Curbside Consult with Dr. Jayne 7/19/21

Due to changes in licensure waivers as states decide that the pandemic is over, despite the fact that we’re not even close, my telemedicine work is becoming rather spotty. Unlike some of my colleagues, I don’t have a dozen state licenses, so I’m limited on the patients I can see.

For part-time people like myself who the telehealth vendors hire as independent contractors, it’s difficult to justify the effort to obtain multiple state licenses, not to mention the ongoing costs. Licensure in the US is a patchwork across the states. Although some belong to an interstate compact, others don’t, which makes it even more confusing.

Looking at my nearby colleagues, however, nearly everyone is practicing some flavor of telemedicine, whether it’s some evening moonlighting or as part of expanded offerings on behalf of their practice. I’m always interested to hear about telemedicine experiences from my proceduralist colleagues, so I enjoyed reading this article in JAMA Surgery last week. It specifically addresses the use of telemedicine in surgical subspecialties, proposing that telemedicine will go beyond being a “pandemic adaptation” and will continue to evolve. The article outlines the timeline of increasing telehealth surgical services – initially when elective surgical procedures were suspended and surgeons began to use the technology for preoperative, follow-up, and emergent surgical care visits, but then later in 2020 as COVID-19 cases began to spike.

The authors note that current telehealth technology can make it difficult for surgeons to physically assess their patients and may impede interpersonal communication. However, many patients are able to report specific data points, such as vital signs and pain scale that are often gathered during a visit, and patients are certainly able to tell a physician whether it hurts when they move or touch certain parts of their body as well as what their current level of activity might be.

They cite several potential advantages for telehealth surgical services, including improved access, continuity of care, and reduced disparities. Additionally, patients may have less travel time and expense. Although the authors don’t specifically mention it, I know from personal experience that surgical telehealth consultations have opened up availability for second opinions across the US. One of my close friends was able to have consultations with multiple renowned surgical oncologists in a matter of days, which might have been weeks to months had she needed to travel. Of course, that doesn’t take into account the time she would have missed from work or the travel expenses.

The article goes on to focus on three factors that will most impact the degree to which telemedicine will replace and/or supplement in-person visits.

First, they note that “with interpersonal relationships being a core attribute of high-quality surgical care, perhaps more targeted implementation of telemedicine is required.” They propose established patients as “an attractive subset” for postoperative visits or routine follow up. My only major surgery was somewhat emergent, and I certainly didn’t have the opportunity to form an interpersonal relationship with the surgeon, who came to the hospital early on a Sunday morning to remove a gallbladder that had gone rogue. The next morning, I was seen by a nurse practitioner from the office, handed a script for 10 Percocet, and hustled out the door. A post-op incision check took less than 90 seconds, and I honestly can’t remember if there was even an exam or if it was just a visual inspection of the surgical sites. The idea that our physician-patient relationship was a core attribute of anything kind of makes me laugh.

Second, they note that “substantial technological innovation is still needed to enhance surgical diagnostic capacity of telemedicine.” They propose the use of remote monitoring and wearables to provide supplemental biometric data such as heart rate, sleep time, activity levels, and electrocardiogram data. They note a need to process the data “in clinically meaningful and easily presentable ways” to “accelerate their use in clinical practice.” I don’t disagree with that. None of us want to see hundreds of disparate data points that might be out of context. However, this bullet might relate better to some surgical subspecialties than others.

Third, and I think most of us agree with this, “given the direct relationship between insurance coverage and adoption of health care innovation, continued coverage for telemedicine services and further refinement to the existing policies are needed to sustain this mode of health care delivery.” They go on to mention that payers are already rolling back coverage for telehealth services not related to COVID-19, and if it hasn’t happened by the time this piece comes out, it’s likely that Medicare will soon end coverage for audio-only telehealth visits. This is going to be the end of telehealth services for many patients, especially those who struggle with technology or who might not have the capability of executing a video visit.

A few messages down my inbox was another article about telehealth. Specifically, “how to bring warmth to your virtual care visits.” This piece from the American Medical Association seeks to answer the question: As the US health care system remakes itself into one that includes more virtual visits, how can physicians maintain the empathy and “human touch” that are so crucial to a strong patient-physician relationship?” It summarizes comments from the AMA’s Telehealth Immersion Program, which is designed to help physicians implement, improve, and build their telehealth efforts.

The speakers quoted in the piece have some good points, such as seeing things in the context of a video visit that they wouldn’t have seen in-person – such as fall hazards in the home, companion animals, etc. However, they note the need to focus additional effort on communication skills and relationship management. Most of the tips offered though are the same we’d recommend for physicians struggling with in-person communication – communicating clearly, showing respect, taking time, and displaying empathy. I didn’t find anything new or earthshaking in the article, but then again, I rarely do when the AMA is the source.

One thing that I think health systems and other entities need to think about when they’re talking about expanding telehealth is balancing the convenience factor with the need to support physicians. For example, if an in-person visit typically has a support staff member who documents the chief complaint, assesses and documents vital signs, reconciles medications, and updates histories, then there’s no good reason to simply shift that work back onto physicians. Unfortunately, that’s what we see in a lot of telehealth practices. Some of it is because organizations are still using telehealth solutions that are not fit for purpose or integrated with the EHR, and other times it’s because organizations are just taking advantage of their clinicians.

Those organizations that offer more transactional or direct-to-consumer telehealth services need to be careful about expanding those offerings without thinking about their providers. Many telehealth-only physicians moved into that sector because they prefer the transactional nature of that model of care. Simply put, they don’t want to go back to doing the things they hated in practice, such as tracking gaps in care, refilling medications, reviewing pages of blood pressure logs, and more. If they’re asked to take on additional responsibilities, they’re likely to ask for greater compensation, which will be interesting in an industry with a fairly thin margin.

All in all, it’s clear that telehealth is here to stay. I’m sure it’s going to continue to evolve, although I don’t have a crystal ball to know which way things might go next.

What do you think about the evolution of telehealth in the US? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/15/21

So many health systems placed everything on hold during the pandemic, so I was excited to hear about a health system not only taking something live but building it themselves. Holy Name Medical Center’s emergency department went live on its homegrown EHR, powered by Medicomp’s Quippe solution. I’ve had the opportunity to test drive the Quippe Clinical Data Engine multiple times in recent years and it really is an impressive solution, so I can’t wait to see how Holy Name implemented it. It will be on display at HIMSS21 in the Medicomp booth and I’m looking forward to kicking the tires. Kudos to this team for the implementation even in the face of a pandemic.

Telehealth is here to stay, and I enjoyed reading a Medscape piece on “What should I wear to see my doctor?” Telehealth has changed the paradigm for care delivery at the same time that life in general has become more casual. I still balk at the idea that my telehealth employer wants us to wear white coats, since there’s no purpose to it other than having it shout, “hey, I’m a doctor.” The article shares a couple of anecdotes about multitasking patients, one who tried to do a medical visit while multitasking on a work Zoom meeting and another where the patient was cooking a meal during the visit. Those are certainly extreme examples, but there are many more where virtual visits have clued us into situations in the patient’s environment that we wouldn’t have known if they presented for in-person care.

There are also some pretty amazing stories about physicians being too casual for patient care, including one telehealth physician who lacked a shirt during a consultation. Another provider was written up by his network for drinking beer and eating chicken wings (both visible to the patient) during a behavioral health therapy session. I’m guessing he wasn’t trying to document real-time, because the grease load on anyone’s computer keyboard wouldn’t be desirable.

I personally use my telehealth patient care days as excuses to dress up, to bring out those chunky necklaces that I normally wouldn’t wear in person for fear of toddlers grabbing onto them or the dangly earrings that typically remained in the drawer for the same reason. I still don’t wear sassy shoes, though, mostly because I’ve become entirely too accustomed to living in the Kino sandals that have been my constant companion since the first time I visited Key West. That will all change in a couple of weeks, though, as I get ready for HIMSS.

HIMSS released the details of its COVID-19 vaccine verification process. All attendees, exhibitors, and staff will have to provide proof of vaccination through one of three processes: Clear Health Pass Validation, Safe Expo Vaccine Concierge Validation, or Safe Expo On-Site Validation. I decided to try the Clear Health Pass option and the experience was less than stellar. Once I clicked on the HIMSS-provided link in my email, I had to enter my phone number so I could receive a link via SMS to download an app. After waiting 10 minutes for it to install, I restarted the process, which started over in the download phase despite having been in the installation cycle previously. After another 40 MB of downloading, there was another three minutes of installation, after which I was asked to enter a code that I didn’t have. I guessed at HIMSS and HIMSS21 and the latter was successful.

From there, I went through multiple terms of use screens and consents, which I know the vast majority of users don’t or won’t read. From there I had to scan both sides of my driver’s license and then take a picture of myself, which rivals my passport for hideousness due to the app’s smile detection feature which forces you to basically frown. From there, I had to go through another selfie process, which converted my picture to a line drawing and seemed tricky to try to fit my face into its weird oval frame.

The next step was adding my vaccination information, for which I had to go through another consent then an electronic authorization to release data to Clear. From there I was instructed to log into MyChart and went through another disclaimer, followed by four panels of information regarding consent and release. Finally, I was asked to give permission to the HumanAPI app to release every scrap of data in MyChart, including allergies, the name of my physicians, demographics, documents, health goals, implants, lab results, medications, problems, orders, procedures, immunizations, vitals, appointments, clinical notes, encounters, referrals, smoking status, and OB/GYN status. It asked to allow sharing for the next 90 days.

I denied permission and went back to the option to submit a photograph of my vaccine card and to key in the vaccine information and dates. After less than 30 seconds, I received my validation, and I didn’t have to share a boatload of PHI to do it. The overall process took 26 minutes, which was way too long, and I imaginethat  if I had actually read all the consents and disclaimers, it would have been close to an hour. I’m sure everyone involved (except the patient/consumer) is making at least a little money on the sale of the personal data that thousands of people will release without thinking too much about it. Just say no to the API, folks.

Amazon Care has asked major health payers to cover its services on par with other in-network care options. Reported targets include Aetna, Premera Blue Cross, and Blue Cross Blue Shield of Massachusetts. Amazon Care was originally piloted with Amazon’s Seattle-area employees, but the company has tried to expand the product since March of this year, not only nationwide to Amazon staff, but also to other employers. Based on the challenges with getting coverage for telehealth, let alone some of the asynchronous services the platform purports to offer, it will be interested to see how long it takes for the big payers to bring the service into the fold let alone provide payment parity.

A recent article in JAMA Network Open looks at the ability of wearables such as Fitbit and Apple Watch to identify the long-term effects of COVID-19 infections. The data is from the Digital Engagement and Tracking for Early Control and Treatment trial (DETECT) which was led by researchers at the Scripps Research Translational Institute. More than 37,000 people enrolled in the study, which ran from March 2020 to January 2021. Subjects used the MyDataHelps research app to report symptoms and COVID-19 test results and shared data from their devices. Researchers concluded that when they looked at wearable data and symptom data together, they could detect COVID-19 cases more accurately than looking at symptom data alone.

A follow-up trial looked at Fitbit users with fever, cough, body aches, and COVID-19 test data. It found pronounced changes in COVID-19 positive patients compared to others. Symptoms included increased sleep, decreased walking, and higher resting heart rates. On average, the COVID-19 positive patients took 79 days for their resting heart rates to normalize compared to four days in the non-COVID-19 group. Definitely food for thought for all those who are still refusing vaccination and especially for those who think that COVID-19 is a hoax.

COVID-19 is on the rise in my area in a big way, and my former colleagues are being slammed. My former partner had 38 people on the wait list at urgent care this morning. Of those patients, 15 were COVID-19 positive. The most tragic story of the day was a family who came in for testing after seeing pictures of their COVID-positive cousin in the ICU on social media after they were all together for a July 4 event. The cousin didn’t even call family to notify them, just posted on social media. It sounds like they were beside themselves and I’m sure the positive results didn’t help things.

Speaking of social media, I’ve written before about some of the lesser talked-about aspects of social media, such as its role in the grieving process and how strange it feels for “memories” to pop up that might not be happy ones. I definitely had some strong emotions at the memory that popped up for me today, which was a picture of my mask-damaged face during a lengthy shift in the emergency department. It was a stark reminder of all that we’ve been through in the past year.

It also gave me pause because we’re still not learning the lessons we need to learn to deal as effectively with this pandemic as we need to. Many of us who read the medical literature and have close relationships with researchers understand that we’re literally one “variant of concern” away from being back at square one with this virus. There’s a constant sense of waiting for the other shoe to drop, and for some of us, I’m not sure we’ll ever be able to feel the sense of relief that we had in a pre-COVID world.

A close friend of mine is a counselor and executive coach who works predominantly with physicians. He agrees that there are thousands of us who meet the diagnosis criteria for post-traumatic stress disorder but who have not addressed it with employers or sought treatment, and in reviewing the criteria during our discussion I’m betting a lot of clinicians don’t know they have it. I’m curious to know if employers are doing any specific outreach to help manage these pandemic-driven symptoms in the workforce, or to know more about the experiences of those who may have reached out for help.

What’s your experience with pandemic-driven PTSD? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/12/21

Sometimes a headline catches my eye, as did the one for this article about workers “epiphany-quitting” their jobs. For many, the COVID-19 pandemic has brought life into sharp focus and has accelerated decisions around what families find valuable and what can be done without. It’s been interesting to watch the flow of people both into and out of healthcare as people search for different work-related attributes: more meaning, better compensation, increased security.

One of my favorite co-workers at my former clinical employer was a seasoned professional sports mascot. He had worked for an NFL franchise before relocating and then hired on with the local baseball team. During the changes of the pandemic season, he saw the mascot workforce reduced from four to two, and despite being a pro at the signature strut and being able to do a backflip in a full-head costume, he decided he needed a change. He signed up for an emergency medical technician course and the rest is history. One of his favorite parts of being an EMT was being able to interact with people directly rather than through pantomime and oversized gestures. It was easy to see he enjoyed being around people and making them feel comfortable, even in stressful situations.

For him, moving into healthcare was about predictability and steady employment after having things pulled out from under him. It was a way to feel like he was controlling his own future, and especially with forecast shortages of healthcare workers, it’s probably a pretty solid bet. He was relatively lucky due to his age (mid 20s) and lack of family responsibilities. Not all workers are in that same situation, and I saw plenty of other co-workers leave healthcare because they couldn’t meet family responsibilities. One of my favorite medical receptionists quit because she couldn’t find reliable childcare to cover the 12-hour shifts that often stretched to 13 or 14 hours. Instead, she started providing in-home childcare, which allowed her to spend more time with her daughter as well as to help out young families in similar situations.

One of my favorite scribes was in the process of applying to physician assistant school when not only the pandemic hit, but one of her parents was diagnosed with a terminal illness. She decided to defer the application process to allow for more time with her family and also requested to go part-time at work. Although the company had a track record of refusing to allow people to go part-time unless they were enrolled in school, the pandemic forced them to adapt. Given the time needed to train a scribe and having someone willing to work in the uncertainty of a pandemic, it was a good solution for everyone.

Not everyone’s employers were that flexible, however. I watched a couple of nurses leave the workforce because part-time employment wasn’t an option and working 12-hour overnights on the COVID wards had simply worn them out. It was gut-wrenching to see these women quit jobs that they liked and would likely have stayed with had they been able to achieve flexibility, while the hospitals paid double or triple their salaries to travel nurses to cover the responsibilities.

Another friend who stayed in her ICU role out of a sense of duty and calling is still bitter about the bonuses paid to travel nurses who actually did less work than the employed nurses since they weren’t approved to use certain kinds of devices or equipment in patient care. She recently took a six-week “job swap” sabbatical where she moved to another part of the hospital and out of the ICU, which has allowed her to recharge to some degree. Still, she’ll be an empty nester in a couple of months, and I wonder if that sense of calling will still be there or if she will put the ICU behind her once and for all.

Even in healthcare technology roles, I’ve seen a change in some of the language used in promoting positions and during the interview process. Companies are more likely to advertise their flexibility and options to help workers achieve work-life balance. I see more mention of programs to allow employees to interact on non-work topics. such as support groups for employees caring for aging parents or small children, or as part of diversity efforts.

However, for every bit of flexibility, it seems another company is swinging the pendulum the wrong way. My local health system is hiring IT workers, but even though the positions are officially tagged as remote, they require relocation to the company’s headquarters state “for tax purposes.” Maybe the hospital just doesn’t want to deal with the paperwork, but they’re losing quality candidates and hiring manager friends are disgusted by the situation.

The sense that workers are evaluating their situations and deciding whether various aspects of their jobs are worth it or not is playing out across a number of industries. Due to the stressors that the pandemic has placed on healthcare organizations, however, it feels like we are experiencing it more acutely. I was having a discussion with one of my favorite revenue cycle folks recently, and in follow up she sent me an op-ed piece that I missed back in December when I was so busy trying to keep my head above water at the urgent care. It’s by Claudia Williams, former White House senior advisor and former director of health information exchange at the US Department of Health and Human Services. Although the question it asks is “Do hospitals need a chief burden reduction officer?” I would argue that the concept reaches beyond the hospital walls. Instead, we should be asking whether any organization would benefit from someone whose main role is to reduce burdens and look for ways to streamline work.

Williams cites the “must-do list of priorities for health systems in 2021” as including the following: recover the bottom line, provide frontline care for the pandemic, address health inequities, reduce provider burnout, and prepare for value-based care. Nearly all of these goals are impacted by frustrating (and often outdated) processes, multiple sets of reporting requirements that might be at odds with each other, rising costs, and the somewhat unpredictable factors of dealing with an ongoing pandemic for the foreseeable future (and perhaps indefinitely). Williams proposes a new title to join the chief experience officers, chief growth officers, and other recently created roles: that of chief burden reduction officer.

I think it’s a fantastic idea having someone who could work across multiple disciplines and service lines to identify solutions that could benefit everyone. They could unlock the potential of all the technology solutions that have been purchased over the last decade and help get rid of paper workflows once and for all. They could help streamline the patient experience as well as the clinician experience so that the two elements work together rather than at cross purposes. A chief burden reduction officer could also work with governmental agencies to help develop policies that make sense not only philosophically, but in their actual execution. No more of the “great ideas, poorly executed” that we’ve all experienced.

One of my favorite lines in the piece is this: “Health systems deeply disrespect patients when they waste their time.” The same goes with their treatment of employees (whether they call them as such or try to use cutesy titles such as associate or co-worker). An employee whose time is wasted is one who could be using that time for patient care, professional development, stress reduction, or a number of other worthwhile pursuits. Williams sums this up beautifully in the closing sentences of the piece: “All of these processes – the email, the paper, the intake form, the chart download, the fax – they are fundamentally wasteful of this beautiful human energy that we desperately need to transform healthcare. We are a nation facing multiple health crises. We need to free precious human time to address them.”

It’s a great way to think about the challenges in front of us. Who’s ready to take the leap and employ their first chief burden reduction officer? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/8/21

It’s always good to hear about true interoperability in action. The Surescripts Clinical Direct Messaging platform has sent over 7 million COVID-19 immunization notifications from retail pharmacies to primary care providers. Now if only we could get health systems to share amongst themselves so that patients could have one cohesive record, that would be great.

I have multiple Epic charts in practices that are literally across the road from each other, but because they belong to competing health systems, they don’t recognize each other’s data. I know that Epic is capable of sharing, but the systems aren’t ready for that. Information blocking, anyone?

The World Health Organization issues its first global report on the use of AI in healthcare. Titled “Ethics and governance of artificial intelligence for health,” it includes six guiding principles for the regulation and governance of AI that are fairly straightforward and frankly are in line with what we should be doing in all facets of healthcare IT:

• Protect human autonomy.
• Promote human well-being and safety and the public interest.
• Ensure transparency, explainability, and intelligibility.
• Foster responsibility and accountability.
• Ensure inclusiveness and equity.
• Promote responsive, sustainable AI.

The report does note that we need to be cautious about overestimating the benefits that AI can provide, particularly if resources are diverted from core investments needed to achieve universal health coverage. I thought it was a nice way of saying, “watch out for shiny object syndrome.” When you’ve got people in the world who lack basic hygiene and sanitation, clean water, and immunizations, it’s sometimes difficult to think about spending millions of dollars on advances like AI.

During the last few weeks, I’ve seen multiple articles looking at the impact of the COVID-19 pandemic on various preventive screenings. One article looked specifically at screening test volumes through the National Breast and Cervical Cancer early detection program. In analyzing data from January to June 2020, the authors found that the pandemic reduced screening rates among low-income women covered by the program. This is not at all surprising to those of us who have been in primary care. When push comes to shove and women are under stresses, they tend to put themselves last because they’re busy caring for their family members. The pandemic added extra layers of stress, including economic burdens, distance learning, and greater care responsibilities for elderly relatives or those at high risk for complications due to COVID-19.

Several of my clients have asked me to assist them with campaigns to reach out to patients for preventive screenings. The more sophisticated clients can trigger scheduling of the services through text messages, but some still require patients to call in or access a patient portal to schedule.

Although they’re excited about the capabilities of their patient engagement platforms, I have to keep reminding them that getting the patients engaged and scheduled is only part of the battle. They need to be making operational changes to make it easy to actually have the tests performed. This means leveraging technology investments to streamline in-person registration processes and history updates. The facility where I had been getting my mammograms is one of my clients and my last experience was so unfortunate that I transferred care elsewhere.

What could they do to better serve their patients? First, leverage the EHR. Use the system’s capability to generate pre-populated patient information forms so patients merely have to update their history rather than filling out a bunch of redundant information, including name and date of birth on every page. Use the data already in the system regarding primary care physician, ordering physician, and date of last exam to make it clear that you already know a good chunk of what’s going on with the patient.

Second, streamline the “COVID hygiene theater” processes that are still going on in many medical facilities, including excessive distancing and unwarranted surface cleaning that slow patient flow or create unneeded levels of concern regarding infection control.

Third, figure out how to schedule so that you can run on time. Use the data from your systems to fully understand your throughput so people can have timely testing and get back to their other responsibilities. Getting a mammogram or a pap test shouldn’t be an all-day affair, but in many places, it is, which adds additional barriers for patients in hourly jobs or patients who might not have protected time off.

Props to Steve Edwards, president and CEO of CoxHealth in Springfield, MO. He tells those who are spreading vaccine misinformation to “shut up.” Even better is the thread where his mother, a 90-year old retired operating nurse, says “I have always told you not to tell people to shut up, but this it is okay.” Ready to rumble, indeed.

I recently heard the phrase “innovation through imitation” used and kind of chuckled at it, but the more I think about it, the more it applies to entirely too many initiatives. The most recent example I’ve seen is the recent announcement that Dollar General plans to jump into the healthcare fray with a push to expand health offerings across rural communities in the US. The press release summarizes the company’s plan to “establish itself as a health destination” by stocking “an increased assortment of cough and cold, dental, nutritional, medical, health aids and feminine hygiene products” in stores. To further this effort, they’ve hired a chief medical officer, Albert Wu, MD, formerly of McKinsey & Company.

I hope one of the first thing Dr. Wu does is to consider bringing the company’s press release writers into the world of inclusive language by using modern terminology such as “menstrual care products” to describe some of the offerings they plan to stock. News flash: transgender men and nonbinary people may menstruate, and the continued use of “hygiene” around menstrual products perpetuates myths that menstruation is somehow unclean. According to the press release, Dr. Wu went straight from his anesthesiology residency to being a consultant at McKinsey, so I’m betting his missed out on the subtleties that many of us learn to appreciate through decades in practice. I’m a little embarrassed on his behalf about the way it was worded, as well as about some of the things in his LinkedIn profile, but I wish him the best in his efforts.

What do you think would be the most helpful strategy for building greater healthcare infrastructure in rural communities? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/1/21

Patient engagement is a hot topic. I’m glad to see organizations really starting to think through how patients of different ages, educational statuses, and technical abilities can interact in the digital health world. Organizations that think that everyone can just “use a smart phone” are likely missing out on a good percentage of the population that either doesn’t want to interact that way or who lack the skills (or confidence) to try. I was pleased to see a Kaiser Health News article covering the topic. It starts with a vignette of a person who bought a computer to email and Zoom with her great-grandchildren, but she ended up never taking it out of the box because of concerns around setup and lack of help.

The article cites some good data from AARP about the number of seniors needing help with technology. I’m far from senior status, but I admit that some new technologies leave me baffled, even as a clinical informaticist. Sometimes what 20-something UX designers feel is intuitive isn’t so easy to use for those who don’t share a common digital experience. Also, depending on people’s learning styles there are many of us who prefer to read a manual or follow a tutorial as opposed to just experimenting around with something and hoping for the best. I am being forced by my wireless carrier to upgrade my phone (despite the fact that it works well for me and does everything I need it to do) and am honestly dreading the process. It’s supposed to be seamless but never is, at least in my experience. I have until February to get it done though, so wish me luck.

For those patients who are tech savvy and want to interact through text messaging or video calls, a recent study looked at those modalities for case-managed patients living with HIV. The sample size was small, but both patients and providers were in agreement that text and video interaction was desirable. Convenience was a positive, but cost and access were potential barriers to adoption. As one might expect, “some providers were concerned that offering text messaging could lead to unreasonable expectations of instant access and increased workload.” The authors concluded that overall, both patients and providers found value in expanded lines of communication, however, “taking both perspectives into account when using implementation frameworks is critical for expanding mobile health-based communication, especially as implementation requires active participation from providers and patients.”

Speaking of telehealth, the state of Florida’s executive order declaring a public health emergency expired on June 26, decreasing telehealth flexibility for Florida residents. Phone-only visits are no longer acceptable for delivering services to non-Medicare patients, physicians can’t use telehealth to prescribe controlled substances to existing patients for chronic non-cancer pain, and telehealth can’t be used to recertify patients for medical marijuana. Additionally, out-of-state physician and nurses can no longer treat Florida residents without a specific Florida license, which they’ve been able to do for the majority of the COVID-19 pandemic. As of July 1, Medicaid behavioral health services will be limited in frequency and duration, and by July 15, prior authorization requirements for those services will go back into effect.

Parts of my state are being hammered by continued COVID-19 outbreaks and hospitals are again stressed, but I guess things are just fine in Florida. They might be an outlier, though, because The Commonwealth Fund notes that 22 states have changed their laws or policies during the pandemic to increase coverage of telehealth services. There are a variety of changes that states have made, including coverage of audio-only services (18 states added this for the first time, for a total of 21) and 10 states created payment parity policies. The report concludes that not all patients have benefitted from telehealth, with usage being lower in economically disadvantaged areas and by patients with limited English proficiency.

The fragmentation of care from state to state will continue as long as we don’t have a national health policy or robust public health infrastructure, and I’m not sure that Congress will have the wherewithal to address the inconsistencies. Time will tell whether telehealth really bends the cost curve or whether it can lead to improved clinical outcomes, but we won’t be able to measure those potential changes unless we commit the funding to study them. Based on some of the behaviors I’ve seen over the last couple of weeks, people think we are completely out of the woods with the pandemic, and I’m not convinced that public health efforts will continue to have the visibility or the funding that they deserve.

A recent study by my friends at Regenstrief Institute, Indiana University, and the US Department of Veterans Affairs shows that EHRs are failing to deliver on their promise for improved primary care. Ambulatory physicians are struggling to make sense of fragmented data that fails to show a comprehensive view of the patient. The authors reviewed numerous studies that describe misaligned EHR workflows, usability issues, and fragmented communication that make it difficult for physicians to achieve situational awareness. They conclude that more user-centric design processes could improve the situational awareness, satisfaction, and decision-making capabilities of primary care physicians.

HIMSS has announced more details related to its COVID-19 vaccination requirements. Participants will have to complete a two-step validation process prior to picking up their badges. Step One involves obtaining Clear Health Pass Validation, Safe Expo Vaccine Concierge Validation, or Safe Expo On-Site Validation. Step Two involves bring proof of one of those validation options, along with a photo ID, to the registration area for badge pickup. HIMSS notes that links to the Clear and Safe Expo validation options will be provided in early July. Given that many of us in healthcare have hastily scrawled and often handwritten vaccination cards, I’m not sure how this is going to go. If you’ve been through either of the validation processes, I’d be interested to hear about your experiences.

Regarding masking, the HIMSS21 guidance states: “Masks will be supported but not required on the HIMSS21 campus.” Every year I come home from HIMSS with a nasty cold, which COVID-19 vaccination will not prevent. Based on the fact that there are plenty of non-COVID viruses circulating freely in the population due to reduced masking and increased mingling, I’ll definitely be wearing a medical grade mask, possibly with something decorative over the top.

Should fancy masks be the new fancy shoes at HIMSS? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/28/21

It’s been an interesting week, and one I’d rather not repeat. I took a brief break from the healthcare IT trenches to do some volunteering at a youth camp, and the theme for the week quickly became “A Series of Unfortunate Events.”

All of our pandemic handwashing and sanitation skills were put to full use as the camp experienced an outbreak of norovirus, which is something I wouldn’t wish on anyone. The state epidemiologists had a rapid response and the camp was quick to put all participants in lockdown while they worked to determine the source of the outbreak.

Since they weren’t sure if the affected campers brought it with them or caught it at camp, all food service venues were closed. The National Guard quickly rolled in with thousands of boxes of MREs (meal ready to eat) and the dining experience was an adventure for many. I highly recommend the chili mac, although the penne with vegetable sausage crumbles wasn’t bad either. As to the Pop Tarts that were welded together by the vacuum packing process, I have no comment.

After the initial contact tracing, campers were released from the strict lockdown to do hikes and fishing with their campsite cohorts while further investigation occurred. I was surprised by how little our participants were phased by everything going on around them, although I attribute that to spending the better part of the last year and a half trying to avoid COVID-19.

After campers were tired of hiking, board games were delivered to the groups and some vicious rounds of Connect Four and Blokus ensued, followed by The Game of Life, which I didn’t know was still in production. It was great to see kids interacting with each other in non-electronic ways and experiencing some of the board games their “elders” grew up with.

The following day, we were cleared to return to activities, but food service was still stalled. Due to some just-in-time supply chain snags, the camp staff was forced to clean out local Sam’s Club and Costco warehouses for breakfast supplies. Lunch was another round of MREs, and since the majority of participants hadn’t eaten one before (let alone three), we prepared to triage additional gastrointestinal complaints. Fortunately, the norovirus cases had stabilized and the field hospital that had been configured was put to little use and we could go back to managing the sprains, abrasions, and blisters we expected. Unfortunately, at the end of the week, we had three medical evacuations by helicopter and one by ambulance, so things weren’t as quiet as we hoped.

It’s always a challenge to see how medical care is rendered in the great outdoors. I’m glad that the majority of the participants stayed healthy since so many camps were canceled last summer. There were certainly some memories created that will last a lifetime, but based on the overall experience, I was for once glad to return to my overflowing inbox. Having an actual bed instead of a cot was also a big plus.

I recently accepted a couple of new clients and am trying to sort out the schedules for the various engagements as I wind down a few projects at the end of the month. Although I’m excited for new things, I’ll miss the teams that I’ve worked with over the last year. But that’s my goal as a consultant – helping clients move forward and celebrating with them when they become self-sustaining. The baby birds are leaving the nest and I couldn’t be prouder of the work they’ve done along the way.

My mailbox contained quite a few HIMSS-related emails, including some party invites, so that added a bit of excitement to the day. I’ve scheduled a couple of Exhibit Hall Booth Crawl sessions with some of my favorite people and hopefully there will be enough excitement on the show floor that it will make for good reading material. I was less excited about my invitation to HIMSS Executives Circle events, which included a VIP luncheon with Alex Rodriguez. I’m a little skeptical about what he has to offer to the healthcare IT world in the form of a keynote address, let alone what might be discussed in a less formal setting, so I took a pass.

My inbox also had its usual complement of LinkedIn invites from people I don’t know who are clearly trying to sell me something, so there was plenty of deleting going on. (Sorry, Fruit Street, you might as well give up at this point.) The usual ads from Office Depot and Staples didn’t entice me to buy anything, nor did Lenovo. Next, I perused messages from my professional organizations and there I found something that caught my eye. ONC has launched an initiative for the public to complete the sentences “Because of interoperability, before/by 2030 [who] will [what]” or “Because of interoperability, _____ before/by 2030” as a part of its Health Interoperability Outcomes 2030 project.

ONC plans to use the public feedback to inform a prioritized set of interoperability outcomes and a road map for what health interoperability can achieve over the next decade. I’ve definitely got a few ideas to throw into the mix:

• Because of interoperability, I will be able to carry my complete medical record on my phone by 2030.
• Because of interoperability, by 2030 a new physician will have complete access to my records before I even walk in the office door or pop up in their telehealth queue.
• Because of interoperability, by 2030 I will never be asked again for a fax number.
• Because of interoperability, by 2030 I can update my records across disparate care delivery organizations with a few keystrokes rather than a dozen visits and phone calls.
• Because of interoperability, by 2030 I can see all my own images and films.
• Because of interoperability, we need to have a unique patient identifier before 2030.

The last one is my favorite, but unfortunately that goal has become more political than patient centric, so we’ll have to see how long it takes. The public can visit the Health Interoperability Outcomes 2030 page to submit a response, or use Twitter to tag #HealthInterop2030 to @ONC_HealthIT if they want to go the social media route. Submissions will be accepted through July 30, so get those creative juices flowing.

What are your goals for the next decade, personally or professionally? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/24/21

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/21/21

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/17/21

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/14/21

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

Are ambulatory medical practices  starting to rebound?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

EPtalk by Dr. Jayne 6/10/21

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/7/21

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/3/21

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/27/21

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/24/21

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/20/21

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/17/21

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.