Curbside Consult with Dr. Jayne 9/28/20

Just when you can’t think 2020 can get any weirder, here comes the story of a copperhead snake that made an appearance during a patient’s televisit.

Every week it seems like there’s something more bizarre going on than there was in the previous week, and that’s really saying something when you’re in the 39th week of the year.

I’ve had another couple of surreal clinical shifts, to the point where I can’t even talk about them. Some of the issues are just medically complex and are nearly impossible to blind for HIPAA purposes. Others have been so traumatic for the care team that I don’t want to relive them in any way, shape, or form.

In that context, I was glad to have a low-key informatics weekend. I spent a good part of it being on call for an upgrade, playing the role of the “IT person who just happens to be a physician.” They wanted someone to be on call to do additional testing of any clinical issues that cropped up during the upgrade, as well as to test any hotfixes that had to be done on the fly.

Fortunately, my client is a solid organization that understands the value of a well-planned upgrade. They’ve been tweaking and enhancing their test scripts over the years to the point where they are super solid. We only had one small issue that turned up early Saturday morning, and fortunately, it was with a new feature that we just turned off while waiting to troubleshoot with the vendor on Monday morning. It was certainly different from the white-knuckled adventures that I had with my IT team in my early days as a CMIO.

The rest of the weekend was spent on various consulting projects. One was to help a startup company with their messaging, which I always find to be fun work. Sometimes the smart folks behind a great tech idea don’t fully understand how to translate their solution into the language their target audience is looking for. I did some proofing for a redesigned web site and editing of a potential case study. The most fun part of the messaging work was working with a couple of sales reps to help them hone the delivery of their pitches. Sometimes being able to correctly pronounce medical words is the difference between building credibility and being shown the door, so I hope I made a difference in how those individuals will be able to convey their message going forward.

Another project involved designing order sets for a mid-sized medical group, which has spent a lot of time trying to do the work without much success. The physicians struggle to agree on anything, and the IT team is trying to distill hundreds of different physician-specific order sets down to something manageable. The project was originated by the quality department, who was tired of trying to promote various quality interventions when physicians would just refuse to use the global set and use their own instead.

Essentially, I had to export all the order sets and compare them by specialty and by location, identifying the commonalities and analyzing data about their use. The physicians had agreed to get on board with a data-driven approach. When I’m done, we’ll have a real understanding of which order sets are used and which parts of order sets are manually altered. They actually allocated ample time to mine the data and achieve physician buy-in, so I’m fairly confident the project will be successful when it goes live in a couple of months.

I also started working on a new medico-legal project, which was at times exciting, but overall made me sad. If there’s anyone in a healthcare IT organization who believes they can take actions within an EHR and not get caught, they really should think twice. Sifting through hundreds of pages of audit trails isn’t what I enjoy doing on a beautiful fall day, but it’s important to my client to understand the havoc that their employee created. I’ve identified the impacted patients (which fortunately isn’t that extensive of a list) and the next step is to audit the individual charts to see whether the employee modified any of the data, and if so, what they modified. I also need to see what kinds of data was specifically visible and whether any of it falls into the sensitive category.

Stories like this are a good reminder for organizations to check their security settings and to make sure employees only have the minimum access necessary to complete their work. It’s not just “a HIPAA thing,” but it’s a major integrity issue when you have to notify patients that someone was caught snooping through their charts.

I’m getting things caught up and organized since I’ll be out of office for part of next week, this time taking a much-needed mental health break. From a clinical standpoint, I know there are a lot of us that have hit the breaking point and I can tell I’m approaching mine if I’m not already there. It’s time for three days in the desert to sort things out while trying not to think of COVID (although I’m sure it will be front of mind on the flights there and also on the way home).

My favorite desert escape is closed through at least 2021, so we’ll have to see whether VRBO can deliver. Regardless of the accommodations, I’m looking forward to lots of sun and fresh air with no mosquitoes or ticks involved. My traveling companion already sent a list of the cocktail supplies she’ll be bringing with her, so it’s looking to be a good getaway even if we have to shake our own martinis since we’re physicians who will be self-isolating. I’ve packed three good books to get me across the time zones and back with some reading material in the middle. One is serious, one is a book club pick, and one is the pure unadulterated madness that only comes from Carl Hiaasen.

What strategies have you used to refresh and recharge during 2020? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/24/20

An article published last week demonstrates the ability for health systems to save money though implementation of clinical decision support (CDS) tools within their EHRs. One major outcome was the ability of CDS tools to help reduce waste by reducing unnecessary laboratory tests and antibiotic prescriptions. Researchers also noted issues with CDS systems, including maintenance costs and malfunctions that could have an adverse impact on bending the cost curve.

The authors “could not draw a sound correlation between vendor-purchased or home-grown systems’ costs to their economic benefit,” however. I would go further to state the need to look at the middle choice in that continuum as well: the heavily-customized vendor system, which sometimes is closer to homegrown than not.

Further studies are needed, and one of the elements that should be included is the impact of alerts on clinicians and the time they spend managing those alerts. They also need to assess the impact on extensive computerized physician order entry (CPOE) order sets that may add orders to a patient’s record when those orders aren’t entirely necessary. There’s always a balance between the technology, the needs of the patient, the needs of the care team, and the bottom line. A well-configured EHR can make your day go well, but a poorly-managed one will be your worst enemy.

On days that I see numbers of patients that would have been considered impossible before COVID, I’m truly grateful that my organization has stripped the EHR down to only the bare essentials that are needed to document quickly, without any extraneous content. The downside to that approach is that sometimes I find myself in a situation where I wish I had a fighter jet, but I’m piloting a Stearman. I’d love to see the vendors that are bragging about their ability to create documentation through voice recognition and artificial intelligence spend a day in my well-worn shoes. I’m sure what they see would be shocking, but we can’t solve problems that we don’t understand.

The US Food and Drug Administration is launching a Digital Health Center of Excellence within the Center for Devices and Radiological Health. Digital health technology within its purview includes mobile health services, wearables being used as medical devices, Software as a Medical Device (SaMD), and technologies used to study medical products. The FDA plans to create a network of digital health experts and to get technology to patients faster by providing technological advice, coordinating work being done across the FDA, advancing best practices, and reimagining the oversight of digital health devices.

I almost missed this one in my overflowing inbox, but apparently a new national system is being developed to track administration of the COVD-19 vaccine. Millions of people who are used to walking into a retail clinic or their local Costco and walking out with an influenza vaccine are going to be surprised by the complexity of the new coronavirus vaccine. Patients must receive two doses and the products are not interchangeable between manufacturers.

Public health officials are justifiably concerned that this new system will bypass existing state immunization registries, while watchdogs are concerned about its $16 million cost. Consulting giant Deloitte has been engaged to develop the Vaccine Administration Management System, which will use underlying Salesforce technology. It’s apparently been piloted in four states over the summer, but details are scant on what data fields are required or when states will be able to obtain access to test versions.

We’re all familiar with the COVID-related hospitalization data debacle from earlier this year, and it looks like we’re teeing up another not-so-successful deployment. Without appropriate user acceptance testing or the involvement of actual stakeholders in the field, software projects usually fail. I’ve seen this enough as a clinical informaticist and it baffles me that in such a critical moment we’re making so many systemic mistakes. Not surprisingly, patient matching is a concern in this effort. Who’s wishing we had a national patient identifier now?

I’m practicing in a community in a surge situation, where we have been featured on several “worst places for COVID” lists. It’s not an enviable position. I’m continually challenged by patients who are wearing what are essentially “non-masks” rather than accepting one of the medical masks that we offer at the front desk. Today I saw a family for COVID testing and every single one of them was wearing a bandana. When offered medical masks by my staff, the parent declined, stating that they were only wearing the bandanas to humor our request for masks, and they refuse to wear a medical mask because they cause lung disease. Unfortunately, we’re not allowed to deny service to non-maskers.

Trying to educate around those beliefs is a losing battle, and since they were there for COVID testing, I certainly didn’t want to spend a minute longer in the room than I had to. If masks are deadly, how are any operating room nurses or surgeons still standing? Why haven’t the attorneys come calling? Kudos to Dove for its “Courage is Beautiful” video that shows what we really look like under our masks. Even though many people across the US have moved back to their normal lives, our lives (and our faces) will never be the same again.

Just when you think you’ve reached the pit of despair, you’re sometimes surprised. When a pediatric patient started crying about having a COVID test, my scribe offered to show her how it was done, and literally took off his mask and swabbed himself right there. Her eyes were wide and so were mine, and the patient went along after seeing how easy it was. I’ve never seen someone perform a nasopharyngeal swab on himself, let alone do it blind, so I was impressed. We did, of course, have a conversation about how he probably shouldn’t do that again since he was unmasked and the patient / family had no way of knowing that he recently recovered from COVID and is considered noninfectious at the moment, but it was a touching gesture.

For those of you in the clinical trenches, what has been your wildest moment during COVID? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/21/20

I’ve given up trying to count the number of healthcare organizations I’ve worked with during the last several years. Each one has had its unique challenges and fun memories.

From an organizational standpoint, though, if you’ve seen one care delivery process, you’ve seen one care delivery process. They are different. Although many things are common, each organization has different issues, and that makes healthcare IT work challenging.

Sometimes it’s a regional variation in care delivery. Hospitals on the East and West Coasts tend to be closer to the cutting edge than do some of my rural clients. Looking at a different aspect, some of my rural clients deliver amazingly coordinated care because the team is personally invested in the patients through their community connections.

I work with some organizations that are part of religious ministries, where their affiliation directly impacts the care they deliver and what can be featured in the EHR. For example, I worked with one large health system that had a contractual agreement with its patient education vendor that no family planning information could be featured in any of the monographs. Religious restriction of EHR content can be tricky when working with patient populations where sex, gender, sexual orientation, and other sensitive factors must be documented in order for the clinical team to deliver culturally competent care.

One of the issues that I’ve run across with increasing frequency is the disparity in various healthcare IT systems with regard to management of the data points around sex and gender. Some systems seem to think the terms are interchangeable, which tells me that they probably didn’t have a clinical informaticist involved in the design of their product.

I worked with one vendor that initially had a field for sex, but wanted to add one for gender. Unfortunately, in the upgrade script where the field was added, they just copied the contents of the old field into the new one, creating false assumptions about patients in thousands of practices. Needless to say, one of their clients that works closely with the LGBTQ+ population was less than amused. It took some custom work to revert the content and allow the fields to be populated as patients came in for their next visits.

This issue is often compounded when interfaces are involved. Engineers either don’t understand what the fields are used for downstream or don’t understand the negative impact of mis-mapping these data elements. Major EHR vendors vary in how they handle this information, even though it was required for certification under the 2015 EHR standards.

I still see a lot of customization in the social history portions of client EHRs as they try to meet needs unmet by the base product. Due to some of my past client engagements, I tend to have a little more expertise in this area than the average clinical informaticist, so I was glad to see an article in the Journal of the American Medical Informatics Association that documented “A rapid review of gender, sex, and sexual orientation documentation in electronic health records.”

The authors looked specifically at literature in peer-reviewed journals and identified 35 core articles that involved gender, sex, sexual orientation, and electronic health / medical records. They note that although certified EHRs must provide for documentation of sexual orientation and gender identity, users of those systems are not required to document the data. In my experience, going beyond the historical documentation of birth sex is confusing to many people, and organizations that are strapped for time and cash aren’t likely to focus educational funding on a minority group, even if they are known to be marginalized.

The core articles identified specific needs for data collection that play directly into hot technology areas, including personalized medicine. Having accurate data is important when you’re looking at therapies that may target the patient based on the genetics of their birth sex as opposed to what an observer might infer from the patient’s outward appearance. The authors give examples of why terminology is critically important, and include a table defining various terms (including birth sex, legal sex, gender, administrative gender, gender identity, and gender expression). I thought it was well done and bookmarked it as a reference for future client engagements.

The authors also provide some illustrative cases that can help in understanding why these data elements are so important in the healthcare community. Patients want to be cared for by organizations that understand their needs and meet then where they are. Their records are best managed in systems that can reflect clinical scenarios, such as a transgender man who needs breast and cervical cancer screenings. Patients may also want to opt out of providing these data elements if they don’t feel comfortable sharing that information, which may require a field to be documented as “not provided” or something similar.

I had a patient recently who walked out of a chain pharmacy, where she had gone to get a flu shot, because they asked about her sexual orientation. She felt it was none of their business because she was just there for a vaccination. In discussing her concerns, it never occurred to her that what she perceived as just a pharmacy also provides limited primary care services, where the question would have more relevance. She never thought about the fact that they were trying to be comprehensive rather than invasive, and I could tell she was really thinking about her own reaction to the question.

The article notes a couple of organizations that have been successful in managing this data, and one might not be the first one you think of. It’s not a progressive academic center or specialty center, but the US Department of Veterans Affairs. The VA took several steps, including creating a patient safety education work group, to address inconsistencies with sex-based EHR rules. The VA then developed informational sheets for patients and staff to help them understand the use of various fields in the EHR and provided training on how to have conversations with patients regarding these data elements.

This area of EHR work may seem like a small niche, but if it impacts you as a patient, it’s tremendously important. It’s an example of the challenges that makes CMIO work exciting, because you know that when you help solve these problems, it can really make a difference for the patients involved. As caregivers, we want to do the best by our patients and it’s helpful if the systems we use support us in those efforts. For those of us doing work in lesser-known realms of clinical informatics, it’s nice to see an article that lets us know we’re not alone.

Has your organization tackled the management of gender, sex, and sexual orientation documentation in the EHR? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/17/20

The Office of the National Coordinator for Health Information Technology, in partnership with the Office for Civil Rights, released an update on Wednesday for the HHS Security Risk Assessment (SRA) Tool. Performing the SRA is required under HIPAA, and in my experience, many small and medium sized healthcare organizations struggle with it. The revised tool includes some user interface and navigation tweaks, as well as options to export reports. There was a corresponding webinar to educate users on the tool, but since I received less than 48 hours notice, I couldn’t make it work with my schedule.

I’ve not been a fan of the tool in the past since it is really just an electronic way to store a lot of manual work. People like it because it’s free, though, although I’ve found you get what you pay for. ONC’s SRA Tool stores data locally, which creates problems when the person responsible for your SRA goes out on medical leave or is otherwise unavailable (ask me how I know). Commercial solutions that are available store data either with the SRA vendor or otherwise in the cloud, making it easier for continuity from year to year as well as making it easier to recover if something unforeseen should happen partway through the SRA process. My favorite commercial solution is the one from HIPAA One, which is kind of like TurboTax for the SRA.

For those of you in the value-based care trenches, the Core Quality Measures Collaborative has released four updated core measure sets. The updates are the product of collaboration among more than 70 members of the group. The impacted sets include pediatrics; obstetrics / gynecology; gastroenterology; and HIV / hepatitis C. Core measure sets are used to help align various payer and governmental programs, which theoretically should help healthcare delivery organizations meet goals consistently and not have to do different data gathering and manipulation for similar but subtly different measure sets. An additional four core measure sets will be updated in the coming months, including medical oncology; orthopedics; cardiology; and one addressing primary care / patient-centered medical homes / accountable care organizations. There are also plans to release two new core measure sets covering behavioral health and neurology.

A recent Viewpoint piece in the Journal of the American Medical Association looks at the idea of “Algorithmic Stewardship” for artificial intelligence and machine learning technologies. At least 50 AI/ML algorithms have been reviewed by the US Food and Drug Administration and have received approval for various medical use cases. They can also be used to predict patient behavior or identify risks for increased morbidity and/or mortality. The authors propose that in addition to the FDA’s oversight process, health systems should also “develop oversight frameworks to ensure that algorithms are used safely, effectively, and fairly.”

The stewards would be charged with ensuring predictive algorithms are used fairly and should receive input from informaticists, patients, bioethicists, scientists, and safety / regulatory personnel. They would also be tasked with monitoring the ongoing clinical use and performance of predictive algorithms. I’d be curious to hear which organizations at the forefront of AI and machine learning have begun to incorporate such a stewardship model.

I’ve seen more than my share of poorly-maintained patient problem lists over the years. One of the goals of electronic health records was that problem lists would be more accurate and complete, and we just haven’t arrived yet. An article published in the Journal of the American Medical Informatics Association this summer looks further at “Characterizing outpatient problem list completeness and duplications in the electronic health record.” The authors looked at records from Partners HealthCare and identified patients with eight common chronic diseases, then reviewed those problem lists. They found a wide variation in levels of completeness as well as levels of duplications. Better completeness seemed to correlate with disease severity. The authors conclude that “further studies are needed to investigate the effect of individual user behaviors and organizational policies on problem list utilization, which will aid the development of interventions that improve the utility of problem lists.”

My very first EHR consulting project, somewhere in the early 2000s, revolved around a problem list. The organization had initially deployed EHR only to primary care physicians, and when subspecialists were brought on board, some of them “cleaned up” patient problem lists by removing entries that they felt were “primary care stuff” that cluttered up their idea of the problem list. Due to poor training (or lack of listening), they didn’t understand the concept of a shared problem list. I had the pleasure of going through thousands of charts and trying to rectify the mess, returning those pesky primary care problems to life. Nearly two decades later, the issues I see are still rooted in governance (or lack thereof). We should know better by now, folks.

I spent some quality time with a new optometrist this week and was blown away by the new contact lenses she suggested. Fortunately, the dramatic change in my vision was due to being a year older rather than anything COVID-related, which made me happy. I was not, however, blown away by the text I received later in the day pre-booking me for an appointment next year, at an inconvenient time on an inconvenient day. There was no way to respond or reschedule via text, which forced me to call, hold within the office phone tree for more than five minutes, than reschedule. This is a perfect example of a good idea that was poorly executed. I know the importance of patient retention and continuity and would have been happy to schedule an annual follow-up before I left, but their approach was inconvenient. I wonder how many patients just no-show the following year?

I also had a dental checkup, and while I was impressed with their in-office screening protocols, I was not impressed by their phone screener. When I truthfully answered “yes” to the “have you had contact in the last 14 days with anyone who has COVID” and noted that I’m a physician and have been wearing personal protective equipment during the contacts, he somehow assumed that I had tested positive for COVID in the past. I was recently flagged in Epic by another physician office as a “high risk contact” and it took a lot of explaining to get it handled. There really needs to be an accommodation for healthcare workers who have positive contacts but are wearing PPE. It’s no fun having your friends treat you like you’re Typhoid Mary, and other healthcare institutions should have a better understanding of and appreciation for our collective efforts.

Have you been denied service or treated differently during the pandemic because you work in healthcare? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/14/20

Over the last decade, I’ve spent a good chunk of my professional time on the road, sometimes for weeks at a time. I’ve also done the “five cities in three days” shuffle, which isn’t my favorite but can be a fun challenge. I haven’t been on a plane since March 3^rd of this year, which seems strange when you’re used to traveling all the time. I had over a dozen trips booked when COVID reared its ugly head, and until this week wasn’t sure when I’d fly again. COVID or not, I was called back into duty this week and traveled to help a friend in need. Now that I’ve dipped my toe in the travel waters, I’ll share what I learned for any healthcare IT road warriors who might be called back into service.

I’ll admit that as I got ready, I had forgotten some of my travel routines. I had to make a point of going through all of my things to make sure I had what I needed. Since I rarely go anywhere but work, I rarely have more than $20 in my wallet, so I had to restock that. I also had to find my airport parking card, which luckily was in the coffee mug on the kitchen counter where I left it, along with some random gift cards that I’m not sure I’ll ever use. I also realized I didn’t remember how to use my iPod, which was pretty embarrassing, although I did figure it out before I had to visit the Apple support website. (Yes, I still use an iPod for music, because I don’t want to drain my phone battery, and it fits in a shirt pocket on the plane so it’s one less thing to have in your hands.)

The parking shuttle had seats clearly marked with bright yellow “don’t sit here” signs, and the other folks on the bus with me were playing along. However, I failed to notice the sign on the parking garage’s lobby that said I’d have to call for a pickup when I arrived back, which came to haunt me later. Now I know, but it seems like they should have had that signage on the bus and not just on the building. The garage has eliminated valet parking and I’d estimate that less than 10% of spaces were in use.

The terminal lobby was fairly busy, with security looking pretty “normal” for the time of day I was traveling, although the TSA Precheck line was empty. The whole Precheck process at my departure airport was unchanged, except for the TSA agent making me lower my mask briefly while she checked my ID. I’m glad I didn’t have my N95 on at the time because that would have been a production. They did have a hand sanitizer dispenser at the end of the security screening area where people organize their things, but there was a group of people standing in front of it, which wasn’t ideal. Fortunately, I had three different kinds in my bag, so a quick spritz and I was on my way.

The volumes are low enough at my airport that Southwest Airlines was only using every other gate, and they had a funny stream of rotating messages at the empty ones. That allowed travelers to spread out in the gate areas, which were the only places to sit because the seating areas at the takeout restaurants had been removed in favor of stickers on the floor for people to stand in line. Only one of the bar/restaurants was open and it had reduced seating. Less than half of the newsstand/snack places were open, which led to some lines that were not very socially distanced, and only one of two Starbucks locations was open. Bottom line, if you’re going to travel, you should bring your own snacks just in case.

There seemed to be a lot of families traveling (even a few groups with shirts and accessories that marked them as obviously Disney-bound) along with a sports team, which was kind of surprising. I saw very few solo travelers, which tells me there weren’t a lot of business types, unless they were taking their family in tow. Very few people had roller bags or hand luggage, which was a change from what I usually see.

I did notice that the Benefit makeup kiosk had been replaced by one selling personal hygiene products including hand sanitizer, antibacterial wipes, and masks. Speaking of masks, I saw entirely too many adults with masks off, most were eating and drinking coffee but were unmasked for an extended period of time. I saw no children with bad mask habits, and even the teenagers were doing pretty well. The boarding process was good with Southwest only boarding 10 people at a time and only on one side of their usual line-up area, so we were well-spaced. They are still serving snacks and water, but nothing else, and the seat back pockets are empty except for the safety information cards. Southwest is only booking 2/3 of the flight so that middle seats can remain open, and I had the emergency exit row to myself.

I landed at Dallas Love Field and was the only person on the rental car shuttle, and it took me a minute to realize that the shuttles had been combined for National, Enterprise, and Alamo, and that all three vendors were operating out of the same building. There were exactly three available cars on the giant (but empty) lot and with two of them I could smell smoke through my mask, so those were a big nope. The traffic on the Dallas North Tollway was every bit as wild as it usually is, so at least there was a small bit of the trip that was consistent with the “old normal.”

When it was time to head home, I was screened at the rental car drop off and asked if I or anyone I had been in contact with on the trip had been tested for COVID or had a positive result return. I wonder how many people actually say yes to that? Since I was on the ground for less than eight hours, it was a resounding no for me. The rental shuttle back to the terminal was also serving as a shuttle for airport staff, who weren’t great about masking until they actually stepped onto the bus. The shuttle was packed, which wasn’t great.

Security at Love Field was nearly empty for my return trip, although I did have one of the last flights of the day scheduled. The DAL TSA procedure was a little different, with the TSA agents in glass booths with louvered speaking openings (kind of like a movie theater ticket booth). They wanted the passenger to put their boarding pass on the scanner but wanted to personally handle the ID, which was different from my earlier flight. Also, all the TSA agents working the scanners and x-ray machines were wearing face shields.

I did see a few passengers with face shields in Dallas, and the mask wearing there was pretty solid. The terminal at Love Field was much busier than the one at home, and the food court was fully open although seating was reduced by about half. Many of the newsstands and carry outs were closed, including my favorite gelato one, but fortunately I still had trail mix. My flight was delayed by a medical issue on the incoming plane, which the folks from Dallas Fire and Rescue handled quickly. The flight only had 50 ticketed passengers on a plane that seats somewhere near 170, and they actually made people space out for weight and balance. Only two of six emergency rows had people in them, so once again I had all the legroom. Only about one passenger in five had luggage for the overhead bin.

Deplaning was another issue entirely, as people raced up the aisle as soon as the seatbelt sign turned off, crowding up in the front of the plane. It was easy to avoid by staying in my seat, and the flight attendants were pretty aggravated and made people back up right away. All services in the airport were closed by the time we arrived, and then my failure to notice the “call for pickup” sign at the parking garage bit me. It was a decent night to sit outside and wait for one to come, which fortunately happened sooner than later.

Knowing that I traveled, lots of people have asked whether I thought it was safe and whether I’d do it again. I was very comfortable with the spacing on the plane, but I know other airlines aren’t doing it as reliably as Southwest. In deciding to make this trip it was a calculated risk, and given the circumstances was worth making. I’m not sure I’d be as crazy about leisure travel though or having to do it under more crowded conditions. I’m scheduled for another flight next month, so we’ll have to see what things look like then.

Have you done any business travel recently? What did you think? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/10/20

My organization uses a scheduling app to manage the work arrangements of our 500+ employees. We switched to it a couple of years ago, moving from one that we were starting to outgrow. The hope was that the new one would have more robust features, but in some ways, it was a step backwards because it didn’t have a mobile app at the time of the switch. They promised it would be available in a couple of months, but in reality it took almost a year to deliver.

When I logged in after the Labor Day holiday, I discovered that they had re-skinned the platform. My easily usable and well-ordered list was now represented as tiled buttons across the middle of the screen, forcing my eyes to track all the way across rather than just parsing down a list as I was used to. The vendor included a page on the re-skinning, bragging on their “fresh fonts” and removal of wasted space, although at least for my access level, the amount of white space is unchanged. Hopefully there are some big wins for the people preparing the schedules behind the scenes, but for the majority of us, it was unremarkable.

We’re in the middle of re-credentialing with some of our payers, and I’m shocked at how manual the process is. All the providers have to print, sign, and scan documents as part of the process. I threw a flag on one payer’s play because the document I was asked to sign said I consented to be bound by their Provider Participation Agreement and their Provider Administrative Manual as viewed on a portal I don’t have access to. When I pushed back on our in-house credentialing folks about wanting copies of the documents I was agreeing to, I received a phone call about ‘being difficult.’ Apparently, the majority of my physician colleagues signed it without reading all the terms, which is somewhat concerning. When I finally received the documents 10 days later, there were over 100 pages to read. There’s no mechanism for electronic signature on these either, so I didn’t bother to ask about that. Since I have to print and scan, they can wait a little longer.

CMS will close the comment period for the 2021 Proposed Rule for the Quality Payment Program at 5 p.m. ET on October 5. Due to the pandemic, CMS is focusing primarily on “essential policies including Medicare payment to providers.” Key elements include: an increase in the complex patient bonus; postponing implementation of the MIPS Value Pathways until 2022; and removing the CMS Web Interface as collection and submission types for reporting MIPS quality measures beginning with the 2021 reporting period. Comments can be submitted via Regulations.gov as well as through snail mail or overnight mail.

The American Medical Association announced new CPT codes this week, with one intended to help practices charge for the added supply and staff cost generated by operating in the COVID world:

99072 Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease.

Don’t get too excited about billing for them just yet. At the same time as they created it, AMA also sent recommendations to the Centers for Medicare and Medicaid Services recommending coverage for them. It will take time for them to be approved by payers, and I suspect that some will try to bundle this code with other services and not pay it, despite its intent. Either way, it only works when we are subject to a declared public health emergency due to respiratory illness, so we’ll have to see how many people actually receive money by billing it. We’ll also see how long it takes EHR vendors to get the code loaded in their systems.

A couple of friends of mine scored some kicky socks at the hospital blood drive. An opinion piece in JAMA Internal Medicine this week highlights the continued inability of many gay men to donate blood. Author Greg Zahner, MD summarizes the history of the restrictions on these donations. For younger physicians and healthcare folks who might not have been around in the pre-HIV world and don’t know the history, or for those who want us to have an adequate supply of blood products, it’s an interesting read.

Lots of people have taken up new hobbies during the pandemic, and I admit to some pastry therapy as well as continuing to learn a new musical instrument. A family member double-dog-dared me to sit for the amateur radio licensing exam, which I completed this weekend. The Greater Los Angeles Amateur Radio Group VEC is one of 14 FCC-recognized Volunteer Exam Coordinators. Exams are usually administered in person, but GLAARG has delivered over 1,000 exams via Zoom since April 2020. I have to say the physical arrangements were as intense as some of the high-stakes examinations I’ve taken to further my medical career. Applicants have to be in a room without any potential reference materials and no chance for interruption and are monitored by a panel of three volunteer examiners while they take the online test. There’s nothing quite like welcoming three strangers into your hall bathroom, where you’re sitting with a laptop and a TV table. You have to show the entire room, including floor and ceiling, to make sure there is no contraband.

It was a well-organized process, with applicants first being oriented in a large Zoom waiting room until they were “teleported” to breakout rooms where they went through a pre-check process to ensure good audio and video, and where they made sure all browser extensions were disabled and popups were suspended before being migrated to the actual testing breakout session. Although I had an initial glitch where one of the panel members couldn’t see all of my shared screen, he was quickly replaced by another examiner. The exam went smoothly with instantaneous grading and electronic signatures on the FCC-required documentation. Even with taking the exam during a holiday weekend, the FCC processed my license quickly and I was ready to hit the airwaves on Tuesday morning.

It’s been fun learning something completely new, although there were some exam questions dealing with the effects of radio frequency emissions on the human body as well as those on how to avoid being electrocuted that overlapped with my previous studies. The amateur radio community is a welcoming bunch, and to any of you out there, I send you a hearty “73.”

Did you try new things or pick up a new hobby during the pandemic? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/3/20

It’s been a busy week in the consulting trenches. Several of my clients had projects that they wanted to take live on September 1. I commend them for choosing that as a go-live date because it’s a Tuesday. Far too many people want to do go-lives on Mondays.

I’m usually opposed to Monday go-lives because it’s typically a busy day, whether you’re in the inpatient world or the outpatient world. Patients who have been ill over the weekend are trying to get appointments and complex surgeries are often scheduled earlier in the week to better optimize discharge planning prior to the weekend. I’m also a fan of doing go-lives on Thursdays, because if it’s rocky, you only have two days in the week and then people can rest over the weekend. Even in hospitals, things are slower over the weekend and many services are only offered on an emergency basis.

CMS has released the Fiscal Year 2021 Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) Final Rule. That’s certainly a mouthful, and I’m not sure the abbreviations help. There are several highlights within the Medicare Promoting Interoperability program. Some of these make perfect sense, such as being to use any continuous 90-day period as the EHR reporting period, and keeping the measure that looks at queries of Prescription Drug Monitoring Programs as optional. Others leave me scratching my head, such as “Modifying the name of 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.” I get that they’re trying to better describe what hospitals have to do, but it just adds to the confusion.

The American Medical Association released the 2021 Current Procedural Terminology (CPT) code set this week. There are some major changes involved, with one outlet describing it as the first major overhaul in more than 25 years. The changes coincide with those proposed by the Centers for Medicare & Medicaid Services and are intended, according to AMA, to free physicians from “irrelevant administrative burdens that led to time-wasting note bloat and box checking.” Office-based clinicians will certainly welcome the elimination of specific history and physical exam elements for code determination.

Since AMA owns the rights to the codes, they’re happy to sell you resources to support the transition, including books and videos. If you use an EHR, chances are that the AMA license fee is already baked into what you are paying for maintenance. Personally, I think if Medicare requires use of something it, should be in the public domain, but there’s too much money and lobbying involved to make a change.

ONC has opened a funding opportunity to “measure the use and impacts of health IT among a nationally representative sample of US office-based physicians” as well as to “produce national-level data on interoperability among office-based physicians.” Prospects have until September 11 to apply. The awardee will run a three-year program to gather “insights on the implementation and effects of federal health IT policies as well as identify disparities or unintended consequences resulting from their implementation.” Funding is $290,000 for the first year with additional funds “subject to availability and progress made against the program.” The program starts September 30, 2020, so it looks like ONC is ready to make a quick decision.

New data from the Centers for Disease Control shows that nearly 30% of healthcare workers with COVID-19 were asymptomatic and nearly 70% reported never having been formally diagnosed with COVID. Researchers looked at 13 hospitals across the US, where up to 6% of staff caring for COVID-patients had tested positive themselves. The concern is that those symptom-free staffers may have spread the infection to patients and co-workers. The report concludes that universal masking of healthcare workers is important, as is a coordinated testing program for frontline workers.

I see patients with COVID every time I work. The highest number of positives I’ve seen in a single work day is 20, which is a lot. Fortunately, my time in the room with patients is limited. I’ve been fortunate to have enough N95 masks so that I don’t have to reuse them too many times, and a family friend made me a fantastically lightweight face shield. Still, being constantly exposed is a stressor and I try not to interact with people in person if I don’t have to, although it’s rough. I’ve made a couple of exceptions, but with distancing and masking, and always with transparency about my exposure history.

I’ve also had the benefit of being able to stack my clinical shifts recently, so I work a ton at once but then have longer stretches without face-to-face patient care. Even with my healthcare friends, we debate who has been the most exposed and whether getting together in person would be riskier than anything else we do. I’d like nothing more than to sit and sip a cocktail and decompress with one friend in particular, but I’m not sure how long it will be before we both feel the timing is right.

I had a chance to play the Zoom Happy Hour game with one of my friends this week, which was tons of fun with lots of laughing involved. She’s a total extrovert and it was great to swap stories about the “new normal” in our respective parts of the country. I’ve been making it a point to connect with people who’d I usually see while traveling since my next business trip is probably months off. As a foodie who loves to try new things across the US, sticking close to home has been a challenge. I’ve checked out a bunch of cookbooks from the library, but unsurprisingly, this cocktail edition is my new favorite.

While we’re in the boozy frame of mind, big props to my friends at Medicomp Systems for sending another care package my way. I’m resupplied with N95 masks along with some Medicomp ones, which I really like because they’re adjustable and don’t sag. They also included some high-octane hand sanitizer supplies, including handy bottles for pocket or purse. I was also advised that the large bottle could be used either as a refill or for slamming down during a zoom meeting. Based on some of the calls I’ve had lately, I’m not opposed to it.

Have you made your own homebrew hand sanitizer or are you sticking with Purell? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/31/20

Over the last few years, I’ve done quite a bit of work with healthcare IT startups. There are hundreds of people out there who think they have the next big thing and jump headlong into the journey of trying to make it a reality. It’s a difficult road from having an idea to going live in production, and an even more challenging one taking a product from go-live to profitability. We’ve all seen the startup failures and even those that make it to the big time seem to struggle becoming profitable.

The biggest issue I’ve seen with some of the startups I’ve worked with is that they fail to determine how they’re going to govern themselves and their application. I’m a huge fan of governance, not only because good fences make good neighbors, but because being able to make decisions effectively also helps prevent wasted effort and rework when it turns out something was built that doesn’t make sense.

There are numerous governance questions that need to be addressed. First, there are issues about how the organization will be formed. Is it a partnership, a limited liability company, or something else? Does everyone have an equal share in the profits and liabilities? Is the company based somewhere with favorable laws? I was recently approached by a startup that had no corporate structure. While I’m comfortable contracting with individuals, I wasn’t comfortable having one partner hire me to fix what sounded like a problem with one of the other partners.

Next, there are issues around contracting and spending money. Who has signatory authority for contracts? Who has the ability to spend money? Can everyone spend money up to a certain threshold, but do expenditures above a certain point require a greater decision-making authority? What kinds of expenses qualify as business expenses? Do various functions have budgets and are expenditures regularly reviewed to ensure things are not getting out of hand? Are the appropriate checks and balances in place?

There are certainly more “business-y” things that have to be done when you’re contemplating a startup, but operational and product governance also needs to be in place if an effort is going to be successful. On the operational side, is there a mission and a vision for the company? Do the involved parties have a common understanding of what they are trying to build and sell? Or are there simmering disagreements about whether the effort is more technology-based or service-focused, or a bit of both? Who is the target audience, and does the group understand their needs? I’ve seen plenty of great ideas fall flat because no one involved in the visioning process understands the target audience, or even the target industry. Cue the music for all the big tech companies that thought they could “do healthcare” and exited after spending a lot of money and not accomplishing much.

There also needs to be some level of product governance figured out before the first line of code is even written. Who makes decisions on what the product is going to do? In a startup, people may wear multiple hats, but who owns the functions of product management, clinical oversight, development/dev ops, testing, marketing, and sales? If there are competing priorities, how will decisions be made? Who determines minimum viable product? Who will represent the voice of the customer? Who will keep up with regulations, if applicable? I once worked in a startup that had a brilliant development mind who didn’t play well with others. He’d stay up all night writing code, without running anything past the clinical advisors (and often without running it past others who were writing conflicting features). When his ideas were shot down, not only did we have to untangle the content from the application, but it took days and sometimes weeks to get him back to his happy place where he could be productive again.

Another sticking point I see people get in trouble with is the management of contractual requirements for customers or prospects. This goes back to the mission and vision part. If a client or prospect asks for a feature to be built as part of a contractual requirement, who makes the decision? Is it more important to land the customer, even if it means delaying other planned features or moving away from the product’s comfort zone? If a contractual requirement is agreed upon, does the agreement contain enough detail to make the feature a reality, or will there be room for the client to claim that it wasn’t properly delivered because the contract was vague? I see a lot of startups that try to be everything to everyone and move well outside their comfort zone and often into the danger zone because they lack governance.

One of the most important things that startups need to develop is the ability to say no. Sometimes a prospect just isn’t a good fit or has needs that are beyond where the company is in its development. It can be more important to walk away from a deal rather than saddle the team with an unwinnable situation, or unreasonable product demands. I recently worked with a group that had a truly cool offering that was just coming into its own when COVID hit. A large health system approached them about modifying it a little and trying to scale it up to fill a COVID-related need. Fortunately, the managing partners said no, because trying to get the health system live would have been a huge distraction from all their other priorities for the year. Although some argued that it was a missed opportunity, the reality is that saying no gave the company additional opportunities to be true to their core mission and their existing clients.

Seeing a cool idea become reality is incredibly exhilarating. It’s also exhausting, and I’ve seen it weigh heavily on individuals, their families, and their careers. Playing in that part of the industry isn’t for the faint of heart, although it’s a relatively great place if you’re an adrenaline junkie or if you enjoy staying awake at night sweating all kinds of things which might go wrong. It’s fun to wake up wondering what adventures each new day might bring, but it’s even more fun when you get to do it within the confines of a leadership team that’s done the legwork needed to increase the odds for success.

What’s your best (or worst) startup story? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/27/20

Telemedicine provider Avera ECARE creates the American Board of Telehealth, positioning it as a national body to develop best practices and standards for telehealth education. The new board plans to focus on telehealth quality and education across the scope of individuals involved in telehealth, from administrators to physicians and everywhere in between. The ABT’s advisory board includes leadership from industry players such as Amwell and the American Telemedicine Association (ATA), along with a couple of academic faculty.

Avera received a $4.3 million grant from the Leona M. and Harry B. Helmsley Charitable Trust last year, which funded a telehealth education center along with a certificate program. The new ABT program will launch online September 7 with a CORE (Clinical, Operational, Regulatory, and Ethics) Concepts in Telehealth Certificate Program. Validated guidelines will be supplied through the Harvard medical Physician Faculty Group and the curriculum will be delivered using seven online modules. I’ve been underwhelmed by previous educational opportunities from the ATA and telehealth vendors, so my curiosity sent me to check out the website. There’s a $400 fee for the program and it sounds like they will mail you a handsome certificate, since they note that there is a $150 fee for a replacement.

My wacky clinical story of the week comes courtesy of our broken healthcare system, because if it was functional, the visit would never have happened. A patient presented to a direct-to-consumer telehealth service after seeing her primary care physician, who referred her to a subspecialist, who recommended a course of treatment that the patient didn’t feel was working. She was unable to reach the subspecialist due to limited office hours, so she called telehealth for a “second opinion.” It never occurred to her to reach back out to her primary physician to further discuss it. She ended up on the phone with an emergency medicine physician who wasn’t able to assist due to both limitations of knowledge and the constraints of his scope of service. Operations people take note: technology is not the answer here (but it can help).

Doing what I do for HIStalk is a great excuse to spend time every week checking out new companies. Sometimes a friend clues me in on an interesting thing they’ve seen, or mentions a need that gets me questioning whether a solution exists. Such was the case this week with SS&C’s Vidado platform, which was formerly under the Captricity moniker. Apparently they are a player in the insurance and financial services sector, with clients such as MetLife and Guardian. They have a track record with OCR and data extraction of insurance history and medical forms, which gives support to their entry into the world of healthcare. They processed over 300 million pages last year and obviously can play at scale.

It looks like their healthcare focus includes drug prior authorizations and specialty pharmacy orders, along with common documents such as claims forms. It sounds like they have a short-term proof of accuracy offer that allows clients to see how the solution would handle their forms before signing on the dotted line. If I was looking for a vendor in the space, that would certainly be compelling. I’ll certainly be keeping my eye on them to see how they fare in the wacky world of healthcare.

There are still plenty of paper forms out there, as I learned at the imaging center last week. They are now two years into their Epic implementation and are still handing patients a paper form to complete that looks like a downtime document – it doesn’t even have the patient’s name or demographics on it. Forms that make you fill out your address when it’s already in the registration system, EHR, and RCM system are just annoying.

One of my favorite techies has been out of work for a while and reached out today to share his acceptance of a new position. He’s been to hell and back in his job search and we caught up about some of the strange behaviors he’s seen among recruiters and hiring managers. One disheartening tale involved a recruiter who reached out twice for the same position, missing the fact that she had previously told him he wasn’t selected to move to the next step. Another involved a manager who noted that he was the first to interview for the position, but they planned to conduct interviews for the better part of a month, so he shouldn’t expect a decision any time soon. Nothing says “we don’t know what we’re looking for” like an admission that you haven’t narrowed your candidate pool.

My friend noted that multiple people asked questions like “why have you been out of work for so long” as if they were unaware of major layoffs in the healthcare IT industry or a global pandemic that has eliminated hiring in many sectors for the last six months. Not to mention that people may have been impacted by COVID personally or with the illness or loss of a family member, so it’s just not that great of a question. I’ve always found it better to focus on what the candidate is bringing to the table rather than the circumstances that led them there.

Regardless, I’m glad he found a position that seems like a good fit and that happens to be in his favorite industry. The fact that it’s work-from-home well into 2021 is a bonus, too. I know there are millions of good people looking for work right now and I wish them productive interviews with companies that have their acts together.

Everyone falls victim to clickbait headlines. I have to admit I was pulled into this viewpoint article in Nature Reviews Urology. “Making love in the time of corona – considering relationships in lockdown” looks at impact of societal lockdowns on intimacy. Topics range from the practical to the philosophical, so if you’re looking for an interesting read, it certainly fits the bill.

What’s the worst clickbait headline you’ve ever fallen for? Leave a message or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/24/20

There’s a lot of talk in the healthcare industry about “wellness.” Everyone is trying to cash in on it, and it seems like there are as many different definitions of wellness as there are companies trying to figure out how to make it part of their portfolio.

As a physician who strives to practice evidence-based medicine, I find many of the elements that are rolled up under the wellness umbrella to be questionable.

I ran across an insurance company last week that is encouraging its members to have “wellness labs” performed. This sounds like a good idea until you look at the contents of the lab panels, which include multiple tests that aren’t recognized as screening tests and aren’t recommended unless patients are experiencing symptoms. We all know that when tests are ordered that aren’t needed, we not only increase the healthcare cost burden, but also place patients at risk, as additional tests may have to be performed to further evaluate the results of a test that shouldn’t have been performed in the first place. I find it shocking that payers would want to spend money on unproven evaluations. I don’t fully understand what they hope to accomplish.

When various groups try to define wellness, they include anywhere from five to eight dimensions of wellness, including emotional, environmental, financial, intellectual, occupational, physical, social, and spiritual aspects. All of these certainly impact the ability of individuals to achieve their ideal state of health, but it’s difficult to quantify the complex interactions and how modifying one dimension might lead to changes in the others.

Many of the companies that are trying to get into the wellness space seem to be playing on people’s insecurities as a means of generating profits rather than being truly interested in the science as we understand it. Gwyneth Paltrow and her Goop brand has made millions of dollars selling wellness products ranging from nutritional supplements to sex toys. Wellness is the place to be, but that doesn’t change the fact that I tend to think twice about organizations that make it a central focus.

This really hit me the other day as I drove by a shop that had a “find wellness here” banner to promote their sales of CBD oil. Even though there is a small body of evidence looking at it, many of the shops promoting it aren’t selling medical-grade product and are certainly hyping it well beyond what the evidence shows.

Especially with confusion around the proven effectiveness of various products, patients have an extremely difficult time determining which wellness interventions they should most vigorously pursue. Does a mammogram or a pap test carry the same weight from a wellness perspective as trying to eat healthier to reduce cardiovascular risk? How do those interventions compare to improving emotional and spiritual health? Should EHR vendors be branching out to gather more data about the dimensions of wellness in addition to gathering all the usual discrete data about recommended screening tests? Or should we recognize that the jury is still out on many of the aspects of wellness and stick with trying to manage the conditions and interventions for which we have the best data?

I have a potential client who would like me to help them build a dedicated wellness practice. I’m struggling with the idea. I know how to help them accomplish what they’re trying to do and can help them with both the operational and technical pieces. They plan to staff the practice with their usual physicians, who will take turns seeing the wellness patients. If they find something that requires more in-depth follow up, they will refer the patients back to the traditional practice.

The client doesn’t seem to care whether the physicians have much buy-in to the concepts of wellness, or whether they are prepared to address all the different dimensions of wellness. In talking with them about their goals, it feels like they’re just trying to catch a ride on a popular concept while making some money along the way. One partner specifically mentioned wanting to keep patients away from telehealth practices that offer wellness services.

On one hand, it would be easy to just take the engagement and get the work done. However, part of me will still have doubts about the validity of the plan since it seems more about the money than offering a comprehensive portfolio of services that would help support their patients in the pursuit of better health.

This situation underscores the issues with healthcare in the US today. We have a mismatch of incentives that leads providers to look for ways to bolster the bottom line at the expense of initiatives that are designed to shift to a value-based approach. Organizations cite the idea of “no margin, no mission” as a way to justify some of the choices they make. Given the financial beating that many practices have taken this year, you can’t blame them.

The decision might be out of my hands, as I’m not sure they’re going to be willing to spend the amount of money that will be needed to build the whole wellness concept from start to finish, including marketing, staffing, and changes to their EHR and other technical systems. I bid on several projects like this each year, where people think they are going to be able to do major projects on the cheap, and then seem shocked when someone fully spells it out for them. I can’t imagine that any of the larger consulting companies can do it more economically unless they’ve dramatically slashed their rates due to slowdowns from the pandemic.

Plus, the practice need to be ready to handle the losses they will incur over the next year or so until they know whether it’s going to turn out the way they hope. Given the uncertainty of the pandemic and the upcoming flu season, I’m surprised they are willing to even consider taking the plunge.

What do you think of the idea of wellness? Do you think it’s a good time to take the plunge on new service lines? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/20/20

There’s been so many notices from CMS in my inbox lately that I missed a biggie, and that was the recent release of the 2021 Medicare Physician Fee Schedule. CMS is planning to shuffle some of the telehealth codes, eliminating 70 or so codes from the 80-ish that were created to cover services during the pandemic. They are adding more than a dozen new codes, though, and some advocates are hopeful that the public comment period will lead them to add even more. They’re going to have an uphill battle since CMS isn’t convinced that the services are beneficial outside the context of a public health emergency. The organization will be looking for data to make a decision, and in reality, none of us know how long the declared emergency will last. Flu season will soon be upon us – I’ve already had patients trying to get vaccinated – and only time will tell.

The Physician Fee Schedule noticed was tucked in between about 10 emails about new resources and strategies and collaboration spaces for eCQM projects. In my previous life with a large health system, the clinical quality measures fell under my purview. I’m fairly certain that dealing with all the calculations and making sure our EHR was handling them properly killed more than a couple of my brain cells. I have tremendous respect for the IT and clinical teams that live in that world all the time, and just wish there could be an easier way to go about gathering the data needed to drive value-based care.

The American Academy of Family Physicians launched their new redesigned website today. Although it’s much cleaner than the old one, virtually no information is available from the home screen without going through menus. The entire first page is sucked up by a big graphical tile and the concept repeats down the screen, offering little value. They also changed the login scheme from one using the member number to one using an email address, forcing every single user to change their password.

A blurb they sent out about the update mentions the addition of new “mega-menus” for users to find their content, and I’m definitely not impressed. The menus are so long you have to scroll through them, and they completely cover the rest of the screen even though a good chunk of the menu popup is blank. Seems like perhaps it’s supposed to be optimized to some other form factor than the PC I was using it on. The menus are so big though I can’t imagine them on a phone screen. It took me four clicks to access content I used to find with one, so I give the update a grade of C at best.

A better website was the one for the COVID-19 Prevention Network, which I visited to volunteer for a potential vaccine trial. Based on the questions, I’m not sure what their ideal candidate looks like, but if they are seeking people who are constantly exposed to unmasked sick people, I might know a couple.

My clinical employer sent out a notice from a local medical testing place that is also doing vaccine trials, but I’d much rather participate in one that is part of a university study versus the commercial lab that was offering cash to participants. Not to mention that I have no desire to be part of a safety trial, but would be happy to be a guinea pig for one that determines whether the vaccine is effective in the real world.

I’ve read several articles in the last couple of weeks about so-called toxic positivity and its negative impact on people as they try to cope through the pandemic. Although experts agree that having a positive mindset can help with coping, when overdone, it can make it seem like the only way to deal with a negative situation is to put a happy face on it.

I’m a huge fan of Fred Rogers. As an adult reading about his life, one of the things I came to appreciate about him is that he told children that it was OK to feel mad, or sad, or bad. One of his goals was to help his viewers learn to process those emotions in a productive way. One study from 2018 looked at “The psychological health benefits of accepting negative emotions and thoughts” and found that those who don’t manage difficult emotions don’t do as well as individuals who manage them effectively.

I used to have someone in my life who told was constantly telling me to smile, which I loathed. Trust me, there is nothing to smile about when you’ve been on call in the critical care unit for over 24 hours, have had to pronounce patients dead overnight, or have had to do any of a number of difficult things that healthcare professionals do all the time. Years later, I understand that the real reason I hated the comment was that it was an attempt (conscious or not) to minimize or invalidate my experiences or to try to mold them into something that the other person was more comfortable with. As we learn more about the trauma that healthcare providers experience and other concepts such as moral injury, it becomes even more important to give ourselves permission to be less than OK.

Getting through this pandemic and whatever other economic and societal crises go along with it will be a long, hard slog across the globe. I saw a figure the other day that some 20% of first line healthcare workers had contemplated suicide in the last 90 days, which should be setting off alarm bells. As someone who has been personally touched by physician suicide this year, I encourage everyone to try to find moments to check on your co-workers and to care for each other.

This week provided another crazy day at the urgent care, where I was completely understaffed and “over-patiented.” We have some newer-ish staffers who are still a little freaked out about COVID, unlike the rest of us who are just used to it by now. Mask, double mask, face shield, let’s go. We were trading stories about whether we’re still doing the whole “strip in the garage and run to the shower” track and field event when we get home from work. 

The paramedic I was working with had me literally laughing out loud. His wife won’t let him in the house until he strips in the garage, sprays a cloud of Lysol, and walks through it to the shower. He refers to it as “the fog of war,” which was just the right degree of hilarious coming from a guy who served his country in both Iraq and Afghanistan and who could probably kill me three different ways with chewing gum and a popsicle stick. Somehow the camaraderie made up for the 68 patients I saw by myself, and I’m actually looking forward to my next shift.

What’s the funniest thing you’ve heard in the time of COVID? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/17/20

Sunday was National Rum Day. Alas, I spent it treating patients rather than enjoying fuzzy drinks in the sun somewhere.

Today was a case study on how broken the healthcare industry is. Given the economy, over the last few weeks we’ve seen a surge in people questioning their deductibles and trying to figure out what the cost of care might be prior to checking in to be seen. Of course we haven’t done anything remotely close to installing real-time eligibility checking and usually don’t have a clue what their benefits might be due to convoluted payer contracts, so they stand at the front desk and debate whether they want to be seen or not. I feel for them because most of them need care, but are feeling like they’re stuck between a rock and a hard place in deciding what to do.

We’re seeing a mix of patients who are terrified that they might have COVID, those who are likely to actually have COVID but don’t think it could possibly happen to them, and the usual things that come into an urgent care, such as lacerations, chest pain, and traumatic injuries. We’re also seeing patients at the urgent care who are terrified of going to the ED since the state is in a surge situation, so they stay at home too long with complicated problems. Tonight ended with an elderly patient who fell and whose family kept them at home due to those fears rather than seeking care. Ultimately, they did little more than prolong the patient’s pain and delay definitive care for her broken femur.

We’re also seeing a total breakdown in the primary care infrastructure. Patients can’t get in touch with their providers to determine the best place to seek care. We’re seeing more and more patients relying on us for basics and necessities such as medication refills and quarterly labs.

Despite everything that is supposed to be going on in the realm of value-based care and management of costs, it feels like things are upside down and we’re just lighting money on fire rather than delivering coordinated care. If we as a society can’t manage something as straightforward as medication refills, I’m not sure how we think we’re going to motivate patients to make major health-related changes or meet their growing psychosocial needs as the pandemic rages on.

I struggle to figure out the answer. I’m certain technology isn’t the full answer, although I’m eternally grateful that Epic has essentially taken over the market in our area. Nearly every patient has a phone and can access MyChart, so those of us in the urgent care trenches can figure out what’s going on. Except for those patients who flit around the urgent care market between CVS Health Hub, the Walgreens clinic, and the handful of urgent cares in town, in which case all bets are off. Most patients don’t know that they can coordinate their MyChart accounts though and pull in data from the different health systems, so it feels like I do a fair amount of technology teaching some days as we try to see an integrated picture of patients who seek care across the different systems.

I have noticed an improvement in the medication history information we can receive back through Surescripts, which helps quite a bit when you’re trying to figure out how compliant your patients are. Our prescription drug monitoring program database also continues to perform like a champ, which helps bridge the gaps. Still, the bottom line is that I’m usually in at least three or four different systems trying to do my job, which doesn’t seem right in the middle of a public health crisis that should be driving us towards greater sharing and improved patient care.

I’ve also noticed an increase in patients who want to discuss politics during their visits. It always gives me a little chuckle when they ask me whether I think COVID is as bad as the media make it out to be. My double mask and the face shield should be an indicator. Still, it doesn’t seem like there’s much realization that healthcare workers are desperate to not take the virus home to their family members, or that we are stressed to the max and both physically and mentally exhausted, given the complaints that we get when anyone has to wait more than 30 minutes for their visit.

We’re squandering resources right and left as colleges and universities mandate COVID testing, but on a clinically inappropriate timeline. A negative test 10 days before move-in day is meaningless unless the students have been quarantining. We’re also still seeing employers that demand patients who have negative tests get a second negative test to return to work despite the CDC updates that occurred more than three weeks ago that say this is unnecessary. I’m sure the local school district’s HR department is far wiser than infectious disease experts, so we do what has to be done regardless of whether it makes sense or is a good use of resources or not.

I had an interesting conversation with my scribe today, I didn’t realize he is a COVID survivor. He was pretty sick and spent a couple of weeks in the hospital, receiving convalescent plasma and not requiring intubation. He’s glad to be recovered, but worries about the long-term consequences of the disease, especially since he’s under 30 and hopefully has many years ahead of him. He’s focused on making it to medical school in a year or so and I can’t help but think that his experience will make a difference in the kind of physician he grows into.

He had never heard of clinical informatics, so I was able to do some education there. It’s good for those who aspire to join the healthcare team to know the underpinnings that try to hold it all together. We talked about some of the work I’ve done in the past, which had me hankering for a good lab interface build or maybe some kind of a legacy EHR conversion. It’s funny how the things we thought were arduous at the time take on a whole new look when we’re faced with something that has changed our perspective as radically as COVID has.

Regardless of how tedious our days seem or how frustrating some of the interactions might be, the reality is that we’re dealing with someone’s mom, dad, grandmother, daughter, sister, and more. It’s a unique privilege to care for people. I’m hoping we will eventually be able to elevate our game and find a better path forward.

What is your employer doing to change the big picture of healthcare or drive innovation forward? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/13/20

For many practices, it’s a COVID-related surprise and not necessarily a fun one. New national requirements for COVID-19 testing data went into effect August 1. Ordering physicians now have to supply demographic information to help public health agencies track the disease’s spread and identify areas that are seeing large number of cases.

The requirements were included in the Coronavirus Aid, Relief, and Economic Security (CARES) Act. It requires that laboratories that test for COVID or its antibodies report 18 data elements to HHS. Some of them don’t typically appear on a lab requisition, such as race, ethnicity, and county of residence. There are also “ask at order entry” questions to identify whether the patient is a healthcare worker, whether they are housed in a residential setting, whether they are pregnant, or if they have been hospitalized.

Labs are pushing back on practices to supply this information when tests are ordered rather than having to track it down manually. Depending on how up-to-date your EHR is and how well it supports the use of these fields during laboratory ordering, you may or may not be compliant.

I worked with several practices this week who were not compliant and were trying to become so after receiving complaints from their lab vendor. Fortunately, I was able to do some workarounds for the paper requisitions that accompany specimens, but I won’t be able to modify the lab interfaces without support from the vendor.

My participation in the ONC Tech Forum this week was interrupted by the crisis with the lab requisitions, although I would have stepped away and helped my client regardless of whether the conference was in-person or virtual. That’s one of the joys of doing what I do in healthcare IT, as I help practices and organizations navigate the many challenges that get thrown their way.

I was glad to hear National Coordinator for Health IT Don Rucker talk about the utility of health information exchanges in dealing with the COVID pandemic. He acknowledged that we have a way to go before we’re going to be able to make the most of data exchange and the ability to share patient information. He called out the ability for HIEs to receive data for organizations that might not be top of mind for care delivery, such as group homes and shelters. My state has a long way to go with regards to HIE, so I’m fairly convinced that having a truly functioning system that shares data from all physicians at any point before I retire is just a pipe dream.

This week has been all about preparing proposals for potential consulting gigs, so I’m actually looking forward to going back to the clinical trenches this weekend. What I’m not looking forward to are the hundreds of charts awaiting my signature for the shifts I worked prior to vacation. I tried to work on them while I was out of the office, but our Citrix platform is unstable unless you access it from the internal network. They don’t have any incentive to investigate the issue since it doesn’t matter to them how arduous the chart signing process might be. The ongoing message is for us to be happy we haven’t had pay cuts or layoffs, so most of us are just staying quiet. Such is the state of healthcare in the US these days, and my colleagues elsewhere are sharing the same kinds of stories.

The American Medical Informatics Association has booked Anthony Fauci, MD for a special fireside chat at its Virtual Annual Symposium to be held November 14-18. The session will only available to registered conference attendees. I’m sure it will have a lot of people on the edges of their seats. The man was already a legend prior to COVID and having served as an advisor for six US presidents speaks for itself. I enjoy his matter-of-fact style and can’t wait to see what he has to say. Apparently I’m not the only one that likes his style since the Dr. Anthony Fauci Fan Club group on Facebook has over 150,000 members.

A friend of mine knows that I’ve been checking out various virtual conferences since the pandemic started and invited me to visit something a little out of my subject matter area. The QSO Today Virtual Ham Expo was the gathering place for thousands of amateur radio operators over the weekend. I have to admit I really liked their platform. They had a virtual expo hall where you could see various “booths” and click on them for a virtual visit and even a live chat. Accessing speaker sessions was very easy even after the conference ended, with the sessions presented as embedded videos within the agenda.

Since amateur radio operators tend to be pretty techy, most of the videos I sampled had reasonably good production values and excellent audio. It was interesting to see how another industry is handling the problems we face, and with over 21,000 registrations, it’s certainly comparable to a healthcare conference.

A couple of friends at software companies say they are working on their own platforms for virtual user groups. I hope they are doing plenty of usability testing and focus groups with prospective attendees. I’ve been to good conferences and bad ones, and there’s definitely a negative impact if the tech isn’t good, the speakers aren’t prepared, or the background filters are doing funky distracting things.

Most of the vendor user groups that I’ve attended are part education, part rah-rah sessions to try to bond users to the company and help them forget all the crummy things the software does to them on a daily basis. It’s going to be hard to get that vibe going virtually unless they really work at it with specific engagement sessions and bulk-mailed swag like they did with the recent InTouch Health / Teladoc conference.

I’d love to hear from vendor folks about how they are planning to approach virtual user groups and the challenges they are facing. I promise to keep you anonymous. If you’re a potential attendee, what are you looking forward to or dreading with virtual conferences? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/10/20

I thought I had previously registered for ONC’s tech forum this week, but when I noticed I didn’t have any meeting information, I figured I should double check. Turns out I didn’t register.

I would have definitely remembered, because I thought their registration form was a little problematic. First, one of the required fields for registering is a Twitter handle. Of course, one could just put junk in that field, but I found it odd that it was the first field required past name and email address. Another required field was “Affiliation” without any indication of what they were looking for. Did they mean employer?

I’m becoming quite the connoisseur of virtual conferences and have enjoyed doing a few more of them than I might otherwise have done had travel been required. For those of us who foot the bill for our own conferences and education rather than charging it back to an employer, it’s all about making the most of your time and your travel resources.

Speaking of, I cancelled my hotel for HIMSS21 “spring edition” today and worked on making my reservation for HIMSS21 “roasting hot desert summer edition.” Unfortunately, my hotel of choice isn’t taking reservations just yet, but I was able to book a backup for reasonably cheap. Like Mr. H, I’m a little uncertain on exactly where the conference will take place since the official notice includes Caesars Forum and Wynn as venues as well as the expected Venetian-Sands Expo Center. I loved my stay at The Venetian a couple of years ago, but it’s not in my current budget. My new hotel is fully refundable, as was the previous one (and the credit was already showing up in my online account before I had booked the next reservation).

The flight is in my budget, however, as I’m sitting on several thousand dollars of unused plane tickets that were supposed to take me to all kinds of interesting places this year. Now the challenge will be to use them before they expire. Some airlines have been more generous than others in pushing their expiration dates well into 2022, but I anticipate more than one will just become a loss. I’ve found charities that you can donate miles to, but haven’t figured out a way to donate tickets since they’re supposed to be nontransferable. If anyone has ideas, let me know. I doubt I’ll be rescheduling my trip to the Vancouver area anytime soon, given the current status of coronavirus transmission in the US.

Once I finished moving my hotel reservation, I was in an administrative mood, so I spent some time trying to do forecasting for what I’ll be doing the rest of the year. It’s a difficult time to be an independent consultant. Earlier in the year, I watched six months’ of bookings evaporate in a single afternoon, and it hasn’t been easy replacing that business. Many of my ongoing clients are mid-sized organizations that are in dire financial straits as they wrestle with continued shortages of personal protective equipment and struggle to try to figure out how to kickstart their revenue streams during failed economic re-openings across the US. My larger clients are experiencing across-the-board project freezes after furloughing internal staff. They’re more likely to reactivate those staffers than to use an external consultant, which is understandable.

For those clients who are continuing to have me work, I’ve seen some fairly extreme layoffs and restructuring, with one client literally moving the work of two departed project managers onto the one remaining one. The remaining project manager is struggling under the workload, but is afraid to complain because he fears he might be next. As you can imagine, the project management that’s occurring is fragmented, behind schedule, and generally ineffective, because you simply cannot just pile work on people and expect them to work magic. I’ve had a couple of conversations with the director of the program management office about it, but she just throws her hands up because she doesn’t have the authority to challenge decision-makers who still want all the projects running.

It feels like everything we’ve learned about happy staff being productive staff has been thrown out the door in the last few months, and people are operating from a position of desperation. This is only being magnified as various parts of the country head back to school and working parents are trying to figure out how they’re going to juggle childcare with assisting children who are expected to learn at home. I have a lot of friends who are able to work their IT jobs from home and have been successful during the pandemic, but all bets are off when they’re expected to support their elementary aged students in virtual learning plans that have varying degrees of planning and forethought.

Despite industry players like Epic pushing to have workers return in person in the name of “culture,” it feels like most of the health system folks I speak with are happy to let people work at home as long as possible while making plans to jettison the soon-to-be-unused office space and its associated costs.

Two more of my physician friends made plans to close their offices this week. One was already struggling with health issues when the pandemic hit, and the stress has definitely worsened her condition. Another is retiring early to move in with her physician daughter to help with her grandchildren. Both of these physicians thought they had much more time in their careers. Their patients will certainly miss them.

The local health systems have all stopped acquiring practices and one has laid off dozens of physicians, so there wasn’t an option to sell the practices. Since they each carry several thousand patients on their panels, I’m not sure where all those patients are going to receive specialty care, and they only have the state-mandated 30-day notice period to figure it out.

We’re certainly living in strange times. Although my practice hasn’t had to lay anyone off, they’ve made it clear that physicians aren’t getting any extra money regardless of our insane patient volumes and that we should be happy we are employed and working a normal number of shifts each month. They did give generous bonuses to the staff, which we appreciate, but you would think physicians seeing an extra 20-30 patients a day might be worth a little financial boost. I suspect that more than one of us is planning to depart after the end of the year because you can only work at this pace for so long before you start to crack.

In the mean time, it’s all about keeping your chin up, your mask on, and putting one foot in front of the other. We’re all looking forward to the time when this pandemic is under control . We are crossing our fingers that it’s not going to be confounded by a hellacious flu season once we ease into winter. Normally we start our flu vaccination campaigns in September and October, so only time will tell on this one.

Are you preparing to cope with children learning at home? Have any good strategies to share with the rest of us? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/6/20

CMS continues to forge ahead as if providers have nothing else going on, releasing final scores for the 2019 Merit-based Incentive Payment System (MIPS) program. Every time I see one of these announcements, I’m again grateful that my practice decided to opt out and take the associated penalties. It’s worth seeing an extra patient here or there to cover any losses so we can focus on care delivery and not clicking boxes.

Other hot federal topics include a Medicare proposal to expand telehealth benefits permanently. I’ve seen what a benefit it can be for patients who don’t want to risk going to a physician office, but I’d like to see more practices offering it as a routine part of their care rather than patients having to go to third-party vendors for care.

A good chunk of what I do in the telehealth arena should ideally be managed by either the primary care provider or a subspecialist managing a particular condition, but our healthcare system continues to be broken in even basic ways. Several recent calls were around medication refills, not only for patients unable to make appointments with their regular physicians, but to even get a response to a refill request for a medication. When you hear some of the stories, you wonder if they’re made up, but based on the recent runaround I’ve had with my own family’s physicians, I have no reason to doubt the stories patients tell.

They also released the 2021 Proposed Rule for the Quality Payment Program via the Medicare Physician Fee Schedule Notice of Proposed Rulemaking. They did at least note that “in recognition of the 2019 Coronavirus (COVID-19) public health emergency and limited capacity of healthcare providers to review and provide comment on extensive proposals, CMS has limited annual rulemaking require by statute to focus primarily on essential policies including Medicare payment to providers, as well as proposals that reduce burden and may help providers in the COVID-19 response.” Although that’s small comfort to the people who have to wade through the original content of any proposed rule, at least they’re recognizing that most of us have other things on our minds. For those of you still in the game, comments are due by October 5 at 5 p.m. ET.

Props to Google Cloud for their “oops, that didn’t go so well” email after a bulk mail failure. It’s always good to tackle errors with a sense of humor, and I appreciate the acknowledgement rather than just getting another email. I also appreciated that their email linked directly to case studies about their products rather than forcing me to give my contact information to download an e-book or other fluff piece.

I’ve heard a lot of talk lately about EHR vendors that plan to use “AI” to help with physician documentation. In reading between the lines of some of these articles and ad pieces, the devil is truly in the details. One client was bragging about his vendor’s plans to add AI to their application and I was glad I was on a voice-only call because I’m sure I wouldn’t have been able to contain my facial expression. You have to have a reasonably robust backbone to add AI to an application, and this particular vendor is far from it. Their EHR is about two steps away from being a Microsoft Word document, and I can’t fathom how they think they’re going to “AI enable” that unless they’re just adding voice recognition and putting a lot of lipstick on it.

I think there is a tremendous amount of promise for AI-enabled documentation technologies, but to be as effective as a live scribe, they also have to be able to handle questions on information recall and analysis. I’m constantly asking my scribes to provide information from previous visits or to see if there are patterns with interactions. There are certainly technologies that can provide these functions as well and I’d love to see them be able to handle mainstream primary care and urgent care encounters like I see day-in and day-out. So far the only ones I’ve seen that are able to do a decent job are only able to do so in the subspecialty realm.

Low tech, but literally cool: Shipping giant UPS is readying freezer farms in preparation for the eventual shipping of vaccines against the novel coronavirus. Each unit can store up to 48,000 vials of medication, with a total of 600 units being placed at facilities in Kentucky and the Netherlands. I’ve only been on the receiving end of vaccination shipping and know what a major logistic undertaking it is for flu season, so I can’t imagine what it might look like when people are clamoring for the vaccine across the globe. (I am betting that for the 60% of US residents that say they won’t get it, there will be plenty of takers in the rest of the world.)

Since we don’t know what COVID will look like when flu season hits, many clinical organizations are already ramping up their plans for vaccination campaigns. There is plenty of good technology out there for the patient outreach piece and getting those patients who typically receive a flu vaccine should be easy. It’s also easy to identify the patients who have high-risk conditions and alert them to the benefits of the vaccine.

What’s not easy, however, is ensuring that practices have enough personal protective equipment for their staff members, which is still a struggle in many practices. Despite the availability of testing supplies in my community, many primary care offices are choosing not to test because of concerns about PPE, which sends patients to urgent cares, other health systems, or the CVS Pharmacy drive through. Fragmentation of care is still the order of the day for many patients, and until we get a national coordinated strategy, I imagine it will continue to be this way.

In the meantime, I’ll keep helping my clients ready their campaigns, prepare their word tracks for patients who are reluctant to vaccinate, and look at creative ways to leverage their technology assets to maximize scheduling and vaccine delivery. Just another day in the clinical informatics trenches.

How is your organization preparing for flu season? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/3/20

I’ve written about business continuity planning previously. It seems like every year it becomes a germane topic as we experience tropical storms, hurricanes, wildfires, and floods across the US and around the world. Throw in a global pandemic that shuts down medical offices and curtails hospital services and you’ve created a situation where continuity planning is an absolute necessity. Did I mention cyberattacks and ransomware? These are a couple of other good reasons to go through a planning exercise if you haven’t done so already.

Business continuity planning is part of the consulting work I do, so I’m no stranger to helping organizations walk through some of the circumstances their practices might encounter. As a CMIO, people expect me to be versed in the IT side of things, and many clients are concerned with the obvious things like EHR outages, power outages, etc. Clients living in coastal areas typically have a decent hurricane / storm plan, but many organizations haven’t thought about the natural disaster aspect. One summer my little corner of the world experienced floods, tornadoes, an earthquake, and locusts, so it was a bit of a sign that we all need to think about these things.

As I’ve worked with clients on this the past couple of years, we’ve spent more time discussing cyberattacks and ransomware, as numerous healthcare organizations have been hit by this. As of the last couple of weeks I have a great new case study for this with Garmin. They were hit by an attack that disabled their services for more than a week. They claim they didn’t lose any client data from their sites, but the reality is that clients lost data because they couldn’t sync their devices with the Garmin services. Understanding the anger in the client community about exercise data from wearables should make physicians think twice about how patients would feel if their actual medical information were lost or held for ransom.

When I go through a business continuity planning exercise with a client, I usually include a discussion of what it would look like if key human resources became unavailable. For example, what would happen if the CEO or COO departed the organization? Do others have signatory or contracting authority, and how would day-to-day operations run? For smaller practices, what is their plan if they lose a key biller or scheduler? Most of the time we’re focused on the operational and financial side of the house, with a brief but general discussion on the clinical side.

The clinical side of business continuity planning certainly came into focus earlier this year with COVID-19, as practices shifted to a telemedicine models and looked for new technologies to be able to safely reopen their patient care operations. I added a couple of different dimensions to my client-facing materials based on those experiences and they’ve been well received by organizations I’ve worked with. Still, I was thinking in more broad strokes about how organizations might be impacted if they can’t see patients and looking at it from a macro level.

Unfortunately, this week I had to think about it from a micro level, as my practice suddenly lost one of our full-time providers. Since I’m just a worker bee at my brick-and-mortar practice, I’ve never been privy to their business continuity planning and didn’t worry about it too much since my clinical work isn’t my main source of support. One would think that in the event of the loss of a provider, they could use the same checklists they might use when a provider quits or retires. It quickly became apparently, however, that they either didn’t have such checklists or were so overwhelmed by grief that they hadn’t worked through the process.

My involvement started when one of the nurse practitioners called me, as the most senior physician working at the time, asking what to do about the fact that the EHR was still putting my late partner’s DEA number on her prescriptions. Pharmacies in our area have an issue with NPs who write controlled substances and often ask for the supervising provider’s information as well, so we’ve added that to our prescriptions. I’m not sure if it’s custom code with our EHR vendor or a feature that they offer, but it’s how we roll. This was three days after his passing, so I can only guess that the other midlevel providers for whom he was the collaborating physician either didn’t write any controlled substances prescriptions in those days or didn’t think about what went out on the script since it hadn’t yet been addressed. In the short term, I supervised the NP for the prescription in question so the patient could be managed, but it made me wonder about the plan.

I also had the unique experience of staffing my late partner’s primary practice location, where our staffers had created a temporary memorial with flowers, photos, candles, and other tokens representing his personality. I’m not sure the organization had thought about how that would impact patients or the staff working at the location, since many patients had questions about the memorial and what had happened that our employees were unprepared to field. I was surprised by one particular patient who hounded me for details. I learned later that she had already posed the same questions to the receptionist and the nurse, but wasn’t deterred by their comments about the situation. Having to constantly respond to questions certainly weighed on the staff throughout the day.

As someone who has led other organizations, part of me wanted to go ahead and raise the question to leadership about the handling of the memorial and potential word tracks for staff, but didn’t want any inquiry to be seen as interfering with our practice’s collective grief. Knowing there are often no good answers to these issues, I opted to say nothing and let the organization figure it out. It felt like a bit of a cop out since usually I’m one to tackle problems head on, but maybe it was part of my own grief reaction. It was hard enough to get through the day with his presence all around us, and after a long day of COVID patients, I was ready to let it go.

It also served to illustrate something I’ve acutely questioned this year, the idea of “who cares for the caregivers?” Most of us are getting burned out and certainly all of us are tired, and the worst part is we know that there is no end in sight. My colleagues who have been in military operations have had the best advice for coping, but I’m concerned that this recent loss will put some of our team over the edge.

I hope sharing this story encourages organizations who may not have thought about these issues to add them to your to-do list, because it’s only a matter of time before a similar loss might impact them. If you haven’t done business continuity planning, you need to do it now. If you’ve already done it, take a moment to look at your plan to see how your organization plans to handle the loss of key staffers and consider how co-workers and the community might be impacted by such a loss. Having a plan and implementing it during stressful times certainly beats feeling like everything is swirling around you.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/30/20

It’s been a wacky week in the informatics trenches, as I had a run of non-clinical days in preparation for working three in a row this weekend. I used the time to attempt to catch up on email and voice mail. Although I’m still woefully behind, it’s a little more under control.

One of the voice mails that was left for me was priceless. “Hi, this is Kate from X Company. We’re one of your company’s approved vendors for staff augmentation services and wanted to talk to you about your upcoming projects and any staffing needs you might have.” Since I’m the person that would approve any vendors and had never even heard of this company, I just chuckled and hit delete. I wonder if this is the way they do business all the time, and if people actually fall for it.

I also had a chance to catch up with some of my colleagues across the country and get a feel for how they’re coping with either an extended first wave, or the beginnings of a second wave, of COVID cases. It seems the theme of the last couple of weeks has become “patients behaving badly,” with increased conflicts at the front desk from patients who refuse to wear masks. Especially entering a medical office, I think having a healthcare institution require a mask is no different from “no shoes, no shirt, no service” anywhere else (although I always wondered why they didn’t require pants, but that’s another discussion).

One colleague’s practice had to bonus their receptionists because they were threatening to quit due to the stress of having people come in and yell at them. Another physician friend told a story about coming around the corner in the office and having a patient raging in the hallway about being refused a rapid test, because his son is a major league sports player and the dad needs a documented negative to be able to interact with him. The kicker – dad was standing in the hallway with no mask on in a healthcare facility that has a 20% positive return rate on tests. You can’t make this stuff up.

In other news you can’t make up, rumor has it that HIMSS is moving the HIMSS21 conference from spring to August next year, but still in Las Vegas. A friend mentioned it after seeing it in Modern Healthcare, but HIMSS didn’t bother to put an announcement on its website or send anything out to members, including our local chapter president. Seems like their communication is really improving since the debacle of this spring.

That would make it almost a year and a half between HIMSS meetings, which is plenty of time for vendors to come up with new and creative offerings. Still, it remains to be seen how many companies will actually exhibit, given how much money was lost on HIMSS20 and the potentially limited pool of attendees if international travel is still snarled and domestic institutions aren’t eager to allow their employees to head to a 40,000 person Petri dish. I spoke with my favorite traveling technology consultant the other day and his employer has him grounded, even though he’s amenable to travel and clients are requesting him on site.

Perhaps by August 2021 we’ll see a healthcare implementation of smart glasses again. Remember the exciting times of Google Glass and when wearables were just coming on the market? We need some cool offerings to get us excited again. Vuzix has an industrial application that includes Bluetooth connectivity and voice recognition, which might be attractive in healthcare. Apparently, several healthcare institutions in the US are already piloting the device and it’s also being used internationally. Battery life is supposedly 16 hours, which is pretty impressive. It uses the same chip as Google Glass, but seems more rugged and can be disinfected with alcohol-based products so it meets the COVID challenge. If they’re looking for a sassy urgent care doc to give it a try, I might know someone. It might also find interesting applications in education, since it looks like many school districts across the nation will be embracing distance learning this fall.

I attended the Health Impact Summer Forum and really enjoyed the keynote speech with Wendy Dean MD, who is a psychiatrist and co-founder of the non-profit group The Moral Injury of Healthcare. I’ve written a couple of times about moral injury and it’s gotten even worse with COVID. Organizations are still rationing personal protective equipment and we’re still operating under crisis standards of care, seven months into this pandemic. Clinical workers are risking their lives daily, often for patients who don’t care and who may be hostile to them. One local practice refused a physician’s request to put up signs asking patients to keep their masks on in the exam room while waiting because it would be perceived as “unwelcoming.” This is nonsense, plain and simple, and Dr. Dean validated the negative impacts of decisions like this.

She commented that calling healthcare workers “heroes” makes the public think we can do anything, when in reality our “superpower” is our humanness. She commented on the business challenges that are impacting clinical care as well. The pandemic certainly highlighted the broken pieces of our healthcare system in the US and identified opportunities for improvement. She notes that there is no clearly drawn road map that gets us where we want to go and proposes that we start orienteering with our moral compass as our guide and excellent patient care as our true north.

As someone who knows her way around a map and compass but who has been lost in the healthcare trenches for years, that definitely resonated with me. I really enjoyed Dr. Dean’s commentary on the issue and just having my feelings validated gave me hope. There’s another Forum in the fall and I’ve already signed up.

Is your employer taking any steps to combat moral injury as the pandemic rages on? How are your support structures? Leave a comment or email me.

Email Dr. Jayne.