answer is that I enjoy it. I enjoy the people I work with and the organization I work for. We have an outstanding workplace culture. Frankly, compared to being a CMIO, it’s like being on vacation. Everyone knows their roles and responsibilities and how to work together as a team, despite the fact that we work with different combinations of people and at different locations all the time.

It’s a fail-fast environment. People who can’t get it done don’t last very long. They give people the tools they need to be successful, and if it’s not a good fit, they’re not going to subject the rest of the team to poor performance. I never played on a select sports team, but I imagine it might feel a bit similar. I’m willing to put up with wacky scheduling in order to stay on a high-performing team.

We no longer have an annual company holiday part  since it has been moved to the spring after flu season is over. But this year, the staff has organized their own get-together. Sometimes people just want to get away from their co-workers at the end of the day, so it’s great being at a place where people like each other enough to want to spend time together. We’ll be bowling the night away along with a “rob your neighbor” gift exchange, which based on the sense of humor held by many of my co-workers, should be highly entertaining.

I was honored to be invited since I don’t think all of the physicians were on the guest list. At least we know that if anyone has too much holiday cheer or sprains something during the “crazy bowl” part of the evening, we’ll be well cared for in the morning.

What does your company do to celebrate the holidays or thank the team for its hard work? Leave a comment or email me.


Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/25/19

November 25, 2019 Dr. Jayne 3 Comments

Clinician burnout continues to be a hot topic, so this American Academy of Family Physicians article caught my eye. It looks at the possibility that being able to better address the social needs of patients might reduce the possibility of burnout. I’m not surprised by this – physicians and other clinicians are trained to do their best to address all their patients’ issues, whether they are purely biological, psychosocial, or somewhere in between.

In many residency programs, we have all kinds of ancillary providers that help us do these things. My training program had PhD pharmacists, social workers, diabetic educators, dieticians, and psychologists to which we could refer our patients for a variety of services. Need a patient to receive education on anticoagulant drugs, their long-term monitoring, and the need for dietary changes? Check. Want to enroll a patient in smoking cessation clinic? Check. Newly diabetic patient who needs supplies and training? You got it. Patient who needs help navigating Medicaid enrollment or applying for supplemental nutrition assistance? Done.

When I headed out into practice, however, I was on my own to try to deliver many of these services. Even referring to subspecialists often became a battle that was made worse depending on the patient’s insurance coverage, ultimately resulting in the patient not receiving needed services.

At one point in time early in my career, only one of the city’s practices was taking new neurology patients who had Medicaid, which made the wait to see a consultant nearly a year long. This led to primary care physicians trying to do what they could to manage complex neurological issues that they weren’t trained to handle. You don’t have to ponder to hard to see where that could cause stress and burnout.

Not much has changed in the last couple of decades, although at times it’s a little easier to get patients in to see subspecialists, or maybe I’ve just built up enough friendships to be able to call in more favors. There are other more complex issues that we can’t solve through a phone call to a friend or classmate. Maybe it’s housing issues, transportation issues, or food insecurity. These are the types of issues that the study mentioned was looking at, along with whether inability to address patients’ social needs was a contributing factor to primary care clinician burnout. The authors went on to note that increasing services in the practice to address social needs tended to reduce burnout and improve clinician morale.

The study noted that participating physicians were concerned about how addressing social needs would impact their workflow. I’m curious about how those physicians went about adding services or training staff to address social needs and how that impacted not only the workflow, but the practice bottom line. Theoretically, some of the new care models, such as Comprehensive Primary Care Plus or Primary Care First, should provide additional funds to cover these additional services. However, it’s still not going to be enough.

A friend’s EHR has the ability to link out to transportation resources for patients, such as Uber. However, the practice has to pay for the transportation, leading to an ongoing internal conflict about which patients should receive those services. Independent physicians can make these decisions locally, but employed physicians are often subject to the whims of their owners, and productivity and case mix determines which physicians (and therefore patients) receive additional support and which don’t.

On the technology side of healthcare, we face similar difficult decisions. We have limited budgets and requests for more projects than we could possibly fund or staff. At one of my large health system clients, decisions often impact broad swaths of patients. Are we going to focus on systems to improve labor and delivery workflows this year, or fund the initiatives that the heart failure program has requested? How many patients would benefit from either approach? What about the community diabetes screening initiative, or the dental care mobile van? Should we look just at patient count, or go further to see how interventions would impact people over time?

At one point, money earmarked for optimization of frontline nursing workflows was diverted to cover consulting services needed to complete a required regulatory upgrade. This led to a relative revolt by some of the staff involved in advocating for projects that didn’t get the nod.

The emotions felt by some of the IT staff were no different than what was probably felt by the physicians in the study. In particular, those whose projects weren’t taken forward felt disenfranchised and often had a profound sense of loss. Some of those whose projects succeeded had something akin to survivor’s guilt as they watched other worthy initiatives wither. It also engendered a sense of fear and concern, with people wondering whether their project would be the next one to be defunded or otherwise not fully implemented. Sure, projects get canceled in every industry, but I think my colleagues in healthcare IT feel it more acutely because they know their work has the direct ability to impact patients’ lives.

The emotions become even more acute when you are working for organizations that are sitting on billions of dollars of resources, but may not be spending as much on patient care as they should. The marble lobby of the tertiary referral hospital is particularly luxurious (and the fountain is pretty darned impressive), but neither of those see patients. They don’t make up for the negative emotions felt by the clinical staff that empties the exam room trash cans every other day because the housekeeping budget was cut and services are only provided on even days. The luxury boxes at the ballpark and the over-the-top billboards are also a visible reminder of the money the health system is willing to spend on non-patient-care activities.

As the old adage goes, you have to spend money to make money, but somehow that spending is becoming less palatable when healthcare is on the line and patients are literally dying due to lack of basic interventions.

It’s easy to see why people in healthcare are burned out, no matter where you work or what your role is. Our inability to meet our patients’ needs is only a proximal cause, with many root causes beneath. I’m cautiously optimistic about new models of care that might help alleviate suffering or reduce gaps in care, but it may take years to determine how successful they really are. In the meantime, we need to support each other and continue to try to come up with innovative ideas to solve some of the most difficult problems humanity faces.

What would make you feel less burned out? Leave a comment or email me.


Email Dr. Jayne.

EPtalk by Dr. Jayne 11/21/19

November 21, 2019 Dr. Jayne 1 Comment

I wrote a few weeks ago about my adventures with flu vaccines and how the charges are handled by my insurance. Kaiser Health News dug into the phenomenon this week, going farther in noting the differences in costs among one payer’s own employees. The payments ranged from $32 in Washington, DC to $85 in Sacramento.

This illustrates the results of negotiations between payers and providers, the madness of which leads to the need for entire segments of the healthcare IT industry to keep up with it. Anyone who has worked with practice management or revenue cycle systems has experienced the phenomenon and the layers of code needed to wrangle it, and I salute you. It remains to be seen whether the government will be successful in forcing providers and payers to disclose this information publicly. Efforts to do so will likely be in the courts for some time.

I’ve been doing some behind-the-scenes work on clinical guidelines, and recently tried to track down data on a drug that is supposed to be available as a generic that we couldn’t find. The Wall Street Journal made note of the problem this week as well, observing that multiple factors keep those drugs from making their way into patients’ hands. It’s a disappointing phenomenon, but an interesting read.

In other drug news, a serious outbreak in pigs is likely to cause a shortage of the critically necessary blood-thinning drug heparin. African swine fever is on the march, killing nearly 25% of the world’s pig population, particularly in China, where the majority of heparin is produced. The World Health Organization is recommending that governments stockpile heparin, so be on the lookout for extra alerts and clinical decision support needs in EHRs.

Mr. H already reported on the AMA’s call for inclusive EHRs for transgender patients, but I want to throw in my two cents. Several years ago, I worked on some focus groups with a vendor who was trying to get this done. It can be complex, because there are many variables to document, including legal status, legal name, preferred name, surgical status, hormonal status, anatomical status, genetic status, etc. The vendor was focused and had several physician advocates who would continually explain to business analysts and developers why this was important. They ultimately they got the job done.

I’ve heard rumblings from other sources that this is a big lift for a small number of patients. But without the ability to document key clinical data and use it at the point of care, it results in a subpopulation being treated differently and in ways that might actually be counter to good clinical care.

The AMA also adopted a policy to promote education on health issues related to sexual orientation and gender identity for medical students and residents. I didn’t know much about the transgender population until medical school, where I had a professor who was public about their transition. It was a tremendous opportunity for learning and understanding and made a great impact on me, ultimately leading to me having a good number of transgender patients in my practice. I’m fully supportive of efforts to make EHRs inclusive for everyone, whether it’s based on differences in gender, age, race, ethnicity, or any other characteristic that may influence health. To be the most effective, we need to be able to meet our patients “where they are” and this is one way to work towards that goal.

Measure-palooza: The American Heart Association (AHA) and the American College of Cardiology (ACC) have released updated Clinical Performance and Quality Measures for adult patients with hypertension. The new report includes 22 new measures and expands focus from blood pressure measurement to care delivery systems and approaches. Their goal is to look beyond individual provider performance.

That’s great in theory, but it’s not how most other clinical quality measures programs work. It may also add workflows to EHRs, resulting in poor usability that will be blamed on the EHR rather than an explosion of guidelines and measures. There are also mismatches in the quality numbers used by AHA/ACC, CMS, and the National Committee for Quality Assurance. I’m sure EHR requirements writers are wringing their hands at this point. The report also includes a focus on digital health, including remote monitoring for hypertensive patients.

Maybe the EHR isn’t so bad: A recent study conducted at the University of Pennsylvania Health System showed an increase in orders for certain cancer screening tests when a “nudge” alerted users from the EHR. The alerts were targeted to medical assistants who created the orders for licensed clinicians to review and hopefully discuss with their patients. Despite the increased orders, there were not significant changes in the number of patients who completed the recommended screenings within a year-long time frame.

I recently worked with a practice that raffled off a big-screen television to patients who completed home colorectal cancer screening kits within a specified time frame. I’m not sure how legal it was, but it was certainly effective at motivating patients to submit a sample.

Kudos to the clinical informatics team at Oregon Health & Sciences University, who recently implemented a drug pricing comparison tool within Epic. It factors in data points such as co-pays, deductibles, and the need for prior authorization. The information has been available to dispensing pharmacists for a long time, but moving it to the point of care is key. It doesn’t matter how effective a drug is when it’s never going to be taken because the patient can’t afford it.

My clinical practice offers cash-only prescriptions at the point of care, which simplifies things for patients who know what their co-pays are (most of our drugs are either $15 or $30). However, many of our patients have no idea what their co-pay might be and are unable to make an informed decision. Having a tool like this at the bedside would be a benefit for the rare cases when we have to prescribe more costly drugs.


Flu season is getting well underway, particularly in the South. My practice is running low on vaccine and expects to be out by the end of the month. If you’re thinking about getting vaccinated but haven’t done it yet, time is of the essence. Three children have already died this season. If you still have plenty of vaccine, maybe an outreach campaign using those expensive population health tools is a good idea.


Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/18/19

November 18, 2019 Dr. Jayne 3 Comments

A former colleague of mine reached out recently, frustrated by a physician in his organization who is demanding that clinical decision support features in some applications be turned off. He was asking for tips to help counter the argument.

It turns out that the physician in question believes that if the application presents you with guidelines that you ignore, you are liable. Fortunately, it’s a pretty easy counterargument. If a guideline exists and you ignore it, regardless of whether it’s in your application, you are liable. In many cases, if a guideline exists and you don’t know about it but a physician would be reasonably expected to know about it, you are liable.

The whole point of clinical decision support is to bring those guidelines  — which you may or may not be familiar with or incorporating into your practice — to the point of care so you can react to them. Of course, this assumes that the clinical decision support in question is accurate and appropriate.

Since crossing into the realm of clinical informatics more than a decade ago, my clinical activities have been limited. This is partly by choice (realizing that I can’t do justice to the traditional primary care paradigm when practicing on a very limited schedule) and partly due to workforce economics. Unless you’re a physician administrator at an academic institution or your CMIO situation includes a specific carve-out for clinical care, it’s unlikely that someone wants to hire you to see patients one day a week.

Since the scope of my practice is relatively limited, one might think it would be easier to keep up with the knowledge base, but it’s still very challenging. I remember a couple of years ago when one widely-used antibiotic fell out of favor for a particular condition. It was a good six months before one of my go-to journals reviewed the primary article and another three months before I actually read it, meaning that I was prescribing a less-than effective medication for a good nine months before I knew any better. What if there could have been clinical decision support at the point of care, which would have alerted me to the fact that the antibiotic selected was no longer recommended for the diagnosis I had entered?

Conventional wisdom is that medical knowledge doubles approximately every eight years. Physicians graduate from medical school and are then trained in residency by physicians who might have been in practice anywhere between one and 60 years. One would expect great variability in those teaching physicians’ knowledge bases as well, which is another plus for clinical decision support.

There are a number of pros and cons around whether clinical decision support should be regulated and how that might impact shifting liability. Others voice concerns about whether this will lead to so-called cookbook medicine or encourage mental laziness among physicians. Regardless of the strength of decision support or whether it’s regulated, physicians still have a duty to determine whether the recommended course of care makes sense or if there are any concerns about the recommendations.

Physicians need to understand where the recommendations found in clinical decision support systems originate. Are they from well-known guideline producers, such as the US Preventive Services Task Force, the Centers for Disease Control and Prevention, the American Cancer Society, or the American College of Obstetricians and Gynecologists? Are they just automated and exposed guidelines that are doing simple checks against diagnosis codes, SNOMED codes, LOINC codes, and medication codes, or are they using artificial intelligence or machine learning?

Rand Corporation blogged about this issue way back in 2012, and the thoughts around it haven’t changed significantly. Straightforward clinical decision support, such as drug-drug interaction checking is great, but alerts have to be at the right level for a physician to highlight the most critical cases while preventing alert fatigue. Users who click through alerts without reading or digesting them will continue to be at risk for increased liability in the case of a poor outcome.

Oregon Health & Sciences University’s Clinical Informatics Wiki covers this issue as well. It notes that, “As long as 25 years ago it was realized that availability of computerized medical databases would likely erode the local or community standard of care.”

Changes to the community standard of care might not be a bad thing. Many of us believe patients should be treated the same whether they live in the city versus rural areas and regardless of differences in income or demographics. However, there have been pockets of the country where physicians were held to a different standard for a variety of reasons.

Take the PSA test for prostate cancer risk. At a time when the US Preventive Services Task Force was specifically recommending against testing (in part because of the number of false positive tests leading to unnecessary biopsies and other downstream consequences) my community performed them across the board because a leading urology researcher at a local academic institution drove expert opinion that they should be done. If you didn’t do a PSA and a patient turned out to have cancer, you were in for a bumpy ride.

OHSU notes correctly that state laws have lagged behind current technology and that the scope of the legal medical record varies from state to state. I’ve worked in organizations that swear that the final signed chart note in the EHR is the legal record, and others who said, “everything in the database is the legal record.” I’ve worked with attorneys going down SQL rabbit holes trying to figure out what a physician knew and when based on various timestamps, user IDs, and other metadata.

The wiki authors also note the need to better understand how clinical decision support systems influence clinician judgment and how their use might impact those who are “not adept at system-user interfaces.” They also note the relative lack of case law in the area, but go on to say that, “Physicians are likely to be held responsible for the appropriate use and application of clinical decision support systems and should have a working knowledge of the purpose, design, and decision rules of the specific decision support systems they use.”

For some EHRs and related systems, this is easier than others. I’ve seen systems where you can quickly drill down to the specific recommendations and understand why a flag was thrown. I’ve also seen systems where alerts don’t seem to make sense and searches of well-known physician resources fail to shed light on the subject (nor do simple Google searches, so a double dead end). The bottom line remains, however, that regardless of the volume of information out there, physicians are expected to know the answers and do the right thing for their patients.

How does your organization address liability for clinical decisions, whether human-created or prompted by technology? Leave a comment or email me.


Email Dr. Jayne.

EPtalk by Dr. Jayne 11/14/19

November 14, 2019 Dr. Jayne 3 Comments

Many EHR aficionados view discrete data as the holy grail of information, but a recent article in the Journal of the American Medical Informatics Association looked specifically at data from unstructured clinical notes. The authors found that such “real world data” was more accurate for use with algorithms to predict coronary artery disease when compared to structured data.

The study looked at data from a six-year time span, gathering a specified set of clinical concepts through structured data gathered from standard query techniques as well as AI-driven analysis of unstructured data. The authors used data from over 10,000 clinical notes and looked at language around existing coronary artery disease, diabetes, and other clinical predictors of coronary artery disease. Food for thought for all those folks who are uncertain about the role that narrative documentation may continue to play as we move forward.

I was glad to see a recent ONC blog that noted that nearly one-third of hospitals can access prescription drug monitoring program (PDMP) data from within the EHR. However, it seems like that number should be much higher if we really want to move the needle on inappropriate prescribing of opioids. If providers aren’t viewing data from within the EHR, that means they have to access a separate system, which in itself adds a barrier to use. The piece didn’t mention rates of integration for ambulatory EHRs, which is where a lot of opioid prescribing happens.

Nearly all states have PDMP registries, with only Missouri lagging behind. (Interestingly, that state was one of the last to have a statewide immunization registry, which makes it look a bit like public health isn’t a priority for the legislators.)  I rarely prescribe opioids, and when I do, it’s usually for 10 or fewer pills, but I still access the PDMP whenever my suspicions are raised about a particular patient. Usually the PDMP confirms my impression, leading to a very direct conversation with the patient.

This hit my radar at the same time as a communication from the American Academy of Family Physicians about its recent vaccine-themed letter to the US Department of Health and Human Services. The letter urges that EHR vendors not create financial burdens for physicians trying to connect to state immunization registries and called on HHS to “hold information technology vendors accountable for creating a national standardized, easily accessible, accurate, robust immunization information system.” It also called for universal payments for vaccinations, which makes sense after my recent experience which I’ll call “A Tale of Two Vaccines.”

One member of my family received their vaccination at their primary physician office. The explanation of benefits statement lists a charge, an adjustment, a payment to the physician, and a patient responsibility of zero since the entire amount was applied to “well care.” I received my vaccination at my clinical employer. Although it’s required as a condition of employment, they bill it to insurance and then absorb any non-covered portion. My explanation of benefits lists a charge, an adjustment, and no payment to the physician since the place of service was “urgent care” and the entire amount was applied to my deductible. If I hadn’t been an employee, I would have paid the entire cost.

Insurance companies should either pay for a vaccine or not, regardless of the place of service, as long as the same CPT codes are being used for billing. Hundreds of patients receive their vaccines from my clinic because we’re fast, friendly, and accessible. I hope they’re not receiving the same rude billing surprises that I did.


I’m skeptical about a new Facebook Preventive Health tool that is supposed to help empower people to seek out vaccines and other preventive services. They plan to use age and gender to identify target populations. My first concern at reading that is that perhaps they don’t understand the difference between sex and gender and how those contribute to the equation. Hopefully that was a lapse on the reporter’s part, since the official Facebook web page notes age and sex as the demographics it’s monitoring.

The official page also notes that it is referring patients to Federally Qualified Health Centers with its “find locations near me” for patients to get checkups and to the HealthMap Vaccine Finder for vaccines. It goes on to say that it “doesn’t verify locations on these lists and the lists may have inaccuracies.”

The feature is available only on the mobile Facebook app and doesn’t give specific sources for all of its recommendations. It did say that a mammogram was recommended for my age and sex and it should be yearly, citing the American Cancer Society as the source. There was no readily visible source for flu vaccination, blood pressure testing, diabetes screening, cholesterol screening, or cervical cancer screening, although they could be found by selecting a details arrow.

It also recommended I have an annual stool blood test for colorectal cancer screening, which is not in harmony with the US Preventive Services Task Force recommendations for my sub-50 age group. It went on to say that “test kits are free with most insurance plans” and I can guarantee that it is not free with my insurance, which covers only what is recommended by the USPSFT. The American Cancer Society (which Facebook cites as its colorectal cancer screening reference) even says clearly that insurers are not required to cover screening for individuals under 50 years of age. Those kinds of discussions will not be enjoyed by physicians when patients roll in with “authoritative” information from Facebook.

The Federal Communications Commission’s Intergovernmental Advisory Committee issued a recommendation last week regarding “State, Local, Tribal, and Territorial Regulatory and Other Barriers and Incentives to Telemedicine.” Not surprisingly, the major issues they cite include broadband access and a patchwork of laws and regulations that impede adoption. Looking at the broadband issue, redundancy is an issue for facility-based telehealth programs.

The report recommends that live video with appropriate image and audio quality be available so providers can accurately assess patients, adding that access to the full patient chart is desirable. They didn’t give much attention to consumer-facing telehealth. They note six policy areas where work needs to happen from a regulatory perspective: reimbursement, licensing, health information exchanges, insurance parity and malpractice overage, privacy-information sharing and HIPAA, and also being able to establish a doctor-patient relationship based on telehealth.


Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/11/19

November 11, 2019 Dr. Jayne 2 Comments

My recent conversation with a local university student about how the US looks at public health efforts got me interested into digging in a little more into a local health system’s work to address social determinants of health. I reached out to a former colleague who is now in a leadership role. He asked to remain off the record, since not all of his views fully align with what he is working on as part of the health system’s efforts. I totally understand having to stay off the radar to keep your job, so I was happy to oblige.

One of the major pushes of the health system has been expanding access to care, whether it’s with a mobile unit to visit areas that don’t have providers or whether it’s creation of school-based clinics. They are finding that even those approaches sometimes aren’t enough.

One of the areas where they set up a school-based clinic has a high absenteeism rate, with girls posting higher numbers than boys. Digging deeper, they found that teen girls sometimes aren’t in school due to lack of access to menstrual products. As someone who has worked with a church group to sew reusable menstrual pad kits for girls in developing nations, this doesn’t seem like something we should be seeing in the US. The clinic set out to solicit donations for menstrual products, and guess what? The absentee numbers went down. It’s a great example of how we need to really understand all the factors that are driving health, education, and wellness.

This approach may resonate with practices who help care for high-risk patients by providing transportation or assist with obtaining housing or groceries. If patients aren’t able to meet their most basic needs, they’re not going to be focused on things higher up the hierarchy, like healthcare and medication.

My colleague said this approach is something he actually struggles with philosophically. Some programs focus on those individual social needs, but don’t look at how you need to go about improving the underlying social and economic situation in communities as a whole. The individually-focused interventions are cheaper than delivering more intense medical interventions for sure, but they don’t assist people who haven’t become patients yet or who aren’t in the healthcare system.

He recounted a recent meeting among community health stakeholders, where they spent nearly two hours debating and defining what they mean when they say “social determinants of health.” The phrase was being thrown around and meant different things to different people, and they felt it was important to get everyone on the same page.

Although I don’t doubt that it was probably a painful meeting, it sounds like it was necessary. As he was telling me the story, it reminded me about how people throw around “pop health” and “population health management” and various permutations that may not mean the same thing depending on who is using the phrases and where they’re coming from.

During one of their community-focused initiatives, they actually had quite a bit of resistance from a small segment of community members. Some felt that the hospital’s participation was a way of trying to “medicalize” issues that community activists want to have a much more social and/or services focus. Instead of heaving the health system lead the charge, they want to see it led by community centers, faith-based organizations, and other community-led groups.

In addition to concerns about medicalization, there were also concerns about the hospital staffers not reflecting the community demographic and the optics of having a primarily Caucasian outreach team working with a community whose makeup is predominantly African-American. That’s something that isn’t always thought about, but may certainly be part of how interventions are received.

Patients and community leaders are also skeptical about value-based care. Some see it as rationing by another name, especially when it’s being primarily led by the medical establishment. Others see it as a way for conglomerate health systems to increase their dominance, which can lead to the erosion of community-focused health services.

My colleague mentioned that he struggles a bit going back and forth between the community outreach projects and the health system’s flagship hospital, where he has an office. The hospital’s lobby looks more like a high-end hotel than a healthcare establishment, and executives regularly divvy up the organization’s luxury box tickets for events at the local stadium. When he sees what might be considered excesses, he immediately thinks of how many social services could be delivered using the money spent.

He also has a hard time wrapping his head around the half billion dollars that has been spent on a recent EHR implementation and associated consulting services when his repeated requests to add a social worker to his team have been rejected. He notes that the EHR project hasn’t been all bad since it has made it easier to obtain and use data about different outreach projects they’ve been doing. It’s been useful for clinical reminders and identifying gaps in care to try to optimize health for individual patients. They’ve also been able to use address data to refine locations for community-based health screenings and vaccination clinics. He notes that has been easier since his request for a 0.5 FTE data analyst position was approved.

Apparently there are some ongoing tensions with the local public health organizations, who feel that competing health systems are more about bringing attention to their facilities than about advocating for essential public health needs such as sanitation, preventive services, and immunizations. The health system is having a retreat in a couple of months to talk about its community health efforts and it will be interesting to check in with him and see if there are any major changes to strategic direction or if the plans remain status quo.

I wonder what that retreat would look like if they invited public health leaders, or better yet, also included representatives from the other major healthcare players in town? Maybe that could lead to a more coordinated effort, but I’m just hypothesizing. I wish there were words to describe the eye-roll that resulted when I made that suggestion.


On a side note, I wanted to say thank you to all our readers who are veterans and also to their families and loved ones. We appreciate your service and your sacrifice.

How does your organization integrate with the local public health infrastructure? Is it working, or are there suggestions you would offer? Leave a comment or email me.


Email Dr. Jayne.

EPtalk by Dr. Jayne 11/7/19

November 7, 2019 Dr. Jayne 2 Comments

It’s been a crazy week, with a couple of days of travel being paid back with hundreds of emails in my inbox. Even as I unsubscribe and use filters, it seems like there is always something going on that generates more correspondence than it should (think reply-all apocalypse).

I’d love to sell services around creating an effective email policy to some of the organizations I work with. It seems to be a skill that is sorely needed both in the commercial space and in the volunteer space. I’m getting ready to head out for a week-long trip and am trying to pre-tie loose ends, and predicting what might need to be taken care of in my absence is always a challenging exercise.

The Drug Enforcement Agency is one of the major causes of increased email traffic in my inbox. It seems like my recent renewal has triggered enrollment in a number of mailing lists that have to be individually stamped out like a game of Whack-a-Mole. Some of them have forced me to go through the unsubscribe process twice to get them to stop. The mailing list preferences have names like “Prescribers” and “Prescribers-All” so you don’t know what you’re really unsubscribing. I like to have as little contact with the US Department of Justice as possible, so I hope I have finally gotten things back to where they were prior to my renewal.


Registration is open for the 2020 ONC Annual Meeting, with the theme of “Connecting Policy and Technology: Bringing the EHR to the Patient.” The event will be held in January 2020 in Washington, DC. The published agenda only shows the various time blocks for sessions, with a note that the full agenda is coming soon. Personally, I like to see the agenda before I plunk down money on a conference, but I’m guessing that most of the people who attend the ONC meeting are going to go regardless.

I enjoy attending conferences as a way of learning new things and engaging with people in person, but the cost of many of them poses a barrier. Maybe we should start a “Send Jayne On the Road” conference fund so I could report from around the country and across the globe. Warm locations preferred between November and February, of course.

CMS is plugging information sessions for its new Kidney Care First (KCF) and Comprehensive Kidney Care Contracting (CKCC) Model Options, which are part of the Kidney Care Choices (KCC) model. They are targeted towards nephrologists and dialysis facilities along with accountable care organizations that focus on kidney disease, and build on the Comprehensive End-Stage Renal Disease Care Model structure.

It’s good to see a model with a goal to delay the need for dialysis and encourage transplantation, but the reality is there is still a shortage of kidneys out there. We also need to be spending money to reduce the causes of chronic kidney disease, including diabetes and hypertension.

I recently attended a local health IT event and sat with some students. One of them was from a different country and is in the US pursuing a master’s in public health. His big observation is that public health in the US is far less prominent (and less well-funded) than in his home country, which was a surprise because he had assumed that because the US has “rich resources” that we would have it together.

Public health often gets the short end of the stick. I learned a great deal about public health informatics while working towards my clinical informatics board certification. It’s a fascinating field that has great potential to positively help people.


If you haven’t received your influenza vaccine, there’s still time, but the season is ramping up. Flu season officially began October 1 in the US and roughly two percent of all visits to healthcare providers in the past week were for influenza-like illnesses.

We’re seeing quite a bit of it at our facility, and even though the flu tests may be negative for influenza A or B, if it walks like a duck, quacks like a duck, and has a bill and webbed feet, we’re treating it as such. Louisiana leads the nation at reporting “widespread” flu activity, so make sure you’re prepared if you’re headed to the Big Easy.

Patients are always surprised when I quote flu statistics to them. I receive a weekly virology digest from our medical center’s infectious disease division that shows how many patients were tested and which viruses are prevalent in the community. I want my patients to know that we’re using evidence and data in their care and not just our best guess.

With Google recently announcing the decision to buy Fitbit, I’ve been asked a couple of times what I think about the company’s role in healthcare. A recent CNBC piece quoted Google Health head David Feinberg outlining plans to bring Google search technology to bear against EHRs as well as generally improving health-related searches on Google. Feinberg spoke at the recent HLTH conference and outlined some pretty far out sounding uses for auto-complete in the EHR as well as better enabling surgeons who visit YouTube before operating on patients.

I like my physicians to already have necessary skills before working on me and am not sure I want them watching a video to know what to do before they walk in the room. I just referred a patient to the emergency department this week because she needed a procedure that I haven’t done in 20 years and my physician assistant hadn’t done in 15. Although it was tempting to watch a refresher video and give it a go, that’s not the best care for the patient.

My clinical care recently has been challenging enough, and the root of much of what I have been seeing is our broken and chaotic healthcare system. One morning I saw a patient who had been briefly paralyzed after a fall, but who came to urgent care because he didn’t have insurance and didn’t want to go to the emergency department. The diagnosis was an unstable neck fracture that could have led to more permanent paralysis at any time, and yet he still refused our calling an ambulance to take him to the ED.

The following day, I saw a patient who qualified for Level 1 trauma status after a vehicular-pedestrian hit and run who also came to the urgent care because he didn’t have insurance. He at least consented to the ambulance transfer. The ED physician called me to give follow up and was shocked that patients like that come into the urgent care. We see them all the time, and unfortunately their visit to us just adds another layer of cost to the system. It’s a sad commentary for healthcare in general.

What’s the saddest commentary on healthcare you’ve seen recently? Leave a comment or email me.


Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/4/19

November 4, 2019 Dr. Jayne 2 Comments

I had the privilege of attending a prestigious medical school, so I’m always on the lookout for articles about our “rivals” doing something that my alma mater’s institutions aren’t. Johns Hopkins recently launched what may be a first: the Center for Psychedelic and Consciousness Research. They received a $17 million donation from a private foundation and four philanthropists, one of whom is Tim Ferriss, author of “The 4-Hour Workweek.”

The center’s director is interested in studying drugs such as LSD and their potential to treat depression, anorexia, substance abuse, and possibly early Alzheimer’s disease. Apparently Hopkins isn’t the only place who wants to be on this cutting edge. Research is also being done at institutions including New York University, Yale University, University of Wisconsin-Madison, University of California, and the University of Alabama at Birmingham. The center’s director expects that federal funding for psychedelics will increase.

In the article, he speaks at length about a typical psilocybin treatment session. It’s about as far from eating magic mushrooms at a party as one can get. Prior to the session, patients spend up to eight hours with the clinical team reviewing their personal and family histories as well as “life circumstances” to build rapport since the drug can make patients feel vulnerable. On the treatment day, patients receive the medication, lie on a couch, wear eye shades, and use headphones to listen to music. They are encouraged to focus their attention inward while two clinical guides monitor them for six to eight hours. Drug effects typically begin after about 30 minutes and peak a few hours later, then gradually resolve. Patients report sensations that range from love and joy to anxiety or panic. Test subjects often feel that they have a redefined sense of self, which can lead to ongoing positive changes in mood and behavior.

The team has studied the compound in patients with cancer who report decreased depression and anxiety. Patients have reported a positive impact on tobacco cessation efforts. I was surprised to hear that a couple of pharmaceutical companies have shown interest in the drug. I suppose it’s not much different from other drug agents where we don’t entirely understand the mechanism of action or how effective it might be, but companies smell profit potential and so they dive in. Psilocybin has been decriminalized in Denver and Oakland, but those cities aren’t entirely representative of the rest of the US as far as potential for future use.

Of course, this topic has little bearing on the world of healthcare IT, other than use of platforms for research and data aggregation, but it was a good diversion from reading about CMS releasing the Final Rule for the 2020 Quality Payment Program.

CMS continues to tweak the recipes for the Merit-based Incentive Payment System (MIPS) along with the Advanced Alternative Payment Models (APMs) under the guise of reducing burden, responding to stakeholder feedback, and better aligning with various legal requirements. I’ve honestly given on up trying to follow all the MIPS details since my practice remains opted out, and most of my clients have hired full-time people to keep up on everything rather than relying on consultants.

Long story short, various performance categories have been re-weighted, thresholds have been increased, and the finish line keeps being moved. CMS is also finalizing its proposal for MIPS Value Pathways, which of course carry the MVP moniker. I’m sure anyone who participates in the program, which starts in 2021, won’t consider themselves most valuable players in the eyes of CMS.

In other random web surfing this weekend, I saw that Amazon and JPMorgan plan to roll out new health insurance plans for their employees for the 2020 year. The new Haven Healthcare plan will include wellness incentives and will be deductible free. Berkshire Hathaway apparently has a similar pilot. The plans will be offered through traditional insurance providers, including Cigna and Aetna, and may vary slightly depending on the state. The plans are supposed to be more clear than other plans as far as what patients have to pay and how co-pays are applied. Patients will receive rewards for meeting health-related goals.

I had the unique opportunity this weekend to deliver an impromptu education session (which I fear may have turned into a little bit of a sermon) about the state of healthcare delivery in the US. We had some unexpected downtime at my clinical gig, so I was doing some reading on value-based care and my staff asked me what it was all about. Since most of them were in high school when Meaningful Use came about, we did a brief tour through the history of US healthcare, the rise of electronic health records, and what life was like back in the dinosaur days before the internet came into being.

Even though several of them are applying to medical school and have been working in various clinical settings for some time, they had shockingly little understanding of how healthcare is financed here, other than knowing that when patients don’t have insurance, things often get dicey. At least one had experience working in a free clinic and had that frame of reference, but for others, it was eye-opening. Many of the jobs done by aspiring medical students are focused tours through the healthcare system. They might be in the emergency department, at a clinic, or volunteering in a medical office. I can’t imagine that many of them are spending time in the local billing office or following around certified professional coders, although maybe they should be.

They left with some homework assignments. Not only books to read, but also to consider watching “Halt and Catch Fire” on Netflix so they can better appreciate the overwhelming assortment of technology that they can choose from every day. If you haven’t seen it, it’s a fictional tour through the early days of the PC industry and the creation of the internet and search engines. I enjoyed it tremendously during my treadmill sessions earlier in the year. I’m currently watching Charité on Netflix, which depicts the prominent Berlin hospital during the 1800s. The series is in German with English subtitles, and I’m enjoying the depictions of famous physicians of the time.

What random tidbits are you thinking about? Leave a comment or email me.


Email Dr. Jayne.

EPtalk by Dr. Jayne 10/31/19

October 31, 2019 Dr. Jayne 2 Comments

From Policy Wonk: “Re: Primary Care First. Great job on your review of this disaster of a program. Thanks for going deep on the 100-plus pages!” I attended the PCF application webinar on Wednesday. Although I shouldn’t be surprised, I’m continually baffled by some of the things that happen with these programs. The most recent highlight is that the application requires the applying practice to list the NPI for every provider who has worked in the practice since 2013, even if they are no longer there, are no longer practicing, or are deceased. No concrete reason was given for this despite several people asking about it. I was also surprised by the continued inability of CMS to release slides for its webinars on a real-time basis. The slides had to be done to deliver the webinar, so why not make them available for immediate audience download? Telling interested parties that they’ll just have to keep checking back on the Primary Care First website is a tremendous waste of people’s time. I’d be interested to hear from anyone who actually plans to apply for this program.

Mr. H covered this earlier in the week, but I wanted to put in my two cents about the Walgreens plan to close 40% of its in-store clinics while adding Jenny Craig weight loss services at more than 100 locations in an attempt to boost sales. The Jenny Craig services will include individual consultations along with customized menu planning and meal delivery. As a clinician, I’m not a fan of Jenny Craig. My patients who have tried it have found the weight loss to be unsustainable when they stop purchasing food from the program. The company also hit a nerve with me last year when it announced its intent to add DNA testing to its weight loss plans because “customizing nutrition plans to an individual’s genetic makeup can offer members even greater personalization for weight loss and overall wellness.” 

The reality is that most people who need to manage their weight don’t need super-sexy-sounding gene-driven remedies. They need basic nutrition advice, including how to prepare their own food rather than using higher-cost commercially packaged options. I love the way that the C-suite folks describe these moves, with the Walgreens CEO saying they are focused on creating healthcare destinations around a modern pharmacy. The reality of most Walgreens stores is that the actual pharmacy space is a tiny fraction of the store, with the rest of it being little more than a glorified convenience store.

I’m always on the lookout for cool healthcare tech, so was intrigued to hear about the Hyperfine portable MRI. The device, which is in the prototype state, is small compared to a traditional MRI, about the size of a large wheeled curbside trash can. Although the images aren’t quite the same quality of a standard MRI, there’s no need to magnetically isolate the patient. Hyperfine’s founder Jonathan Rothberg cites the ability to image patients without moving them as another benefit. The unit is slated to be significantly cheaper than existing machines, with a cost of close to $50,000 rather than the millions needed to buy a standard machine and set up a dedicated imaging suite. Rothberg’s previous entrepreneurial experience includes Butterfly Network, a handheld ultrasound that connects to the iPhone. The MRI device is under study in the neurological intensive care unit at Yale University. The company has applied for FDA clearance for brain imaging in adults and children.


St. Louis-based clinical genomics company PierianDx closed a $27M series B funding round this week. The round included ATW Partners and SJF Ventures, with participation from existing investors including Health Catalyst Capital, Inova Health Systems, RTI International, and ARUP Laboratories. The company was founded in 2014 from Washington University in St. Louis and focuses on advancing cancer diagnostics and enabling clinical genomics as the standard of care. The company plans to use the funds to expand current operations and further develop its solutions. For those of you whose memory of Greek mythology is fuzzy, the Pierian Spring was sacred to the muses, and was regarded as a fountain of knowledge that would inspire anyone who drank from it.

From Gong Show Afficionado: “Re: earnings calls. The 10/21 article is phenomenal and I wanted to thank you for taking the time to share it! I used to think a lot about earnings transcripts and coming up with % allocations of speaker (i.e. if CFO is speaking less % of the time or answering less % of the questions quarter over quarter, I would assume a bad thing?) but not tone or word choice, so you got me thinking about it. I’ve bee on the sales side and now that I’m on the other side of sales pitches I have that inescapable feeling of you are lying to me and I know it because I’ve been on your side of the table. It makes decision-making difficult. It would be incredibly powerful to have a sales pitch BS evaluator hooked up to an LED scoreboard that you could have hanging above the conference table during the pitch so the buyer could provide real-time feedback to the seller on how they’re doing. Every time someone mentions their use of a data lake, the scoreboard goes straight to zero.” I’d go further to suggest a trap door that dumps onto a funhouse slide that takes the rep directly to the door and could be triggered by either an overall buzzword count or by a “whammy” button that we could hit when we the sales effort goes off the rails.


Hopefully your Halloween night will be ghoulish but not dangerous. The Journal of the American Medical Association came through this week with a host of Halloween-themed articles sent via email:

  • “Spook House Sporotrichosis.” This piece from 1997 highlights the risks of hay bales used as props in haunted houses. Outbreaks of the condition are rare, and the article highlights an outbreak noted in a dermatology practice. Four of the patients had handled hay bales in a haunted house and one visited the house. The causative organism, Sporothrix schenckii, is one of my favorite things to say, so the article caught my eye.
  • A more recent piece  focuses on “Pedestrian Fatalities Associated with Halloween in the United States.” It highlights that the relative risk of a fatal pedestrian accident was 43% higher on Halloween compared to control evenings, with the average Halloween leading to four more pedestrian fatalities. That’s a good reminder to wear reflective clothing, use flashlights, and make sure your vision isn’t obscured.

Personally, I plan to spend the evening pairing the occasional Reese’s Peanut Butter Cup with a nice glass of cab.

What’s your favorite Halloween candy? Leave a comment or email me.


Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/28/19

October 28, 2019 Dr. Jayne 3 Comments


CMS has finally delivered its Request for Application for the Primary Care First program, which had long been promised to arrive in summer of 2019.

Everyone loves an endless summer, except for the people who have been waiting a really long time for the application for a program that was to start in January 2020. Now, applications are due by January 22, 2020 for a program that won’t begin until January 2021. CMS also promises that “in the coming week” it will release a “Statement of Interest” form for prospective payer partners who want to declare their interest in a non-binding fashion. A formal solicitation process for payer partners will then run from December 9 through March 13, 2020. CMS notes that “this timeline will allow payers to clearly assess where there is likely to be high practice participation in Primary Care First, and make an informed decision about regions in which to develop their own aligned approaches as payer partners.”

Continuing with some vague deadlines, CMS notes that the selection process for practices and payers will take place in “Winter-Spring 2020,” which gives them a fairly long runway since summer apparently stretches to October 24 in their universe.

The CMS FAQ document had some interesting tidbits, for those of you who haven’t had a chance to dive into the documentation yet:

  • If more than 3,000 practices apply and meet the eligibility criteria, CMS will use a lottery system to select final participants.
  • A second round of applications will occur for practices that are participating in the Comprehensive Primary Care Plus (CPC+) program, to begin participation in Primary Care First starting in January 2022.
  • Neither Federally Qualified Health Centers or Rural Health Centers are eligible to participate. CMS states this is because the program is designed to test payment reform for traditional fee-for-service payments, where the excluded centers bill under different but distinct rules.
  • Participants will have to comply with interoperability requirements that will be spelled out in the Participation Agreement, which is not yet available for review.
  • CMS “anticipates that Primary Care First will qualify as an Advanced APM for all give years of the model test.” I’m not sure why they can’t put their nickel down at this point and declare it. I find the “anticipates” language bothersome.
  • CMS will be using a modified CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey “to allow for increased response rate and ease of use among beneficiaries.”
  • CMS will allow practices to reduce or waive the applicable co-insurance for the flat primary care visit fee, but practices are responsible for assuming these costs. Practices can determine which patients might benefit most from this, such as patients with frequent emergency department visits or hospital admissions. Practices will have to submit an implementation plan for this at a later date.
  • Practices can offer other “beneficiary enhancements,” such as transportation to the primary care provider or other follow-up services. Patients can also receive access to remote monitoring technology or nutrition programs such as Weight Watchers. These will be detailed in the Participation Agreement, which again we haven’t seen.
  • Additional guidance regarding telehealth will be provided at a later date.

I began to dig into the 102-page Request for Applications document and immediately began to regret it. There are seven possible levels of performance for regional performance bonuses dependent on the practices’ performance relative to a regional reference group. There are also tiers for the Continuous Improvement bonus.

When I reached the part about “Quality Gateways,” which practices have to meet in Year 1 to receive a bonus in Year 2, my eyes began to cross. My vision cleared up, though, when I saw that participants must agree to participate in CMS efforts to evaluate the model, which may include everything from surveys and interviews to site visits and other unspecified activities. Everyone loves agreeing to more site visits, and the part about “unspecified activities” certainly leaves room for uncertainty.

I was glad to see that the appendix does have all of the application questions listed out, since the application itself requires a login. That at least allows practices to make sure they have all their information gathered before they try to key it all in.

At this point in the game, I doubt any of my current practice clients will want to participate, but if any do, I’ll be referring them out to some consulting colleagues who are more specialized in this area than I will ever be. The devil is definitely going to be in the details for practices that go this route, and only they will be able to truly determine whether the proverbial juice is worth the squeeze. My state isn’t one of the ones that has been selected for the program, so I won’t be hearing about it in the physician lounge, that’s for sure. I do have enough colleagues around the country, though, and I hope at least one of them bites so I can share their experience with our HIStalk readers.


Having to wade through all the Primary Care First documents was enough to make me grateful to have back-to-back clinical shifts scheduled. Unfortunately, I saw my first vaping casualty,  a teenage patient whose lung collapsed after he decided to celebrate a recent academic event with some vaping in the high school parking lot. Luckily, he was in the car with a friend who saw him begin to go into distress and brought him for attention right away. The patient went from being reasonably conversant to beginning to turn blue over the course of a few minutes while we were waiting for EMS to arrive.

It was just another day at the office for our team of in-house paramedics, but based on the level of terror his friend experienced ,I doubt either of them will be vaping much in the near future. Due to the acute timeline of the incident, the patient’s parents didn’t arrive at our office until we had already bundled him into the ambulance and sent him on his way. That’s got to be just about one of the worst feelings a parent can have.

The rest of the weekend was largely uneventful, for which I’m grateful.

How did you spend your weekend? Leave a comment or email me.


Email Dr. Jayne.

EPtalk by Dr. Jayne 10/24/19

October 24, 2019 Dr. Jayne 1 Comment

I enjoy mentoring students and I am always excited when one of them is admitted to medical school. There is a lot of buzz around the schools that are offering free tuition or that are subsidizing a large amount of tuition, but most people in medicine don’t realize the financial barriers that occur upstream.

My student has to pay a $1,500 deposit in the next two weeks. Although he’s working full time in our office as a clinical tech, that’s a hefty amount of money after he’s already paid for the application process, travel and lodging for interviews, the MCAT exam, test preparation, and of course an undergraduate degree.

This is a timely topic that was recently covered in the New England Journal of Medicine. The article looked beyond the shocking costs to explore how they impact the types of people that apply. Not surprisingly, few applicants come from lower-income households and minorities continue to be underrepresented in the applicant pool.

Some schools are trying to reduce application costs by having students host applicants. Other programs may reduce the cost of the MCAT and applications or offer guaranteed admissions for students at a certain level of performance at affiliated undergraduate institutions. Schools are starting to look at virtual interviews as a way of lowering costs. It’s been suggested that schools should revisit their supplemental “secondary application” processes as a way of increasing the diversity of the applicant pool while reducing the cost burden.

All of us would benefit from a more diverse physician workforce, rather than having a full quarter of applicants coming from households with greater than $250,000 in annual income as the current statistics demonstrate. Still, it illustrates the pressures that clinicians have already been under before they ever enter practice. For those of us that look closely at clinician burnout, these are contributing factors that have already raised the stress game for those who haven’t even begun to stress around government regulations or burdensome technology.

Score one for AI. A recent study by researchers in NYU School of Medicine shows that an AI tool that uses machine learning can identify breast cancer with 90% accuracy. The tool was trained on over a million images and 14 radiologists reviewing 720 images were included in the study. The tool was able to identify “pixel-level changes” in breast tissue, but radiologists were able to use logical reasoning that the AI could not. The authors conclude that AI can augment radiologists.

It remains to be seen whether this can be extrapolated to other data sets and whether it can be brought into clinical practice, but for those of us in high-risk situations, such AI augmentation is welcome. I don’t personally read mammograms, but for those of us in age brackets where eyeglasses start appearing in our pockets, it’s a nice idea to have a set of extra “digital eyes” on radiology images.

I missed this a couple of weeks ago, but apparently Senator Rand Paul has introduced a bill to overturn what he considers the “dangerous provision” of legislation allowing the US to institute a unique patient identifier. He claims his physician creds make him an expert. Clearly he’s not an informaticist and has never had to disentangle the merged records of premature twin siblings Andrea and Andre, that were combined due to a faulty matching algorithm. He cites breaches as another reason. I’m pretty sure most data breaches that would reveal a universal patient ID would also reveal name, address, DOB, phone number, and often SSN, which are the current keys to your data.

Jenn clued me in on this article answering the question of, “What’s the best shoe for the busy physician?” Physicians were surveyed with 255 responses received, including 172 men and 81 women. The idea that shoe choice is important was nearly unanimous, with 40% expressing a fondness for casual shoes or loafers, 29% choosing dress shoes or heels, 20% wearing sneakers, and 11% wearing clogs or similar.

I was initially surprised to see that more younger physicians are choosing dress shoes since that demographic is often accused of being overly casual. However, it would make sense as they have less overall mileage on their feet compared to the rest of us.

According to the article, physicians suffer from flat feet, plantar fasciitis, pain, and bunions. Physicians are sometimes self-conscious about their shoes. One of my mentees started wearing what she considers “ugly” shoes because she had too many patient comments about her “cute” shoes and felt patients weren’t taking her seriously because of her choice of footwear. My personal favorite shoe, pictured above, is the Medimex Plogs line. They’re vented for breathability, have massaging nubs on the footbed, and are also autoclavable, perfect for whatever might be on the floor of a medical environment.

Speaking of people having opinions on how people dress, I was unsurprised to see this report about women at Ernst & Young being coached on how to dress. Even if a fraction of the allegations in the piece are true, it’s a fairly horrifying read. Unfortunately, I continue to see companies who have different expectations for employees based on sex and/or gender, and also those that have no idea what to do with non-binary employees.

I have been in a position where two executives debated another’s competence while making comments about her lack of artificial hair coloring, including comments on how “all that gray makes her look old.” From that conversation, I learned that apparently men with gray hair are distinguished, but women who go natural look old.

I worked for another client that required female employees to wear at least a two-inch heel and skirts, with no slacks allowed. They didn’t last long on my roster. I’ve seen assertive women labeled as “shrill” when their male counterparts are revered as “go-getters” in the last several months, regardless of publicity around discrimination and lack of equity or parity.

I recently attended a retreat hosted at a facility owned by a traditionally male-dominated company that had a large number of female participants. The company has made many public statements about its deliberate actions to increase female participation and empowerment. Interestingly, a visit to the newly created female showers at the athletic facility revealed a urinal in one of the two stalls. At least they created some individual showers rather than the group / open showers I had heard were in the male locker room area, but it’s hard to believe that organizations still think that group showers are OK for anyone in this day and age, regardless of whether they’re separated by sex or gender.

All the restrooms were clearly marked male or female, with no availability of non-gendered, family-friendly, or separate accommodations for those who might need additional assistance even though the facility is open to families. Nothing rolls out the not-so-welcome mat like inadequate restroom facilities, so I wouldn’t be surprised if they continue to encounter challenges in recruiting women or people outside their historical demographic.

Does your company have a corporate dress policy? Is it equitable regardless of sex or gender? What do you think about the current climate? Leave a comment or email me.


Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/21/19

October 21, 2019 Dr. Jayne 3 Comments

The past week has been entirely too crazy, working on projects for a couple of vendor clients whose offerings are starting to overlap with each other. Everyone is chasing after certain industry buzzwords, and if you can add a feature or two that gets you into a different space where people might be more willing to spend money than your current prospective clients, apparently you go for it.

It’s been challenging for me as it’s hard to keep track of what’s a real feature that is able to be delivered vs. something that is in the works, but only parts of it are actually in the code, especially in an agile development organization. It’s particularly challenging when company leaders talk about features under development as if they are actually part of a general release.

In a startup organization, words are thrown around much more freely than they typically are in publicly traded companies, who sometimes mind their language a bit to stay on the right side of the shareholders. With that in mind, I was excited when a reader clued me in to a recent analysis looking at corporations’ earnings call transcripts in an attempt to determine whether the words used in the calls are harbingers of credit risk. Researchers at Washington University in St. Louis looked at over 132,000 earnings call transcripts and used machine learning methods to create a measure of credit risk. The resulting information informs an algorithm that assesses elements from changes in credit ratings to risk of bankruptcy.

What if you could extrapolate those findings to examine the earnings call transcripts of EHR vendors to create a model that would let you know how much of what they were saying was possibly accurate vs. what might be considered creative accounting? What if you could use proxy words to identify impending layoffs or bad decisions that were about to make your stock drop? Mr. H follows some of the earnings calls much more closely than I do, but I have definitely heard some interesting comments on calls in the past that could be interpreted in a variety of ways:

“Our cash generation capabilities continue to expand our storehouse of dry powder.” I’m not sure using gunpowder as a comparative term is a great idea in this day and age. Does the company want to seem like it’s war-like and on the offense? Or perhaps it’s a commentary on the executive team’s ability to blow up the company by continued poor decision-making?

“Scary.” I recently read an earnings call transcript that used the word three times in a variety of contexts. Could there be something predictive about the state of mind of the people on the call?

“Our team is always impatient to go faster.” That’s the kind of reassuring language end users love hearing from vendors with a track record of under-delivering or overpromising on features. Not to mention that when you’re caring for people’s loved ones, you typically don’t want your primary tools to be fueled by a spirit of impatience.

Those are immediately attention-getting, but I’d be more interested in the subtle comments that show that something is slightly off or that there might be some level of obfuscation going on. One recent call characterized what clearly looked like a cost-cutting layoff as an effort to speed compliance with new regulatory requirements. With a training database of thousands of vendor earnings call transcripts, I bet you could come up with some very interesting themes and potentially useful indicators.

In the next year or so, I have to start thinking seriously about a performance improvement project so that I can complete it and check the box for renewal of my clinical informatics board certification. Maybe I could build a tool that would better enable the HIStalk team to detect language that would be most predictive of a company that might have juicy things for us to write about, or what their odds might be of winding up on the HISsies ballot. I doubt those applications would be approved by the folks at the American Medical Informatics Association, but they would be entertaining.

If I don’t come up with a project soon, I’m going to have to seriously think about letting my certification lapse. The required projects are actually referred to as “Improvement in Medical Practice” projects, and since I don’t actually practice clinical informatics where I practice clinically, that gets a little dicey. My primary clinical employer doesn’t want the physicians to have anything to do with the EHR – there isn’t even an informatics committee. The COO (who is a practicing physician) calls all the shots on whether we’ll implement new features and how they will be shared with the masses. The likelihood of my being granted any ability to query the data or perform any kind of project is exactly zero.

They do allow a diplomate to substitute a 360-degree evaluation project instead, where they survey a half dozen of their colleagues to find an area that needs improvement, then work on it and survey again. That doesn’t exactly work in the consulting model, where I think my clients might be generally appalled if I asked them to spend resources essentially providing job coaching to someone they’re paying as their expert advisor.

Doing these projects as a way to maintain certification is frustrating regardless of your specialty. During a time when I wasn’t practicing clinically, I had to do a mock “hand hygiene” project where I had to manually enter a downloaded data set and then analyze it. The goal was to simulate the paper surveys that my peers were getting from live patients, but I learned exactly zero sitting there and keying in the data. It’s just another hoop that physicians have to jump through to try to stay certified.

That takes me back to the earnings call transcript project. Maybe if I write it as an abstract with enough sexy buzzwords I can sneak it past the evaluators. Sprinkle in some artificial intelligence, machine learning, and blockchain to get the job done.

If any of you other clinical informaticists out there have creative ideas for what a consulting clinical informaticist can do as a project, I owe you a drink at HIMSS.

For the rest of you: what’s the wackiest thing you’ve ever heard in an earnings call transcript? Leave a comment or email me.


Email Dr. Jayne.

EPtalk by Dr. Jayne 10/17/19

October 17, 2019 Dr. Jayne 1 Comment

I had occasion recently to talk with a personal liability attorney, fortunately just socially and not professionally. He had some questions for me about the role of artificial intelligence in healthcare. Fortunately, I was able to point him towards a recent editorial in the Journal of the American Medical Association.

The article has a nice summary of the concerns that many in practice have about AI: communicating recommendations without the underlying rationale; poor training data sets used in the development process; and failure to reach an accurate result or recommendation. The JAMA article notes that case law on AI-related liability is lacking, but existing law can be extrapolated to cover these situations.

The authors’ examples support the use of AI as an adjunct to the existing decision-making process in order to prevent additional liability. However, as AI becomes engrained as part of the standard of care, this approach may necessitate more trust in AI systems at the point of care, in order to prevent the physician from making the error of underutilizing technology that could be of benefit. It’s a complicated equation, for sure.


The VA recently announced planned steps to increase data sharing with non-VA providers using the Veterans Health Information Exchange. They’re going to shift the current opt-in protocol to one where opt-out is the norm, so patients no longer have to provide a written release for the VA to share their data electronically. A quote from the VA in one of the articles I read about it states that community providers and organizations must have partnership agreements and be part of the VA’s trusted network to receive VA health information. I hope they meant to say that you have to be part of the network to receive information electronically, unless the VA isn’t covered by HIPAA, which allows providers to share information for Treatment, Payment, and Operations without a specific release.

The HIE plans to share information including: problem list, allergies, medications, vital signs, immunizations, laboratory reports, discharge summaries, medical history, records of physicals, procedure results such as radiology reports, and progress notes. Veterans who don’t want their data shared can still opt out, but they will have to be either all in or all out – previous mechanisms which allowed some data to be shared but not others will no longer be permitted.


Speaking of veterans, telehealth middleware provider Medici has launched “Operation 11/11” to provide no-cost virtual consults to all US veterans on Veterans Day, November 11. Proof of military service is required and participants can pre-register for services from 8 a.m. to 8 p.m. in their time zone on November 11.

Medici is welcoming four military advisors for the initiative and has also partnered with 2nd.MD to provide virtual second opinions for veterans with complex patients. Medici has an interesting model where providers pay to be on the platform and set their own rates for virtual visits. I can imagine it might be compelling for independent physicians, but struggle to see how it plays for the majority of physicians who are in employed situations.


I was intrigued to hear about Black + Decker’s new automated medication management and home health care assistant device, Pria (first covered on HIStalk nearly a year ago). It’s the first foray into healthcare from the people who brought us the Dustbuster. The voice-activated device tracks and schedules up to 28 medication doses along with reminders and timely dispensing. It also allows patients to have access to family members or caregivers using a built-in camera for video calls. It can also enable reminders for drinking water or other key health-related activities. The product is pricey at $600 plus a $10 monthly subscription.


I recently became aware of a club I have no desire to be a member of: telehealth providers who have licenses in all 50 states. Becoming licensed in a handful of states is enough work, so I can’t imagine wanting to have dozens of applications in process. The CNBC piece profiles a couple of telehealth providers who advocate for the approach as a way to treat patients more effectively particularly patients in underserved areas.

Data from the Federation of State Medical Boards indicates the club is pretty small, with only 14 physicians licensed everywhere as of 2018 data, up from six in 2016. The number will likely be higher for 2020 given the overall growth in telehealth. One interviewee notes the cost of procuring 50 licenses is around $90,000. In addition, there are annual fees to maintain them. If providers ever surrender a license, there’s also a process to explain that in future license renewals in other states, so if you’re going to do it, you had better be ready to maintain it. I’ve found telehealth compensation for physicians to be lower than pay rates in brick-and mortar situations. Unless you have the temperament to conduct, complete, and document visits every couple of minutes, I don’t see a lot of physicians opting for this type of practice.

An interesting potential use of artificial intelligence was detailed this week in The Wall Street Journal: prediction of marital arguments. Engineers and psychologists are using speech patterns, physiological data, and acoustic / linguistic information to detect potential conflict. One described use case is sending a text message to a highly stressed individual, warning them of an imminent conflict so they can take action.

The original 2017 study followed 19 Los Angeles couples and tracked data such as heart rate, perspiration, and activity levels. A phone app prompted them to document hourly reports on their feelings and also recorded speech content, pitch, and frequency in taking a three-minute recording every 12 minutes. Researchers were able to detect conflict with nearly 80% accuracy. The original data was gathered during a one-day period, which is a significant limitation along with the size of the sample.

A more recent investigation by the same researchers looked at 87 couples, using speed of speech and intonation to detect conflict. The research sounds promising. I hope they consider the next logical investigation, which would be parent-teenager interactions. I’m sure that would be a target-rich environment for conflict identification. Or, we could install such systems in healthcare IT conference rooms across the country – certainly there’s some conflict there!

What do you think about AI identification of conflict? Leave a comment or email me.


Email Dr. Jayne.

Text Ads


  1. re: Cigna payment model/denials - this is not surprising at all. I had a client sue another large national payer…

  2. The Cigna operational model closely resembles the fictional insurance company that is at the center of John Grisham's novel The…


Founding Sponsors


Platinum Sponsors




















































Gold Sponsors











Sponsor Quick Links