Curbside Consult with Dr. Jayne 6/15/20

I had the chance to catch up with a good friend last week. We were talking about the odds of telehealth truly achieving payment parity and continuing into the future. We share a healthy dose of skepticism, mostly around the fact that payers (including CMS) aren’t going to want to pay the same amount for an item that they used to get for less, and in some cases, for free.

Unless they’re involved in administration or work in a multi-state organization, most physicians don’t realize that CMS has different payment rates depending on what part of the country you’re in. These rates vary due to labor and real estate costs – it’s more expensive to hire nurses in the San Francisco area than in rural areas of the Midwest, for example. There have also been special payments to certain sites of care, such as designated Rural Health Clinics.

Providers are excited about being able to see patients in their own homes from their own homes, cutting down on commuting, office costs, budgets for professional clothing, and more. The reality, though, is that CMS and other payers are going to feel like they’re subsidizing your love of fuzzy bunny slippers, and it won’t be long before there is an adjustment.

CMS leadership has stated “I can’t imagine going back” and “People recognize the value of this, so it seems like it would not be a good thing to force our beneficiaries to go back to in-person visits.” I think a lot of folks in the technology space, especially those looking to get their piece of the pie with telehealth, are missing the key connection between doing the work and getting paid for it. Although equal payment drove the expansion of telehealth during the pandemic, it’s a good bet that once the payments start changing ,we start to see more visits being pushed back to the office setting unless providers are participating in programs where they’re paid on a capitated basis versus fee-for-service.

Mr. H picked up on conflicting comments that CMS has made around the long-term viability of telehealth and mentioned them earlier in the week, especially those made during announcements encouraging a return to face-to-face visits that “while telehealth has proven to be a lifeline, nothing can absolutely replace the gold standard: in-person care.” I bet it won’t be long until they begin changing the payment structure.

Another dose of reality comes in the readiness of practices to actually see patients in person. Despite the multiple announcements encouraging patients and providers to get back to business as usual, some facilities just aren’t ready. I continue to hear from colleagues who can’t get adequate supplies of personal protective equipment, and  when they find supplies, prices are exorbitant. It seems like not much has changed since the start of the pandemic as far as the availability of N95 respirators, despite our having had months to ramp up the supply chain.

My employer has provided four N95s to each employee, which we are expected to rotate indefinitely until they become soiled or the straps break, in which case we can get a new one. If I want to take advantage of the Battelle hydrogen peroxide processing unit that my state has brought in, I have to personally drive my masks to a drop point across town, wait three days for them to travel across the state and be processed, and then drive across town to pick them up. We have one option for masks and no formal fit testing (since CDC waived it due to the public health emergency), so doing your own quickie fit test every time you put it on is how we roll. If you become allergic to the foam on the office-provided masks as some of us have, you’re kind of on your own since officially the CDC says we don’t need N95s and that simple surgical masks are OK since there are shortages.

For providers, continuing or expanding telehealth necessitates understanding the reality that telehealth requires a paradigm shift, and not everyone can make the jump easily. You have to go from being able to use reliable measurements performed by your staff to trusting patient-reported data or hoping that your patient can use available technology to capture their vital signs or pictures of a rash. You have to also start trusting other indicators of a patient’s status, such as level of anxiety, tone of voice, etc. that some have tuned out during in-person visits because it seems like many patients are anxious and stressed by the entire in-office visit process, especially if it occurred at a large healthcare complex with parking challenges, wayfinding issues, etc. Additionally, some specialties aren’t amenable to telehealth visits, so brick-and-mortar offices will continue to be a must.

For patients, access can be a double-edged sword. While some rural communities have embraced telehealth as a way to avoid long and time-consuming travel, others struggle with the connectivity that is needed for successful telehealth visits. Although the majority of adults in the US have access to a smart phone, that doesn’t mean that it’s their personal phone or that the access is 24×7. Sometimes it takes patients a couple of visits to get the hang of telehealth, and even then there can be issues with dropped calls or anxiety about displaying video of their living situation.

Only time (and the will of patients and payers) will tell how this is going to play out. If payers cut back, will we reach a point where patients will be willing to pay a premium for telehealth visits? Will clinical employers use telehealth as a way to shift more burden (including scheduling, pre-visit data gathering, and more) onto providers while saving money on ancillary staff salaries? Or will they embrace using ancillary staff to continue to perform pre-visit clinical work to better support physicians? Will telehealth technology improve to a point where it’s almost like being there, perhaps with the addition of virtual reality devices? Will data from third-party tools flow seamlessly into the EHR, or will we be stuck working with multiple systems and siloed data?

I’d be interested to hear what the HIStalk community thinks. What does your crystal ball say? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/11/20

CMS Administrator Seema Verma blogged for Health Affairs last week, sharing a discussion of CMS payment model flexibilities that stem from COVID-19.

The healthcare system in the US was broken to begin with and the pandemic has pushed many organizations past their breaking points. Many of my physician colleagues have retired, closed their practices, or been downsized by their employers in the name of cost savings. Hospitals and health systems have laid off countless employees from everywhere in the process. Very few job classifications have been spared, and I suspect we’ll see a number of CEO, COO, and CFO heads start rolling before long.

Although it was a well-written read, I was disappointed that it mostly rehashed the changes that have been ongoing for the last several years in attempting to transition us from a fee-for-service to a fee-for-value model. She mentions the concept of providers taking financial risk as “the cornerstone of value-based care,” but over the last few months, most providers have figured out that financial risk is the cornerstone of all of fee-for-service as well. Plenty of providers and hospitals who counted on a certain number of procedures or encounters have been hobbled, if not sent to bankruptcy. It’s not clear if they would have been better off under value-based care arrangements since they don’t fit every specialty and situation. Verma notes that such arrangements “provide stable, predictable revenue,” but that doesn’t really apply to urgent and emergent care situations or unpredictable needs for things like cancer surgeries.

She goes on to talk about flexibilities CMS is adding, but a quick look at the summary table shows that many of the changes are extensions of existing models or delays to the start of upcoming or changing models. A handful of models have changes to their financial methodologies. Verma also mentions flexibilities with telehealth, which I hope become permanent. Nearly every patient I’ve spoken with has been happy with their telehealth visits and not having to experience the hassle of visiting an office.

Congress is paying attention to telehealth, with a bill recently introduced that would require HHS to study how telehealth has been used during the pandemic and to deliver a report back to legislators within one year after the emergency ends. The bill is HR 7078, the Evaluating Disparities and Outcomes of Telehealth During the COVID-19 Emergency Act of 2020.

I didn’t have time to dig deeply into the federal register since I’m in the middle of a couple of big projects, but I’d be interested to see how they define telehealth and how data points would be gathered. Many physicians I know haven’t been using proper billing codes while they deliver telehealth, instead performing what is essentially a free visit in the name of ensuring patients are cared for. Some of the major telehealth vendors don’t use standardized billing codes, especially if they offer a direct-to-consumer option. The bill would require analysis of the types of telehealth platforms used as well as the locations where care was delivered (hospital, physician office, health clinic, private home, etc.) I wonder how they would classify the RV flying down the highway, which was my patient’s location the other night.

ONC announces its all-virtual Tech Forum for August 10-11, 2020. Sessions will include a mix of keynotes, panel discussions, and breakout sessions. The full agenda isn’t available, but I registered anyway. How can you not like a conference that gives you more than an hour for lunch plus two 30-minute breaks and you can do it all from the comfort of your own home? Get your fuzzy bunny slippers ready and I’ll see you there.

News of the weird: A surgery professor in California leverages telehealth and maggots to treat a patient’s wound, saving his limb and likely his life. David Armstrong, DPM, PHD is co-director of the limb salvage program at the University of Southern California Keck School of Medicine. The maggots in question, which he refers to as “nature’s microsurgeons” are larvae from the common green bottle fly. The patient had experienced tissue death after a surgical procedure, but also had diabetes and recurrent pneumonia and was high risk for an emergency department visit due to COVID-19; the necrotic tissue in his arm placed him at high risk for sepsis. Armstrong shipped a package of larvae to the patient then instructed a home care nurse via video on how to apply the larvae and dress the arm. Two days later, they used a telehealth encounter for a dressing change. After another course of treatment, the necrotic tissue was reduced from 46% to less than 1%.

I worked with the best scribe this week. He was geeking out on ICD-10. With the nice weather and lifting of stay-at-home orders, we’ve been seeing plenty of orthopedic injuries and trauma. At the end of the day when reviewing and signing my notes, I was glad to be surprised by entries that went well beyond the usual sprains, strains, and lacerations:

• W29.3XXA Contact (accidental) with hedge-trimmer (powered).
• Y92.832 Beach as the place of occurrence of the external cause.
• Y93.G2 Activity, grilling and smoking food.
• Y92.828 Other wilderness area as the place of occurrence of the external cause.

My recent shifts haven’t been much to smile about, so I was glad for the distraction. Needless to say, I rewarded him handsomely via our on-demand bonus system. He’s leaving soon for medical school, so he’ll definitely need the extra dollars.

Although emergency physicians aren’t expressly there to deliver preventive care, I’d like to offer some guidance based on my recent experiences. First, if you’re going to be using an electric hedge trimmer, may I suggest not “rushing to beat the heat of the day” and also wearing a pair of sturdy work gloves. Second, if you’re going to engage in a beach barbecue, follow the instructions on the charcoal lighter fluid and don’t squirt it on the coals beneath the already-cooking food. Third, if you’re going to use the hunting knife you just sharpened to open the cheese and sausage packages on your picnic table, please wear shoes. That’s a wrap on today’s safety moment, folks.

What’s your favorite summertime ICD-10 code? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/8/20

Most of the journal articles that come across my desk during the last couple of months have understandably been about the novel coronavirus or its downstream effects. Since there have been a flurry of retractions of articles recently, I was glad to see this study that took me back to my healthcare IT roots.

One of the main reasons my first practice implemented an EHR was to increase safety – reduce handwriting errors, reduce medication errors through the addition of allergy and interaction checking, reduce errors due to missing or incomplete data, and more. Although we did see some initial improvements, it quickly became apparent that EHRs could be the source of safety issues we didn’t even dream of in the paper world.

The study, published in JAMA Network Open, looks at trends in EHR safety performance in the US from 2009 to 2018. The authors drew data from a case series using over 8,600 hospital-year observations from adult hospitals that used the National Quality Forum Health IT Safety Measure, which is a computerized physician order entry (CPOE) and EHR safety test administered by the Leapfrog Group. The authors found that mean scores on the overall test increased from 53.9% in 2009 to 65.6% in 2018. However, they noted “considerable variation in test performance by hospital and by EHR vendor” going on to voice concerns that “serious safety vulnerabilities persist in these operational EHRs.”

Digging into the methodology, the Health IT Safety Measure test uses simulated medication orders that have been previously proven to either injury or kill patients. They are entered into the system under study to determine how well it can identify potentially harmful medication error events.

Looking deeper at the measures, it was interesting to see the difference between the various levels of clinical decision support: Basic Clinical Decision Support (CDS) scores increased from a mean of 69.8% to 85.6% where Advanced Clinical Decision Support scores increased from a mean of 29.6% to 46.1%. Basic CDS functions include drug-allergy, drug-route, drug-drug, drug/one-time dose, and therapeutic duplication contraindications. Advanced CDS functions include drug-laboratory, drug-daily-dose, drug-age, drug-diagnosis, and corollary orders contraindications. Researchers looked at whether the EHR’s CPOE system correctly generated an alert, warning or stop (soft or hard) after entry of an order that may cause an adverse drug event.

The Health IT Safety Measure test is included in the Leapfrog Group’s annual hospital survey and is performed by a hospital staffer. Detailed demographic data is provided for test patients, including diagnoses, laboratory results, and more. These test patients are loaded into the EHR so that they function the same as actual patients. (Hopefully this is all being done in a copy of the production environment, but the study didn’t mention the specifics.)

Once the patients are created, a clinician is supposed to enter test medication orders for those patients and record how the EHR reacts to the orders, including whether it generates alerts, and if it does, which kind. Hospital staffers are then responsible for entering this data into the tool. The tool includes protections against the hospital trying to game the system, such as control orders that aren’t expected to generate alerts. The process is also timed and must be completed in under six hours.

As I read the study, I kept waiting for the juicy part where we would learn the details about which of the “hospitals using some EHR vendors had significantly higher test scores.” The authors used self-reported data and reported each vendor with more than 100 observations as a single vendor, although it grouped all vendors with fewer than 100 observations as “other.” Unfortunately, “vendor names were anonymized per our data use agreement.” Although the vendors all had overall scores that were in the same ballpark (ranging from 53% to 67%) the minimum/maximum score data literally ranged from zero to 100%.

The closest statement I could find to anything that might indicate how real-world vendors performed was this: “In our results, the most popular vendor, vendor A, did have the highest mean safety scores, but there was variability among Vendor A’s implementations, and the second-most popular vendor had among the lowest safety scores, with many smaller EHR vendors in the top 5 in overall safety performance. Additionally, while we found significant variation in safety performance across vendors, there was also heterogeneity within vendors, suggesting that both technology and organizational safety culture and processes are important contributors to high performance.”

As someone who has spent many thousands of hours doing consulting work in the area of organizational change, that last statement hit the nail on the proverbial head. I’ve been in plenty of hospitals and offices where safety features have been disabled or modified, and for reasons including alert fatigue and the cumbersome workflows needed to override alerts, as well as organizational culture. It would be interesting to see whether the top-performing installations were using the vendor’s EHR out of the box or in a modified fashion, and what the CPOE build actually looked like.

The authors note several limitations, including the fact that the data set only includes hospitals that completed the Leapfrog survey, which may not be representative of all US hospitals. Although it was out of scope of this study, I would be interested to see how ambulatory EHRs would fare in such an analysis. In my experience some ambulatory systems can be even less uniform, as IT teams are pressed to perform whatever customizations or configurations are requested by the physicians who sign their paychecks. I’ve seen organizations that allow physicians to turn off all medication alerts, and others who require physicians to slog through a mind-numbing parade of low-quality alerts throughout the day, and everything in between.

Regardless, the study was thought-provoking, and I hope it generates thought for additional opportunities designed to assess EHR safety and measure vendor progress towards a more optimized EHRs in the future. It will be interesting to see what the data looks like in another five years or 10, and whether individual institutions improve in their performance. I would be interested to hear observations from any hospital IT staffers or clinicians who have been involved in performing this test, including whether you feel your scores are representative of the organization’s safety culture.

What do you think about EHR safety data? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/4/20

I attended the ONC working session on patient identification and matching on Monday. It was scheduled as a seven-hour Adobe Connect meeting, and for me, getting the most out of it in this format was challenging.

The only agenda available had been sent more than a week prior, along with my registration confirmation. It had two, three-hour blocks with the broad titles of “Challenges around Patient Identification and Matching – Boots on the Ground” and “Exploring Potential Solutions.” Under those blocks they had a list of individuals and their organizations, without a lot of detail around what they would be presenting.

According to the welcome, each presenter was supposed to have about eight minutes to speak. I tried to make my own time-boxed agenda, but it quickly was off by more than 10 minutes, so I gave up.

The first three sessions were largely review for anyone who has been dealing with this problem. Although the speakers were good, I wasn’t sure I wanted to commit a full day to gambling that I’d hear something I didn’t already know. It would have been good if the agenda included the theme of what each presenter was going to discuss so we could tune in and out in a way that made sense for us.

One of the best (or worst, depending on how you look at it) parts of some of the presentations was the inclusion of examples of how things have gone wrong due to poor matching. It’s terrible from the patient perspective, but it is useful to provide concrete examples to try to engage stakeholders who may not think matching is a priority issue.

I continue to see organizations create their own matching nightmares by deliberately creating duplicate charts for patients depending on their payment status. I worked with one client who had separate charts when the payer was employee health versus when they were using insurance or cash pay. I understand their concern about having the employer have access to sensitive medical information, but if you have an employee health department that has to certify an employee’s readiness / safety for work, shouldn’t they have all the pieces of the puzzle? I worked with another practice that had separate charts for work comp versus insurance visits for a patient, simply because they didn’t understand how to use their practice management system to set up different payers on a patient and toggle from visit to visit.

Overall, the speakers did a great job of keeping within their time block, often running shorter than anticipated. Frank Opelka from the American College of Surgeons talked about silos in surgical care. The number of tax IDs that touch a patient during a major surgery could be more than 20. That’s pretty unbelievable,  but of course is believable in healthcare.

I really enjoyed hearing from Congressman Bill Foster of Illinois, who was a co-author of legislation last year that attempted to remove the ban on activities in support of a national patient identifier. I didn’t know much about him before today, but I was impressed by his background as a businessperson and also a scientist. He worked as a high-energy physicist at the Fermi National Accelerator Lab and was part of the team that discovered the top quark. For science nerds, that’s pretty cool.

I also enjoyed Henry Wei’s explanation of “circles of trust” that evoked Robert DeNiro in “Meet the Parents.” Another great quote was David Speights from Appriss Health, who notes that regarding matching, “We’re trying to science the heck out of this.”

The bottom line for the day: Improved patient matching is a critical need, and a unique patient identifier would help and would  bring us into line with many other developed nations. A lot of smart people are working on this, but many barriers remain.

We are all knee-deep in COVID-19 projects, dealing with furloughs and working outside our usual norms. but CMS continues its churn with various rulemaking and other activities. On May 11 they issued the FY 2021 Inpatient Prospective Payment System (IPPS) for Acute Care Hospitals and Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) Proposed Rule. That’s a lot of abbreviations right there within a single rule, but I guess calling it the IPPSAPCLCHPPSPR would be a bit much.

The proposed rule includes minimum 90-day reporting period in CY 2022; maintenance of the Electronic Prescribing Objective’s Query of Prescription Drug Monitoring Program measure as optional for five bonus points in CY 2021; renaming the Support Electronic Referral Loops by Receiving and Incorporating Health Information measure to the Support Electronic Referral Loops by Receiving and Reconciling Health Information measure; and increasing the number or quarters of electronic clinical quality measure data reporting. Comments can be submitted through 5 p.m. ET on July 10.

Speaking of COVID-19, Quest Diagnostics has received Emergency Use Authorization (EUA) approval for its self-collected COVID-19 test last week. They hope to have half a million kits available by the end of this month. Other vendors already have similar tests available, but providers aren’t falling all over themselves ordering the tests for their patients. There are serious concerns about the self-swabbing ability of patients and with the ordering and management of the tests.

Go Mississippi: The Mississippi Hospital Association is launching a state-wide health information exchange in partnership with several regional hospitals and health systems. Initial capabilities will include admission and emergency department visit notifications, along with post-acute care transfer updates. Later phases will include clinical document exchange and referral management.

HIMSS is at it again, spending its efforts on frivolous activities such as “rebranding” rather than figuring out how to earn back trust among members and show attendees who are still smarting from financial losses. Last week they launched new branding for their regional chapters.

I really dislike it when organizations discuss their branding strategy. Branding, when done right, should be invisible to the consumer. I dislike it even more when the branding strategy is explained in buzzwords. “Our HIMSS brand architecture has been designed to do two things. First, to maximize clarity across our brand spectrum for both internal and external audiences. And second, to enable us to realize our full brand value, both now and in the future.”

I’m pretty sure most of us already recognize the HIMSS brand by its exorbitant fees and punitive housing and refund policies. Great job, marketing folks.

Happy 17th birthday to HIStalk this week. Being part of this industry has been a wild ride at times and I’m glad to have shared the journey with the HIStalk team and all our readers.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/1/20

This week’s tour through the virtual physician lounge brought news of additional departures among my physician colleagues. Although several were accelerations of planned retirements, others were not only unplanned, but unwelcome.

A local physician group decided to lighten its headcount by nearly 50 physicians. Their selections seem to have been made along economic lines, with primary care and non-procedural specialists hardest hit. Those who have the ability to drive surgical volumes or high-revenue procedures seem to have been spared. The majority of physicians who were terminated were over 55 years old, and a good number of them are planning to just stop practicing because they feel the prospects of finding a job at that stage of their careers are slim. Several of the younger physicians are also planning to hold off on looking for new positions, opting to assume stay-at-home parent roles instead.

For those who had planned to retire but accelerated their timelines, COVID-19 played a significant role. The financial impact caused intense pressure, especially among the smaller primary care practices that tended to run month-to-month with their finances. Even if they could return to seeing patients, some were concerned they would be unable to get the personal protective equipment needed to run their practices safely or to pay the exorbitant prices being asked.

Others were concerned about their own health. New data from the Centers for Disease Control shows that COVID-19 has killed more than 300 health care workers in the US and sickened 66,000. Those are scary numbers. For those who have the resources to leave the industry, I can’t blame them.

The idea of bringing home COVID-19 to a family or loved one is another influencing factor. The University of Arkansas for Medical Sciences (UAMS) recently surveyed their caregivers to assess acute stress among health professionals. Staff returned over 800 responses in early April and the University used those responses to help shape its response. The top fear identified was the need to keep family members safe after caring for patients who are suspected or confirmed to have COVID-19. The lack of personal protective equipment was another major factor, with one respondent using “PPE” 25 times in their response.

The university responded to those concerns by discussing PPE status in their communications, in addition to statistics on ICU beds and ventilators. Although that may have been reassuring to their clinicians, I know that when my own organization discusses its PPE status, I’m not terribly reassured.

An interesting finding in the survey was that many respondents felt that the pandemic increased their sense of purpose, reminding them of why they chose healthcare as a career. I know I personally am tired of hearing “that’s what you signed up for” when I try to talk about the stresses of in-person care with non-medical friends. Actually, no I didn’t sign up to care for patients during a global pandemic with inadequate protective gear. I didn’t sign up for fighting a forest fire while wearing flip flops.

“What I signed up for” was in fact gone by the time I got there. We all know that the idea of an old-timey family physician who sees patients across their lifespan was killed off by the insurance industry, constant switching of plans by employers, and market consolidation by hospitals and health systems. I’m lucky that I found something else to fall in love with that actually exists, and that’s clinical informatics. But I digress.

Digging deeper into the Arkansas data, the UAMS associate dean for faculty affairs is quoted in the AMA article as saying, “The vast majority of people in our organization – about 62% – felt valued by the organization. So that was important for us to hear too.” Certainly, that’s a majority, but I’m not sure I’d call it a vast majority, since 38% of the people don’t feel valued. That’s a big chunk of individuals who are likely carrying some resentment and bitterness.

He goes on to say that, “If there is one bright side of this crisis, it is that people will now value healthcare workers more and recognize the values and risks associated with our practices.” I’m not sure I’m seeing that where I live, where some of my colleagues have been told that they and their families are not welcome in their houses of worship due to concerns about infection risk.

I’m also starting to see some divisiveness among my colleagues. There is definitely some survivor guilt among those who kept their jobs while their partners and colleagues were terminated. There is also quite a bit of mudslinging against practices that are offering antibody testing, since the CDC doesn’t recommend it for individual patients, but plenty of practices are doing it in an attempt to shore up the bottom line.

Physicians who have continued to work or who have recently returned are still scrambling for strategies to protect themselves from the pandemic. I was excited to hear about a technology effort for early detection. Although it won’t prevent COVID-19 infection in an individual, it may help reduce the spread, identifying early disease since we don’t get to quarantine when we’re exposed. Investigators at Florida Atlantic University’s Schmidt College of Medicine are hoping to use a smart ring to identify physiologic changes that could indicate COVID-19 infection. It’s part of a larger effort led by the University of California San Francisco looking at both frontline healthcare workers and the general population.

They’re using the Oura smart ring to track heart rate, temperature, movement, and sleep data, which they meld with daily surveys in an attempt to predict sickness. It looks a bit like a wide, flat wedding band. Although a smooth surface is probably the least of the evils for hygiene purposes, it would be better to not be worn on the hand at all since being jewelry-free is recommended for those caring for COVID-19 patients.

The study will also follow participants with weekly viral testing, although they’re fortunately using a saliva-based test developed in-house rather than the dreaded nasopharyngeal swab. They will also receive antibody testing twice during the 12-week study. Maybe Oura could acquire some technology from the folks at now-defunct Ringly. I still love my bracelet even though most of the features are no longer supported.

How are you coping in the post-COVID world? Do you feel valued by your employer? If you were terminated, would you stay in healthcare? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/28/20

Memorial Day in the US looked a lot different this year to most of us. I hope people were able to have some thoughtful time about the challenges our nation has faced in the past. Although the National Cemetery Administration didn’t allow “public” groups to place flags in the National Cemeteries as we usually do, I was glad to see that the 3rd US Infantry Regiment was able to take care of Arlington National Cemetery. I found this picture with a great piece featuring quotes and remembrances to honor those who died for our freedom.

It’s nearly impossible to keep up with my inbox lately, so I was glad that the announcement for the ONC Virtual Working Session on Patient Identity and Matching on June 1 caught my eye. Feedback gained from the meeting will inform ONC’s report to Congress. Nearly all of the organizations I work with struggle with patient matching, and the problem frequently leads to patient safety issues (missing data, erroneous data) or excess costs (repeating tests because they’re not in the right chart). Participants are encouraged to discuss their insights into existing challenges and innovations that can help. I’m registered and hope to see you there.

Another inbox item that caught my eye covered Google’s efforts to help COVID-19 responders find hotel rooms. The recently-launched feature allows searches to be filtered for hotels that offer “COVID-19 responder rooms.” I tried a couple of searches to see what the special rooms might include – discounted price, quiet floor, consolidated part of the hotel, etc. – but all of them just said “contact the hotel for details.”

I was dabbling in telemedicine prior to the pandemic, and then things got real very quickly. Patients were scrambling to understand whether they had been exposed and trying to obtain refills from medications they would usually obtain from doctors whose offices were suddenly closed.

As offices reopen in my area, volumes are trending back to the baseline. I chuckled when I saw the headline of this op-ed piece, “Telemedicine Tales: Let’s Reschedule When You’re Not Shopping.”  Especially when wait times were long, it wasn’t unheard of for calls to connect when patients were somewhere other than at home, but fortunately I didn’t encounter some of the situations described by the author, including the “telephone encounter plus scalp exam” that resulted when a patient couldn’t resolve a camera angle issue. I completely agree with his assertion that he is “looking forward to the time when patients and doctors can determine whether in-person, video, or telephone visits best meet their mutual needs rather than having this dictated by public health emergencies or inflexible payment rules.”

Physicians in my area are sharply divided on whether telemedicine is going to be the wave of the future or the proverbial flash in the pan. There are some significant data points coming out of institutions like NYU Langone Health, which recently published in the Journal of the American Medical Informatics Association. They saw 683% growth in virtual urgent care visits and 4,345% growth in non-urgent virtual visits between March 2 and April 14. Most of my physician friends have enjoyed being able to see their patients virtually and be paid, especially when performing services that were previously uncompensated under traditional fee-for-service reimbursement models.

Those owning their own practices were happy with the flexibility, but employed physicians were a little less thrilled, depending on the arrangements. One large health system made the physicians physically come to the office to perform telehealth services, stating that it is required by HIPAA.

Speaking of large health system response to COVID-19, we’re not out of the woods yet for PPE. At my workplace, each employee has been issued four masks that they are expected to rotate on a daily basis and can only replace masks when the straps break or when they are visibly soiled. Apparently Missouri-based Mercy isn’t doing quite so well, with workers reporting that they’re wearing the same masks three shifts in a row. Competing health systems in the region are sterilizing masks daily. Most of the physicians I know still report a critical shortage of PPE and many are wearing non-medical respirators, such as those used for woodworking. Now that businesses are reopening and even more people need masks, the problem is worsening for some types of PPE, including surgical masks and gloves.

A recent Perspective piece in JAMA Internal Medicine describes some of the tensions found in expanding hospital volumes. It looks at the difference between making the hospital safe and making it feel safe, which aren’t always the same thing. I’ve experienced this in my own practice. Patients who acted shocked when I was masked during flu season and asked if I was afraid of catching their cold have become patients who file a complaint if they see a staffer removing their mask to grab a quick drink of water.

The author describes a new world where services that were previously in demand are no longer in demand and the importance of creating an appearance of safety. He notes the fine line between how new routines and procedures are presented, and whether they create an appearance of safety or danger that might cause hospitals to “inadvertently scare away the patients who need them.”

He closes by noting the difference between his weekend errand-running and life in the hospital with its critical care tasks. These are the skewed realities that many of us are living with every day, when we go from 12 hours of hazmat duty to hearing people complain about masks at the supermarket. Some days it’s surreal.

I see a lot of masks and gloves on the ground at retail locations, and at the same time, my office is limiting workers to one surgical mask per shift if they elect to not wear one of the four provided N95s. It’s a jarring visual and I certainly understand why many healthcare workers are seeking care for anxiety and acute stress reactions. This may be our new normal, but it doesn’t quite feel routine just yet.

The bottom line is that healthcare is still in crisis mode, but it feels like the rest of the world has moved on, especially when you see the videos of debauchery at some of the country’s lakes and beaches.

Is there anyone who is not operating under crisis standards of care? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/21/20

There has been a significant amount of chatter among my friends in the public health community, mostly around how COVID-19 tests are being documented, counted, and tracked. When we deal with other public health scourges such as measles, typically there would only be one positive test per person. With this pandemic, patients may be receiving numerous tests, generating both positive and negative results.

I followed one case where a patient tested negative three times and then positive four times before finally getting the two negative results that were needed for release from quarantine. There are plenty of public health organizations out there that are using lower-tech solutions — including paper, fax, and Excel — as opposed to the sophisticated databases that we all picture.

The issue of multiple tests per person is only one of the issues. Another is understanding which humans have been tested, since patients use a patchwork of identifying information that depends on the circumstance.

Let’s say a patient gets tested at an office that sends the specimen out to a national reference lab and wants the test billed to insurance. It’s likely that patient is going to be registered at the office under the name that is on their insurance card so that the claims get paid. If the patient goes to a drive-through public health clinic that is funded by grants, they might use the name that’s on their driver license, which may not match the one on their insurance card. If they order a kit online, such as those offered by a couple of labs, they might use the name on their credit card if they are paying out of pocket.

Now you have three names, which hopefully are similar, but might not be associated with one date of birth. Less-sophisticated matching algorithms might not identify them as the same person.

The Pew Charitable Trusts sent a letter to the US Congress last week, urging legislators to work with federal agencies such as ONC and the US Postal Service to enhance patient matching. Matching can be improved even with small steps, such as adding more data elements and standardizing those in use. The final ONC interoperability role focused on interoperability for EHRs, but didn’t address the role of other systems, such as those that handle laboratory information. Mandates for all systems to handle this information would be of benefit for data sharing.

This level of mismatch isn’t new. These are the same kinds of issues that EHR users have been having for years. We have been mandated to do various things that other parts of the industry are not. This has created all kinds of confusion in prescribing workflows and delays in patient safety efforts, as rule makers mandated actions for providers that receiving systems were unable or unready to process.

Standardizing existing data elements, such as phone numbers and addresses, would also be a benefit. According to a 2019 study in the Journal of the American Medical Informatics Association, patient matching could be increased by 3% with the addition of address formatting that is consistent with that used by the US Postal Service. The use of the USPS formatting is complicated by the fact that USPS doesn’t share its address standardization web tools with healthcare providers – they are reserved for exclusive use in shipping and mailing efforts. Congress would need to address this and expand the use of the tools to healthcare.

I’m always interested in solutions that promote desired health behaviors or encourage patients to receive recommended services. I wasn’t initially sure what to think of a recent article in JAMA Network Open that looked at participation in an end-of-life conversation game and its association with advance care planning. The study participants included nearly 400 underserved African American patients who participated in a game that was designed to help overcome reluctance to discuss death and dying. Researchers found that a positive association with care planning behavior among patients who participated in games at community events.

My initial skepticism at the idea of a game around death and dying was overcome by their results. The intervention was low cost and delivered by community organizations rather than health professionals. There are significant disparities among end-of-life care and I’m a huge proponent of access to a “good death,” so I hope these results can be replicated on a larger scale.

I picked up an urgent care shift this week and it was an absolute circus. The site was offering coronavirus antibody testing and the community came out in force to have their blood drawn. It was almost more exhausting than flu season, since every visit involved a fairly extensive discussion about what the results might mean, whether they were positive or negative.

The majority of patients were under the impression that a positive antibody test is akin to an immunity passport that allows them to run out and see their grandkids or have a bunch of people over. A couple of people wanted to have the test to know if they could donate convalescent plasma, and were saddened to learn that in our area, they can only donate if they had a positive COVID-19 test while they were sick rather than just having the antibody. One patient wanted to know whether the intravenous vitamin C he received from a mobile infusion center would be protective, and wasn’t too receptive of my explanation that we have no data on that treatment for this disease.

The best patient of the day was a retired general surgeon, who responded to my introduction by taking my hand firmly, staring deeply into my eyes, and asking, “How ARE you? How are you holding up in all this?” He was genuine and his compassion was palpable. I spent a few extra minutes with him and learned that he had previously been a residency program director, but retired “when selecting residents became all about the test scores and not about whether they were a good person or whether they could walk and chew gum at the same time.” I’m sure he could tell that I was just about laughing behind my mask. He was reading the latest issue of JAMA, and not surprisingly, had his surgical mask tied in precise knots behind his head.

It’s always great to see a patient like that, even in the midst of a wild and crazy day. It certainly recharges your clinical batteries. I’m not sure when I’ll work again, but it’s a nice memory and I can hope our paths cross again.

What has your bright spot been amid all the coronavirus chaos? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/18/20

As a consultant, you never know what’s going to come your way. Even projects that seem like they’re going to be straightforward might not be, as was the case with something I worked on recently.

I was dealing with a practice that had an issue with a staff member who was allegedly snooping through employee charts. They asked me to take a look at their audit trails and put together documentation so they could confront her. Finding the data in the EHR was easy since it has an activity log for each patient encounter that can be accessed by clicking a link at the end of the visit note. This is front-end visible data, so any user with the right access can look at it. That made me wonder why they needed to hire a consultant in the first place, other than to be able to say that they worked with an expert resource. I was sad that I didn’t even need to access the database.

The next step was cross-referencing the access time stamps with the actual patient visit time stamps, to either rule in or rule out whether the staffer might have rightfully accessed the charts as a part of the clinical encounter. When the charts are being accessed at midnight, it starts pointing towards an unusual pattern of behavior. When the midnights occur while the employee is supposed to be on vacation, you start to know that you have a winner.

Getting confirmation of the employee’s work schedule and days off was one of the biggest challenges since the practice didn’t want people to know they were investigating the employee. I had to talk to the payroll people to confirm the dates. Much of my engagement was being coordinated through an office manager who was relatively new to the practice, so I assumed that either she was just overwhelmed and wanted me to deal with everything or wasn’t sure of all the data points that needed to come together to make the case for inappropriate access.

Once we had the data in hand, the next step was putting together a report of the intrusions into various charts. Excel is my second language, so I had it all documented in a couple of hours and sent it over.

This is where the engagement turns strange. They wanted me to add documentation to each episode of chart access to specify why it was inappropriate. Sure, I said, send me over your employee handbook and I’ll tie each episode back to the relevant parts of your code of conduct and whatnot. I also offered to review their HIPAA training materials and link my findings back to that as well, functionally putting the nail in the coffin of this medical records misadventure. Since I haven’t been working clinically, I was happy to add a couple more hours to the engagement.

I didn’t hear back for a couple of days and the office manager didn’t respond to follow up emails. I escalated to calling (which I rarely do) and didn’t hear back from the voice mail messages I left either. I finally became irritated and reached out to the physician in charge of the practice, figuring that since he signed my engagement agreement, the buck would stop with him. I caught him in the car, and either he was distracted and just started talking off the top of his head or he had forgotten that they had left out a few key points when they hired me to do this work.

The snooping employee in question turns out to be the ex-wife of one of the practice’s physician owners. The situation is not just an employee discipline problem, but is also linked to a spousal support situation, with concerns that if the employee / ex-wife is terminated, the physician owner / former spouse might have to pay more. He doesn’t want her terminated.

Are you kidding me? Is this not something that could have been brought up when the engagement was outlined? I guess I’ll have to add some interrogatory questions around this type of shenanigans to my engagement intake form.

The plot thickened further. It turns out that the practice didn’t send over the employee handbook because they don’t have one. They also have no documentation of its employees having attended HIPAA training except for a log showing the date the employee watched some YouTube video on HIPAA. That video is no longer accessible, so we have no idea what they watched or whether they agree that they watched it. There is no documentation of a post-test or other evidence of mastery, so it’s going to be awfully hard to tie the misbehavior back to clear violations of office policy. The practice is liable for a HIPAA violation, but they can’t claim that the employee should have known better if there’s no documentation that she ever knew what HIPAA was or how it affected her.

Once this mess became apparent, it was clear why they hired a consultant. No one in the practice wanted to deal with the steaming pile of finger-pointing and ex-spousal angst that it was.

A couple of days later (and after a couple of calls with all parties involved on the practice side), the engagement was again expanded, with additional time for the creation of office policies and procedures regarding HIPAA training, chart access, use of practice resources outside working hours, and more. What started as a simple little project became not only a decent amount of work, but a great story for my next healthcare virtual happy hour. You simply cannot make this stuff up.

I have no idea what forces transpire to make a practice think it’s OK to operate this way in the year 2020, but apparently it has been going on for a long time. They were shocked that I also recommended they discuss this with their various liability carriers and their general counsel, to obtain additional advice on what to do next. I love writing policies and procedures, so it was great to settle into the sofa and spend some quality time with my laptop on a long, rainy weekend. I’m presenting their updated training plan to them next week along with their new employee handbook. Although this after-the-fact effort won’t do much to help them with their problem employee / ex-spouse, it will at least put them on a more solid footing moving forward.

How does your practice handle employee medical records violations? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/14/20

EHR vendors have officially started canceling their annual user conferences or moving them online, with Cerner receiving coverage in the Kansas City Star. NextGen Healthcare hinted at a move to virtual in their recent earnings call, but I haven’t seen a formal announcement.

I agree that large gatherings, especially those with international attendees, are as Cerner officials noted, “irresponsible and ill-advised.” Epic is still showing their event scheduled for August 24-27 in Verona, with hotel reservations open through June 18. This year’s theme is “The Magnificent Land of Oz,” but I just hope it doesn’t turn into a magnificent viral exposure.

Funds are being granted from the pot spelled out in the CARES Act. The Department of Health and Human Services will distribute $20 million to four telehealth programs for pediatric and maternal care, and two projects focused on increasing the portability of medical licenses across state lines. The grants are being awarded through the Health Resources and Services Administration (HRSA), with two grants of $2.5 million flowing from HRSA’s Federal Office of Rural health Policy to the Federation of State Medical Boards (FSMB) and the Association of State and Provincial Psychology Boards. The FSMB launched the Interstate Medical Licensure Compact initiative back in 2017, attempting to make it easier for physicians to become licensed in multiple states. Those of us whose main licenses are in states that don’t participate are out of luck as far as being helped by the Compact.

Although HHS hopes the grant recipients will “work with professional and state licensing boards and national compacts to develop a streamlined process for telehealth clinicians to obtain multi-state licensure,” it begs the question whether this shouldn’t be for all clinicians and not just those practicing telehealth. I would love to be licensed in multiple states and travel more, but maintaining multiple licenses is a pain and a significant expense. I would love to see medical licensure go national since we have to take standardized national board exams anyway. States can still discipline physicians for improper activities that take place within their boundaries, but let’s free up the licensure pathway.

The remaining $15 million was granted through HRSA’s Maternal and Child Health Bureau, with $6 million going to the American Academy of Pediatrics, $4 million each going to the Association of Maternal and Child Health Programs and the University Of North Carolina-Chapel Hill’s Maternal health Care program, and $1 million going to Family Voices, which is a New-Mexico-based program for families of children with special healthcare needs. The grants are aimed at increasing telehealth services for adolescents, young adults, children with special healthcare needs, and pediatric practices that need to develop telehealth capacity for rural and underserved areas. Other offerings include virtual doula care, remote prenatal care, and behavioral health services.

I’ve spent what seems like a lifetime in bad meetings, many of which are not productive because there are no agendas and no designated scribes. It’s hard to follow up on action items when no one documents them. I was excited to hear about Cisco’s Webex Assistant, which claims to be AI_powered and capable of “everything from automatic note-taking and real-time transcription, to identifying meeting highlights and action items.” I watched their very slick video and have to say I’m intrigued. I’d be interested to hear from anyone who is actually using it. How does it work in real life? Can it handle speakers with different accents? Is it able to parse medical or technical verbiage? Or does it quickly become like Clippy and you just want it gone?

On the flip side, I was on a great call the other night, having been invited to a virtual happy hour with a group of sassy ladies. I’m glad we didn’t have a virtual assistant capturing our conversation because it was wide-ranging, and at least without a transcript, we have plausible deniability. It did get me thinking, though, that Cisco’s product would be even more compelling if you could put it in “snark mode” and have it capture side bar notes such as “Bob’s dog is barking again” and “We can hear the ice cubes clinking in Dave’s glass. Based on the pitch, it’s half empty. Do you think it’s vodka?”

Speaking of slightly stalker-ish software, my clinical employer (from which I am once again furloughed after working a couple of shifts) is offering social medial monitoring as part of its defined benefits plan. The package promises to deliver “actionable alerts when there are any potentially racist, derogatory, vulgar, or inappropriate comments within your social media posts.” Since I know my employer is already monitoring what we post and occasionally asks us to take things down, I’m not terribly interested in giving them or their affiliates any more personal information than they already have.

An editorial in JAMA Internal Medicine addresses the topic of “Commercial Influences on Electronic Health Records and Adverse Effects on Clinical Decision Making.” They retell the story of the Practice Fusion opioid prescribing debacle in plain terms that might be news to physicians outside the healthcare IT industry — that the pharmaceutical manufacturer’s marketing team contributed to the design of clinical decision support alerts that promoted opioid prescribing practices that deviated from the standard of care.

The authors call on EHR purchasers to “require vendors to attest that no commercial interests improperly influenced clinical decision support design and that all tools are based on unbiased and clinically appropriate standards.” That might work for out-of-the-box code, but I’ve also seen healthcare organizations and providers themselves manipulate clinical decision support tools, including order sets, to preferentially position services with a higher profit margin for the organization. Somehow we’ve got to get past the place where money is a key driver in the delivery of healthcare.

Atlas Obscura is one of my favorite time-wasters, and I’m always intrigued when something medical is mentioned. This entry hit two targets – women in medicine and handicrafts. The pillow sham in question dates to 1896, when a group of graduates of the Woman’s Medical College of Pennsylvania embroidered their signatures along with medical symbols such as a doctor’s bag, a thermometer, and a skeleton. My medical school class was the first at my school that had more women than men, and I am in awe of the women who truly pioneered our path during the 1850s.

For trivia buffs, the Woman’s Medical College of Pennsylvania was the alma mater of “Dr. Quinn, Medicine Woman,” which remains one of my favorite medical TV shows of all time, along with “M*A*S*H,” “Call the Midwife,” “St. Elsewhere,” and “Trapper John, MD.”

What’s on your list of favorite medical movies and TV shows? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/11/20

If you’ve been a longtime reader, you probably know that I’ve done quite a bit of camping. I also usually teach at an outdoor leadership course a couple of times each year, which is good for stories on team dynamics and resilience. Needless to say, COVID-19 has put a bit of a dent in my outdoor activities, canceling three planned local camping trips, the outdoor school, and an outdoorsy trip to Victoria, BC.

This weekend I attended my first virtual campout, where everyone put up their own tents close to home and we got together on a Zoom meeting. As with any adventure, there were some learning opportunities. First, a shortage of my usual extra-wide egg noodles at the supermarket negatively impacted my standard Dutch oven dinner, so if I’m going to do it again, I had better plan in advance so I can avoid the linguine-esque ones we wound up with. The corn bread muffins cooked outdoors in a cardboard box oven, were delightful, however.

Next, I learned that I probably shouldn’t have put the laptop right next to me, since campfire smoke always finds me and therefore my laptop. After a quick run into the house for canned air, we were back on track.

The third thing I learned was that bad skits can be absolutely hilarious when performed on a conference call. I think I’m going to have to consider assigning remote skits for the next consulting gig I get where teambuilding activities are needed.

Last, I had the opportunity to confirm what I already suspected, which is that the people in my immediate household have some pyromaniac tendencies. Fortunately, we kept the inferno confined to the actual fire pit, and no grass was harmed this time. We were rewarded with great weather, so although the overall experience was a little strange, I’m glad we did it.

It was a welcome departure from the chaos that has been the last two months of my professional life. Run around frantically trying to get personal protective equipment so you can fight a pandemic? Check. Figure out how to quarantine yourself away from the others in your house? Check. Get furloughed and wind up with unanticipated free time? Check. Channel that free time into random IT projects? Check.

At the end of each calendar year, I go through a planning exercise and try to forecast what my year will look like based on what I think clients will ask me to do. This year was going to be full of travel, with lots of trade shows, expos, and meetings. We all know how that turned out. However, I was pulled into projects doing things I never thought would be on my plate. Need to set up chatbot-based screening for patients arriving at a drive-through testing clinic for a disease no one had heard of two months ago? Sure! How about using the ZIP code data from the patients to figure out where to put an expansion site for additional testing? Definitely. What about figuring out how to help practices reopen safely, routing patients to different reception areas depending on their symptoms? Of course.

I did more telehealth visits in a couple of weeks than I did all of last year, and even though it has its challenges, I’m fully convinced that it’s a critical part of healthcare strategy for the future. Patients like it, clinicians like it, and with the right supports and an appropriate mix of in-person care, it could really make the difference for some patients. It’s also a way to allow providers who might not be able to practice in a face-to-face setting to continue seeing patients.

A good friend of mine went through chemotherapy last year, and although she felt up to seeing patients, her physician wouldn’t clear her to work in the office. Telehealth would have been ideal for her, but it wasn’t on her health system’s radar at the time. Especially with the shortage of primary care physicians, we don’t want to lose people who are willing and able to care for patients.

There’s also been a fair amount of wackiness the last couple of months, mostly in the form of conspiracy theories and distrust of “the medical establishment.” I never thought I’d have to reassure people that my highly-regarded medical school didn’t offer a course in “Conspiracy 101” and that I don’t actually get paid more for diagnosing patients with COVID-19 than I do if I diagnose them with boring old bronchitis or pneumonia. I also never knew that so many grown adults didn’t wash their hands before all of this happened, or that some of them still think it’s optional. If there’s one good thing that comes out of the pandemic, it’s that maybe we’ll have fewer colds and flu because people have actually learned that washing your hands is important and you should stay home when you’re sick.

As we approach the middle part of the year, I typically do a brief planning check-in to see whether my forecasts are on track and what I think the bottom half of the year will bring. Guess what? All bets are off this time. I think instead of trying to plan, I’m going to just hit the patio with a bottle of wine and spend a couple of hours contemplating what’s blooming in the yard and wondering whether my pampas grass will come back after the household pyros torched it this spring rather than simply cutting it off as usual. (I realize that prairie fires are a thing and are part of a healthy ecosystem, but I don’t think my single clump of grass deserved what it got.)

If there’s one thing I’ve learned this year, it’s that although having a plan is generally a good idea, if the universe decides to start throwing flaming meteors at you, all you can do is adapt. For the first time in a long time, I have absolutely no idea what I might be working on in three months, let alone six. I don’t even know if some of my health system clients will be solvent in the bottom half of the year, or whether my small practice clients will ever reopen. It’s pretty clear, though, that we’re going to need plenty of IT solutions to get through some of the challenges that are coming, although they probably won’t be with the traditional vendors we’ve all looked to in the past.

What do you think the bottom half of the year will hold, personally or professionally? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/7/20

This week is National Nurses Week. I salute all the nurses who taught me what I really needed to know to be successful on the wards, since most of it wasn’t covered in the formal curriculum presented by the medical school faculty.

I came across this pastry shout-out to nurses from physician Cindy Chen-Smith @artmeetscookie and was blown away by the airbrushing. Whether you’re a superhero in chunky shoes, New Balance sneakers, sassy heels, or tactical boots – I salute you.

I also enjoyed reading the comments on National Nurses Day from Patti Brennan, director of the US National Library of Medicine (and a nurse herself). She notes, “While the Library can’t manufacture more time, fabricate personal protective equipment, or stand beside the bed of a patient in need, we can help nurses find freely accessible literature.” Brennan mentions special search strategies such as LitCovid, which I admit I’d never heard of. It’s a curated hub for tracking the most recent scientific information about our current situation and categories articles by topic and by geographic location.

I enjoy seeing the breadth and depth of the projects my clinical informatics colleagues are working on. This research letter published in JAMA Internal Medicine last week looks at “Internet Searches for Unproven COVID-19 Therapies in the United States.” Since we’re looking at a disease with no reliable proven treatments there are plenty of ideas floating around the internet (and directly from political figures) that are catching people’s attention. The authors looked at internet searches that were “indicative of shopping for chloroquine and hydroxychloroquine” by monitoring Google searches “originating from the United States that included the terms buy, order, Amazon, eBay, or Walmart” in combination with chloroquine or hydroxychloroquine.”

They cross referenced the data against the dates when Elon Musk and President Trump endorsed the drugs, as well as the date when news reports on treatment-related poisonings were published. The authors found that “queries for purchasing chloroquine were 442% higher following high-profile claims that these drugs were effective COVID-19 therapies.” Searches for buying hydroxychloroquine were 1389% higher. Searches for purchasing the drugs continued to remain high following news reports of their dangers, although at a lower level (212%).

In the discussion, the authors note that “Google responded to COVID-19 by integrating an educational website into search results related to the outbreak, and this could be expanded to searches for unapproved COVID-19 therapies.” I’m sure there will be more research questions to come in this area as the pandemic rages on.

Most of my physician colleagues have been doing at least some level of telehealth, and after a couple of months, some of them swear they don’t want to go back to in-person care at the same levels they practiced previously. Many patients don’t want to go back either, especially in economically depressed areas and among patients who previously had to travel long distances to receive treatment. A Stat news piece looks at patients in coal country, where the University of Pittsburgh Medical Center (UPMC) has seen a 3,700% increase in telemedicine visits.

One of the reasons for greater patient satisfaction during telehealth visits was noted by UPMC’s CMIO, who noted that who “doctors are able to type notes while facing the patient, instead of looking over their shoulders.” That seems like an operational / technical issue to me. Perhaps UPMC should look at reconfiguring their exam rooms and employing laptops on carts or a better type of device to make their in-person visits more hospitable. He also notes the struggle with initial visits, with patients succeeding on the second or third attempts.

Although many physicians are assuming that the wild, wild west of telehealth (non-HIPAA-compliant platforms, reduced requirements on service location) will continue, we’ll have to see what the payers decide to do. We’ve already seen many of the cross-state licensure waivers end, and there’s already a lot of financial pressure to return to the status quo. (How do you justify charging a facility fee when neither the provider nor the patient are in the facility? Inquiring minds want to know.)

As hospitals start to pass the peak of COVID-19 and clinical care teams start to learn to breathe again, the folks in finance are continuing to have increased anxiety. They have to figure out what it will take to make their balance sheets positive again, or at least less negative.  A recent article featured Dan Michelson of Strata Decision, who discussed what CFOs will need to weather the long-term changes after the COVID-19 storm. I’ve chatted with Dan a couple of times, and he’s usually spot-on in his observations.

Among the things he recommends: rolling budget forecasting, adherence to coding guidelines for complications and secondary diagnoses, and being able to anticipate patient behavior changes, especially the desire for non-emergency procedures. Organizations will also need to truly understand their costs, including PPE, overtime, and additional supplies in the new world post-COVID. They’ll also need to understand the role of self-pay in their overall financial picture, since many patients have lost the health insurance that was tied to their employers.

Another issue in the “new normal” post-COVID is understanding how we catch up on diagnoses that were missed due to multiple months of delayed preventive services. A report from the IQVIA Institute for Human Data Science looks at trends in the US for five common cancers.  The report estimates that 80,000 cases may be missed across breast, cervical, colorectal, lung, and prostate cancers based on decreased screening volumes in April compared to February.

I’m high risk for two of those conditions and am behind on my regular tests due to the closures, so I can definitely understand concerns about screening delays from the patient perspective. Interestingly, I’ve received no communications from either of the providers involved in my regular screenings, so I suppose I’m left to assume that their strategy for handling patient recalls during the pandemic was to just stop contacting people. That’s not much of a strategy for patients who might not be as compulsive about their health as I am. I’ll just keep bumping my calendar reminders forward a few weeks at a time until I hear the hospital is back in the screening business.

The American Academy of Family Physicians came out with a checklist for reopening practices to non-essential face-to-face visits. Usually their advice is pretty practical, but one bullet caught my eye. They recommend that common areas such as patient waiting rooms and staff break rooms should remain closed if possible. Although they recommend allowing patients to wait in their cars until it’s their turn to be seen, they conveniently avoided any recommendations on where staff should take breaks. In my travels, I’ve seen plenty of people eating in clinical care areas because they don’t have time to take an actual break or the office doesn’t have adequate facilities.

Seeing patients face-to-face in these new conditions is more tiring than before and staff do need a place to take a break (not to mention a safe place to take their mask off so their skin can breathe). They also call for staff to wear face masks, gowns, eye protection, and gloves when caring for suspected COVID-19 patients, We’re still in a shortage of gowns, so that’s just not realistic.

There was a recent story on “Good Morning America” encouraging graduates to donate their unworn gowns for healthcare providers to use as personal protective equipment. Although I appreciate the sentiment, I’m horrified that several months into this situation, we’re still in crisis mode. Will the surgeons be asked to wear hand-me-down graduation gowns to the operating rooms now that they’re starting to book cases?  I think not.

Does your staff get to use the break room, or to do they take their meals in their cars? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/4/20

Many organizations are knee deep in the process of expanding coronavirus testing. Although it has become easier to get test kits, some of us are still eagerly awaiting the rapid kits from Abbott.

One of the challenges though with adding COVID-19 testing to your scope of services is dealing with the reporting aspect. COVID-19 is a reportable disease in all public health jurisdictions. Depending on how large your organization is (and how many counties or states it serves), the reporting aspect can be daunting.

I was excited to attend a webinar last week that was presented by the American Medical Informatics Association (AMIA). They reviewed the “eCR Now” effort to broaden the use of electronic case reporting for COVID-19. From a clinical informaticist’s point of view, it was the most exciting thing I’ve seen in weeks. For those of you who were like me and hadn’t heard of it, I’ll give you the highlight reel.

Electronic Case Reporting (eCR) is the ability to automate generation and transmission of case reports from EHRs to public health agencies so that those agencies can review and act on them. Depending on the jurisdiction, that might include sending a formal quarantine order to an affected patient, performing contact tracing, or enrolling them in a daily disease tracking and/or surveillance program. Public health agencies rely on case reports for numerous diseases and conditions beyond COVID-19, from sexually transmitted infections to dog bites.

The problem for providers is that each public health jurisdiction has its own reporting process, which may range from email to fax to phone calls. Automating this process from data already in the EHR is key, both in reducing the delay in getting information to the agencies as well as receiving information back from the public health agency.

Apparently a pilot for eCR was already in the works well before COVID-19 hit our shoes. Coordinated by a collaborative of healthcare, public health, and health IT industry partners, Digital Bridge came together to solve the problem of data exchange. After some small implementations, the effort began to expand in late 2019, with sites implemented in Texas, Utah, New York, and California, plus 19 other state and local public health agencies.

Once COVID-19 became a thing, they started reporting those codes through the existing infrastructure. By the end of January, 142,000 case reports had been sent from seven implementations. The process uses HL7 standard documents to move information from providers through HIEs or other exchange frameworks to a platform that is supported by the Association of Public Health Laboratories (APHL). For public health agencies that aren’t completely integrated, the platform can render the files in HTML, which functions a lot like the faxes they previously received.

Most of the current implementers are Epic and Cerner sites, but given the importance of public health reporting for COVID-19, there is a push to move eCR capabilities into more EHRs. They’ve created a program called “eCR Now” that has three main parts:

1. Rapid implementations for cohorts of organizations that have eCR-enabled EHRs.
2. A FHIR app that non-eCR-enabled EHRs can rapidly implement.
3. Extension of the existing eHealth Exchange policy framework through a developing Carequality eCR implementation guide

As far as the accelerated implementation cohorts, what used to take 2-3 months is now taking 3-4 days. In fact, Sutter Health has issued a challenge, promising a bottle of wine for any cohort participant that can beat Sutter’s implementation record.

Organizations whose EHRs don’t support the standard can use the FHIR app, which was due (along with its source code) to be released May 1. There’s a nationwide HL7 FHIR Virtual Connect-a-thon scheduled for May 13-15. EHR vendors that don’t support the standard are being encouraged to develop the ability to trigger report generation and send data based on the standard, and state and local public health agencies are being encouraged to accept eCR instead of requiring manual case reporting. Who doesn’t love getting rid of a clunky manual process?

Needless to say, I immediately took this information to a couple of the organizations I work with, because it’s the kind of project that’s a win-win in a lot of ways. Manual reporting sucks up time that could be spent doing other things, and being able to rapidly process information about COVID-19 diagnoses and lab tests is going to be key to our management of the disease especially without a vaccine or broadly-applicable treatments. Plus, I selfishly want one of my clients to bite on the idea because I love this kind of a project – it takes me back to my first “build from scratch” project more than a decade ago, when we decided to add CCOW functionality between several applications at my health system.

I still remember the calls with Sentillion, when they agreed to give us the software development kit and I had to quickly learn about Vergence and the fact that “the vault” didn’t live in a bank. It was probably my first deep dive into the world of development, and led me to meet all kinds of wild and crazy developers and even build a friendship with my own personal “Citrix Guy.” Sure, there were many late-night testing sessions (since we didn’t have a complete test environment and had to quietly test things in production after the physicians were off the system, but before the backups and billing runs started) and probably too much alcohol, but it was a really fun time that I will always remember.

Technology moves on. Microsoft bought Sentillion, all those developers are now working at other places, and CCOW has mostly gone the way of the dodo as healthcare organizations either move onto monolithic platforms that handle everything or instead move the data around through interfaces.

I’m hoping I get to work on an eCR project and that it continues to grow well beyond COVID-19 and into the realm of all the other reportable diseases that require complicated manual reporting. Many of us believe healthcare is entering into a time of massive transition, and we’re going to need lots of tech to get us through.

Anyone looking for an ex-CCOW expert that likes to play with FHIR? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/30/20

I’ve always enjoyed baking, and once upon a time, I even worked in a bakery. Even with exposure to some truly exceptional baking, I’m very impressed by the Chicago-area physician who is creating cookies to honor key figures in the COVID-19 pandemic. Her designs are hand painted and include tributes to physicians such as Anthony Fauci, Ohio’s Amy Acton, and others. Pediatrician Priscilla Sarmiento-Gupana is truly an artist and I wish her good health, along with many happy hours of baking.

CMS has suspended advance payments to providers and is re-evaluating accelerated payments to hospitals. Over $100 billion in loans has already gone out the door, but many healthcare delivery organizations are still struggling. The payments split 40/60 between Medicare Part B providers and hospitals. Recipients are expected to repay the funds within one year. Reasons for suspending the program include the availability of funds through other programs, such as those in the CARES Act, along with the Paycheck Protection Program and Health Care Enhancement Act.

Most studies indicate a 60% decline in outpatient visits during March. Factors at play include providers who want to reduce exposure to their staff, along with patients who don’t want to come into contact with COVID patients. Between 30-50% of physicians report using telehealth for at least a portion of visits. Some specialties, such as ophthalmology, have been hit harder than others, primarily due to recommendations from their professional societies about practice closures.

An intrepid reader sent me this ad from SSM Health that promotes telehealth visits. He notes that the clinician is wearing the traditional dress of nurses in the UK’s NHS. Last time I checked, SSM was located in the central US. They recently furloughed over 2,000 employees, and I wonder if eagle-eyed proofreaders were among those let go.

I often see companies using cheesy stock photos without thinking deeply about whether those photos actually convey the culture of their organization or whether they represent their employees and patients. The picture reminded me that I’m two episodes behind on the new season of “Call the Midwife,” so I know what I’ll be doing tonight.

EHR vendors continue to work to make it easier for clinicians to document patient visits. A recent article in the Journal of the American Medical Informatics Association looks at the accuracy of the physician’s note compared with a concealed audio recording obtained from an unannounced encounter with a standardized patient. Standardized patients are typically professionals who compensated for filling the patient role during a mock office visit, where the clinical team’s performance is evaluated.

Researchers looked at 105 encounters across 36 physicians. They found 636 documentation errors, with 181 findings being documented that did not actually occur and 455 findings that occurred but were not documented. Nearly 90% of the notes had at least one error, with 21 of them over-coded and 4 under-coded. Theoretically, technologies such as ambient clinical intelligence could provide a solution to these issues. I look forward to seeing data on how well it delivers on its promises.

I haven’t paid much attention to the attempts at delivering a virtual HIMSS20, but this week an email came through that listed a session I was actually interested in. Unfortunately, going to the site wasn’t fruitful, as I couldn’t find the session I was looking for. The site has filters but not a keyword search, and since I didn’t want to dig through dozens of screens, I gave up. I’m not sure how well-received HIMSS20 Digital has been, but I doubt I’ll be back.

April 30 is the last day to submit MIPS data for 2019. The data submission window closes at 8 p.m. ET. CHS has added flexibilities due to the stresses that COVID-19 has placed on healthcare providers. Individual clinicians who aren’t able to submit MIPS data by April 30 will qualify for the “automatic extreme and uncontrollable circumstances policy” and will receive a neutral payment adjustment for the 2021 MIPS payment year. Groups and virtual groups will have to submit an application for the exception, and those can also be submitted until  8 p.m. ET on April 30.

Speaking of deadlines, May 1 is the deadline for payers to submit proposals for the Primary Care First program. It seems like it’s been a million years since we’ve talked about programs like this, as opposed to emerging infectious diseases. Delivery of primary care services has been significantly changed by COVID-19 and it remains to be seen whether Primary Care First will even get off the ground, let alone have the power to transform care.

I’m a sucker for evidence-based and data-driven approaches, so I enjoyed learning about the new scoring system that is being discussed by the American College of Surgeons to help surgery departments start scheduling medically necessary operations. The system looks at the level of hospital resources needed, the impact of a treatment delay on a patient, and the risk the procedure poses for the surgical team. The Medically Necessary Time-Sensitive (MeNTS) Prioritization process was published ahead of print and is gaining interest among surgeons who are operating under differing guidelines from various subspecialty organizations.

The system has been in use at the University of Chicago for approximately two weeks. They have been able to increase the number of non-emergency surgeries performed to approximately 15 per day. I’m sure that’s a far cry from their usual surgery volume, but hopefully the scoring system will help create a path forward.

Recent updates to Microsoft Word have been driving me crazy. I was glad to have my experience validated by a recent article in Smithsonian Magazine. Millions of typists were taught to place two spaces after a period, while modern keyboarding technique now only includes one space. I’m thinking about trying to teach myself to type with only one space at the end of a sentence. It might be something to challenge my brain since I’m not working clinical shifts. In the mean time, I’ve asked the new editing tool to tolerate my double-spacing.

One space or two? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/27/20

Just when I was getting used to being furloughed from my clinical gig, I was called to action for three days of work that just happened to coincide with the expected peak of COVID in my state. Although I was initially eager to get back in the game, I must admit that 36 hours in the trenches has eliminated any such enthusiasm.

After my initial shock over a couple of things, I decided to give it the benefit of the doubt and try not to draw any conclusions until I had worked at three sites with three teams. Now, with those shifts in my rear-view mirror, I have to say that some of my first impressions were correct. Here’s what I learned.

I’m probably more likely to be exposed to the novel coronavirus by my colleagues than by the general public. Our team is generally young and healthy, mostly EMTs and paramedics. Many of them are super fit, with extensive workout and nutrition routines. Several of them questioned why I was wearing my N95 mask all day, even for patients who didn’t have respiratory symptoms. It’s clear that our internal education has not met the mark as far as their understanding the idea of asymptomatic spreaders or the need to treat everyone with universal precautions since you can’t tell from looking who might be a carrier.

Most of them were donning and doffing various masks (alternating between N95 and standard surgical masks) and setting them on the workstation counter in between patients. Only two of us had a dedicated “drop zone” for our masks (a.k.a. paper towels with our names on them). Others were lowering their masks under their chin in between patients, which is a less-than-great infection control procedure. The good thing is that most of them responded well to a little in-person education and started doing better with mask hygiene.

Leadership note: just because you send out memos and instructions, it doesn’t mean people get it and are following the instructions. Sometimes you need the face-to-face contact to get the message across. It’s an expensive kind of communication, but it’s worth it.

Speaking of masks, the general public isn’t doing a great job of wearing them even when they have the good ones. I saw too many people with masks covering the mouth but not the nose, and too many whose nose pieces weren’t pinched to fit well around the nose. People whose glasses are fogging up due to their masks are incredibly grateful when you teach them how to pinch the nose of the mask. We as healthcare providers take it for granted that people know how to use them correctly.

I saw everything from top-of-the-line 3M models to simple bandanas. The best one was a homemade model on a patient whose wife is a professional seamstress. As someone who does a little sewing myself, the craftsmanship was something to behold. I told him to be sure to let her know that the doctor noticed her attention to detail and excellent topstitching.

I also learned that a good part of our surge was made up of people coming in for non-emergent conditions. People certainly aren’t afraid to venture out for minor things such as having wax removed from their ears even though they don’t have symptoms. Multiple people were there for medication refills since they either couldn’t get in touch with their physicians or were having trouble getting refills in a timely manner, and I was happy to help them.

We did see our share of urgent and emergent conditions as well, including multiple cooking-related lacerations among people who don’t usually cook, along with several home improvement injuries. Patient education note: working on an aluminum ladder while barefoot is not a good idea. We also diagnosed and treated multiple sexually transmitted infections, so some people’s ideas of stay-at-home might be a little different than others.

I ordered my fair share of COVID-19 testing swabs, and now I get to play the waiting game to see how long it takes the results to return so I can start my own “known exposure” countdown. I don’t know when I’ll be asked to work again, but I’ll definitely be staying close to home until the results turn up. I’m grateful we have testing capabilities and can at least collect the samples in the office without having to send patients elsewhere or fight the health department for approval like I had to a little more than a month ago.

My employer is keeping a close count on the testing swabs since they aren’t sure when we can get additional supplies. We’re a long way from testing everyone who wants to be, as we were promised once upon a time.

After my first day of patient care, I pretty much fell into my bed. As I tried to fall asleep, I wondered how long it would take the tingling in my face to go away. If you wear them properly, the N95 masks are pretty tight, and I was glad that my face was back to normal by the morning. However, after three days in a row, my face feels like it’s been in a vise and I have a splitting headache that I can’t get to go away.

I cannot even fathom what it must be like for the healthcare workers who are on dedicated COVID units or who have been working like this for weeks on end. I’m hoping to cruise some forums for tips on pressure reduction before I go back again. Hopefully, my face will bounce back overnight since I’m supposed to film some EHR training videos for one of my clients.

I’m glad I could pitch in, but I feel guilty for having been parked at home while my colleagues have been working. It’s definitely more mentally and emotionally exhausting than the work we were doing before, even in the middle of flu season. I never thought I would wish to go back to the Flumageddon season of 2017-18, but I do, to some degree. At least back then we knew what we were dealing with, we could test for it, and we had a hope of treatment. With this situation, we’re often flying blind and looking for outlier symptoms, such as loss of smell or “COVID toes.”

I noticed that our EHR vendor has added quite a bit of telehealth-specific content. Even though we’re not using it, I was glad to be able to check it out. It prompted a good conversation with my scribe, who was also seeing it for the first time. She didn’t know I worked in telehealth. She recently wrote a paper about telehealth for an undergrad class. It was good to have a bright moment like that in the middle of a very tiring day, and hopefully she learned something beyond what her research had shown her.

She also offered me the tip of putting Preparation H on my face if the redness doesn’t go away. Apparently, she learned it “on the pageant circuit,” but I’m too tired to even remotely consider masking up and going to the store.

Have any tips for dealing with the squeeze of a badly fitting mask when there aren’t any other mask options? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/23/20

Telehealth is a hot topic in the virtual physician lounge, with various specialty organizations providing cheat sheets and other reference materials to help practices figure out how to get paid. The American Academy of Family Physicians put together a nice table and flow chart identifying the appropriate E&M codes to use for various clinical and technology scenarios.

As the coronavirus response shifts, some states are allowing their emergency licensing waivers, which allowed many of us to see telehealth patients across state lines without separate licenses in those states, to expire. The recent expansion of telehealth coverage by the US Department of Health and Human Services also allowed providers to avoid HIPAA penalties for the good-faith provision of telehealth during a public health emergency, which led to a boom in use of things like Skype, FaceTime, Facebook Messenger, and other non-secure platforms. It’s unclear exactly how long the “public health emergency” status will last and how much warning we’ll have before the original rules return in force.

Although many healthcare delivery organizations are strapped for cash due to declines in elective procedure revenue, it’s time for them to start thinking about how they’ll transition to a HIPAA-compliant solution. In addition to the HIPAA angle, providers deserve better than using consumer apps. To have the best efficiency and patient safety features, telehealth platforms should integrate with the EHR and scheduling system for streamlined documentation and follow up.

I’ve heard of a couple of health systems looking at telehealth as a way to reduce their physical footprint and get out of costly leases. One executive I talked to spoke of turning some of their offices into the medical equivalent of WeWork sites, where providers could purchase just the time and space they need for face-to-face visits, which may fall below 25% in some specialties.

Stories about providers having their hours cut are everywhere, along with recent reports that healthcare staffing giant Envision Healthcare might be preparing to file for bankruptcy. The company has over $7 billion of debt. The entry of private equity into healthcare in recent years has sucked money out of the system at an alarming rate. Perhaps its time for hospitals to go back to employing physicians and treating them like valued members of the community instead of commodities.

Several physicians have asked me if I had read the statements from the Office of the National Coordinator regarding flexibility with the Interoperability Rule, and I had to admit that I hadn’t. The bottom line is the ONC and CMS, along with the HHS Office of the Inspector General (OIG – just wanted to see how many abbreviations I could string together) announced “a policy of enforcement discretion to allow compliance flexibilities regarding the implementation of the interoperability final rules announced on March 9th.” They went on to say that this “flexibility” is specifically due to the COVID-19 public health emergency. The discretionary period will run for three months past the original compliance dates, but I wouldn’t be surprised if it ends up being extended.

I was initially excited to see an email from Provation offering a “free COVID-19 order set and care plan” in order to “keep all our healthcare heroes equipped with the latest evidence-based order set and care plan content available for COVID-19.” Unfortunately, it requires provision of your email address and company info prior to access, followed by acceptance of terms of agreement that say you can download a single PDF copy “solely for evaluation purposes.” Given the lack of proven treatment for COVID-proper, there wasn’t anything too earth shaking in it.

I was pleased to see the American Academy of Family Physicians come out with a forceful statement about the lack of evidence for off-label use of medications for COVID. Physicians are getting numerous requests for unproven drugs, and those who give in to the badgering are inadvertently causing shortages for people that need the drugs for their actual approved use.

A colleague clued me in to a Miami organization that mailed her mother a bottle of hydroxychloroquine without her requesting it, along with information stating that patients were being placed on it as a preventive. I was happy to see that references to that activity have been sanitized from its website, although the South Florida Sun Sentinel preserved the CEO’s statements and advocacy for the drug for posterity. I hope regulators and license officials take the time to investigate any shenanigans that have already occurred.

I was also happy to see the announcement of an AMIA webinar next week focusing on Electronic Case Reporting. This is a problem I’ve been trying to solve for a client. Due to geographic spread, they have to report COVID-positive cases to dozens of public health authorities, all of whom have different forms. Required transmission modalities include phone, fax, email, web forms, and snail mail. The client has largely given up on reporting, preferring to ask for forgiveness rather than permission. Hopefully the pros on the call will have some ideas to help so I can stop tearing my hair out. If any readers have inside scoop, please share with the rest of the class.

I was less happy to see the CMS document detailing strategies on how to reopen healthcare delivery in the US. First off, its title “Opening Up America Again” is a little too close to a political slogan than should be permissible with an official CMS document. I detest the use of the word “America” as a synonym for “the US” because it makes us appear ignorant of the fact that “the Americas” are a big place inhabited by lots of people other than us.

In short, the document recommends that organizations use telehealth when they can, but in-person care can resume in areas that have “the resources to provide such care and the ability to quickly respond to a surge in COVID-19 cases, if necessary.” Consideration should be given to facilities, workforce, testing, and supplies.

However, the CMS statement on Personal Protective Equipment (PPE) is weak. Basically they are recommending only surgical facemasks for healthcare workers unless high-risk procedures are being performed, and “patient should wear a cloth face covering that can be bought or made at home if they do not already possess surgical masks.” No mention was given to the relative ineffectiveness of cloth face coverings or the lack of science supporting their use, nor of the studies that show that in some circumstances cloth face masks can actually increase transmission of infection.

On the delivery side, the plan is to “conserve PPE,” which basically means healthcare organizations can require their employees to use items in ways that contradict documented approved uses and increase risk to staff. I fully understand that we can’t just use new masks for every patient like we used to, but I would love to see Seema Verma have a conversation with my friend Lil, a pediatric OR nurse who was denied a new mask by an OR supervisor despite her mask being soaked with sweat (and likely ineffective, since you’re not supposed to wear them if they’re saturated).

The document also calls for routine screening of workers and designation of “COVID-19 Care zones” and “Non-COVID Care” (NCC) zones, with separate buildings or separate entrances in the same building and with staff not crossing from zone to zone. It goes on to say that “all patients must be screened for potential symptoms of COVID-19 prior to entering the NCC facility, and staff must be routinely screened for potential symptoms as noted above. When adequate testing capability is established, patients should be screened by laboratory testing before care, and staff working in these facilities should be regularly screened by laboratory test as well.” I’d love for someone to sit down and explain how that should work in the average primary care office or urgent care, because it doesn’t feel like CMS is thinking beyond the hospital walls.

What do you think about the plan to reopen healthcare in the US? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/16/20

HIMSS could learn a lesson from the American Academy of Family Physicians, which is offering a “worry-free registration” guarantee for its annual conference that is scheduled for October 2020 in Chicago. Attendees can cancel their registrations at any time, for any reason, up to the day before the meeting and will receive a full refund. Bookings prior to April 30 can also receive an additional $100 discount in honor of National Doctors Day. AAFP’s hotel policy is deposit-free and rooms can be canceled within 72 hours of the meeting without penalty. Cancelations within the 72-hour window will incur a one-night charge. It’s unclear if the world will be ready for major conferences by that point, but at least they’ve come up with a good solution to try to make a go of it.

There has been a lot of chatter in the virtual physician lounge around plans for testing and contact tracing in preparation for the end of stay-at-home orders. Excitement about the point-of-care ID Now COVID-19 test from Abbott Labs has been building, as many practices already own the machines that are needed to run them. The company has shipped 560,000 test cartridges across the US, but I haven’t heard of anyone in my area receiving them despite having placed orders as soon as the company started taking them. An article says that the majority have been sent to “outbreak hotspots,” with a request for customers to prioritize testing for frontline healthcare workers and first responders. They are manufacturing 50,000 tests per day and plan to increase the capacity to two million tests per month by June.

Rapid testing is key to strategies for reopening the US economy, along with robust contact tracing. Even though San Francisco is located in a tech hotbed, they are going somewhat back to basics with their approach to contact tracing. They’re putting together a task force to interview patients and trace their interactions, building their team from 40 people to as many as 150. They are engaging researchers, medical students, and staff from the University of California, San Francisco.

Even though major parts of the process will be manual, the group will use online and phone-based tracking tools to follow up with exposed persons and assess them for symptoms. The team will also seek permission to review phone location data for additional tracking.

Where other countries are mandating use of state-developed apps to track movements and trace contacts, many people in the US would fight any mandatory sharing of data, despite the fact that they willingly give it up every day to random apps that sell their data and aren’t trying to keep people from dying.

Testing and contact tracing efforts are going to be expensive and will further stress an already burdened healthcare system. Nearly every facility has a story of salary cuts and hiring freezes along with layoffs and furloughs. Hospitals are still struggling, even those who are not yet in the midst of the surge. They’re paying inordinate amounts for personal protective equipment and still can’t get enough of what they need to function under anything but crisis standards of care.

Next time you read an article about COVID response, look at the pictures. Are the clinicians wearing consistent PPE, or is it a hodgepodge of gear, some brought from home? Do people have head coverings, masks, gowns, and face shields? Do they have masks that fit? Are all clinicians protected, or just those performing the highest risk procedures?

It saddens me to know that I had better PPE when I played the Quipstar game show in Medicomp’s HIMSS booth than some of my colleagues now have. Once we reach the point where healthcare workers have enough PPE that they can use in the way it was designed, not in a way that is modified for scarcity, then we’ll know that we are moving in the right direction.

Greenway health did a great job with their recent blog helping practices understand how the CARES Act may impact them. I’m on a number of vendor email lists and Greenway consistently sharesg relevant information without being too salesy. This particular piece included brief descriptions of the different types of loans and funds available to practices. It may help a practice who don’t know their options for weathering this storm.

If you’re on the team maintains your facility’s charge master or load contracts, make sure you’re keeping up with all the changes CMS is throwing your way. Today’s update was an increase in the payment Medicare is making for certain high-volume coronavirus lab tests. This payment of $100 covers “COVID-19 clinical diagnostic lab tests making use of high-throughput technologies developed by the private sector that allow for increased testing capacity, faster results, and more efficient means of combating the spread of the virus.” High-throughput systems are defined as those that can process more than 200 specimens in a day. Medicare will also be paying new specimen collection fees for homebound patients and those who can’t travel, like nursing home patients.

Road warriors of the US, rejoice. DoubleTree by Hilton has released the official bake-at-home recipe for their signature chocolate chip cookies. As a consultant who has opted to drive an extra hour each day from my hotel to the client site so that (a) I didn’t have to stay somewhere sketchy, and (b) I could have these cookies waiting for me, I am thrilled. I haven’t made them yet, but I am intrigued by the inclusion of lemon juice in the recipe. Apparently more than 30 million cookies are baked every year, and the cookie was the first food to be baked in orbit on the International Space Station a few months ago. It took two full hours for the cookie to bake in microgravity, although the experiment log documented the smell of cookies at 75 minutes. The official DoubleTree statement says, “A warm chocolate chip cookie can’t solve everything, but it can bring a moment of comfort and happiness.”

I bake an inordinate amount of cookies every year with my dad, so I couldn’t agree more. (The picture above is just a fraction of our 2019 effort). My local market is finally back in stock with flour, so these are on the schedule for the weekend.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/13/20

Despite my clinical employer’s failure to get on board with telehealth, many organizations are embracing it. The American Medical Association released a Telehealth Playbook last week. It has a lot of good information for people who might not be sure how to approach the process. It’s a bit lengthy at 128 pages, but don’t let that dissuade you, because the last 40 or so pages are worksheets.

The AMA did a good job gathering information from people who have figured this out in the past, when they weren’t in a rush as people are now. Situations are a little different when you are trying to ramp something up quickly or are using solutions that are unproven, though. Your mileage may vary to some degree, depending on how nimble your organization is and what your tolerance is for just getting something live without achieving perfection.

Not all organizations have done well with trying to manage patients remotely or making sure that the needs of patients with chronic issues are met. I have heard from multiple friends and neighbors who have visits scheduled during the next two weeks (while our state is still under a stay-at-home order) and they have received zero communication from their physicians on whether the visits will happen or how they might be executed. I’m sure some of them might be waiting to see how things unfold since they seem to change from day to day, but especially given the availability of patient portals and texting solutions to communicate with patients, it’s surprising that the practices are running silent.

There’s also an error component as practices shift visits. I have already had one pharmacy error when my primary physician canceled my annual visit. They usually send a year’s worth of refills to Express Scripts when I appear in person. This time they sent an order for a 90-day supply to tide me over until I have a visit, and Express Scripts promptly misprocessed it and sent me 30 pills. Four phone calls later, I still don’t have what I need. Fortunately I’m a bit of a pharmacy hoarder and always stay a month ahead on my refills, and it’s not something that will cause grave harm if I miss it for a few days, but I’m sure patients in those situations are experiencing similar confusion and delay.

The AMA playbook divides the process of implementing telehealth into 12 steps, with the first six being planning. Those steps typically include needs analysis, building a team, defining success, evaluating vendors, gaining buy-in, and contracting. In many organizations, these steps can take 12-18 months, and practices are now trying to do it in a matter of weeks (if not days). The playbook includes a concise “Warmup” section that talks about telehealth and provides some basic definitions, helping people understand synchronous versus asynchronous technologies and how they might benefit organizations. It glosses over some of the barriers to telehealth, though, listing them but not really explaining how much of a showstopper they can be for organizations.

Licensure issues are big, especially for organizations that are on state borders and see patients from multiple states. Although there has been some relaxation of interstate licensure during the COVID crisis, some states have their own regulations around it, where others are a bit more of a free-for-all. Even the big telehealth companies have handled temporary licensure waivers differently. One is requiring physicians to opt in to see patients in states where they are not licensed, while another is just assuming that its providers want to see patients from all states where there are waivers. Some of the waivers are already expiring, causing dramatic shifts in how many patient visits are available for physicians to staff.

Privacy and security issues are also paramount, especially given the recent federal relaxation in the level of security needed for billable visits. Providers can use commercial platforms that weren’t specifically designed for patient care, which may increase access, but also increase the risk of exploitation. Another concern is whether telehealth visits can deliver the same level of care as in-person visits with the same outcomes. Having worked for a telehealth organization that has a strong quality program, and where the antibiotic metrics are higher quality than those I saw in my brick and mortar practice, I have to say it’s more about the organization and its culture than it is about the delivery platform.

Funding a telehealth program is also a big issue. The playbook puts it squarely back on the practice to figure out, although it does define a few examples. Organizations will have to work with their payers to understand how visits might be covered and how they might impact other aspects or practice, including Accountable Care Organization cost and quality attribution. The document makes it clear that practices that go down this road will need to have dedicated resources to stay up to date on the constantly shifting landscape with payers, rules, and regulations.

Several of the steps they identify are being largely skipped over as organizations race to get telehealth solutions live. Some of them include getting feedback from staff on pain points and figuring out how different telehealth solutions might solve those issues, along with evaluating the organization’s readiness for telehealth solutions. It’s clear that whether organizations are ready or not, here it comes, so that definitely shifts the dynamic. Budgeting and identification of funding sources are also being skipped as organizations view telehealth as a way to try to preserve care delivery (and financial margins) versus just closing to patient traffic in the face of an outbreak.

Other pieces that are being skipped over include gaining stakeholder buy-in and identifying success metrics. From a vendor analysis perspective, it seems like many organizations are trying to go with solutions that might be already integrated with their EHR or otherwise using commercial solutions. There are multiple third parties that are offering no-risk or low-cost agreements for 90 days during the crisis, so that’s a good thing for practices who might just want a quick solution without significant commitment.

It’s a risk for vendors to take this approach, but if they have a solid offering and treat their clients well, it’s a great way to prove their capabilities. The contracting piece of the document made some great points about ensuring that clients understand who is going to have access to their patients’ data and ensuring scalability.

Steps 7-12 fall into the “Game Time” portion of the document. Some of these steps — like workflow design, prepping the team, and partnering with the patient — are being done in a matter of days in real life. Many of my colleagues are embracing telehealth. It will be difficult to convince them that they need to return to face-to-face visits for many of the issues they are treating. Patients are also happy with the convenience factor, so I don’t see it going away any time soon.

I’d be interested to hear from people who have rapidly executed a telehealth strategy. What worked and what didn’t? Are patients accepting it? Have you had claims come back and are there issues, or are you still waiting for the other shoe to drop? What would you warn someone who is farther back in the process? Leave a comment or email me.

Email Dr. Jayne.