Curbside Consult with Dr. Jayne 7/6/20

I survived the Independence Day weekend in the emergency department trenches without seeing anyone who had finger or eye injuries, so it was a good one.

I didn’t get to see any fireworks or have popsicles, but the PPE fairy paid me a visit. I’m happy to report that exactly four months after seeing my first positive COVID-19 patient, I finally have an honest-to-goodness actual 3M healthcare N95 respirator, as opposed to a non-medical version from the hardware store. To be precise, I have two of them. Which I’m supposed to rotate indefinitely.

Excuse my cynicism, but I’m not exactly sure what the US has to celebrate today. The actions of our fellow citizens exercising their freedom to not wear masks and their freedom to congregate in large groups is sending patients to the hospital, if not to their graves. Our testing volume is up by about 20%, but our positive case rate is nearly triple what it was recently, so we’re gearing up for a bumpy ride.

Our group has moved into testing entire cohorts of workers from various employers, which is straining resources. The first bolus of patients came from a hair salon, where they are meticulously separating clients with plastic barriers and stylists and clients are all masked. Unfortunately, the 20-somethings who work there all huddle up in a break room together between clients with masks off, or stand outside the door smoking, so close to 80% of them came back positive. No surprises there.

The next set of workers came from a country club, where even though the dining area has been moved outside, servers are still in close contact with patrons. The wait staff also had a communal break area, and frequently took masks off in between runs to the dining area. Now everyone gets to hang out at home for 14 days waiting for tests to come back. Unless something changes with our reference lab, there’s a good chance we’ll be clearing them based on time before their results come back — the lab’s turnaround time has skyrocketed to 10 days.

At this point, I truly wish my EHR had the capability to do a standard visit that could be copied from patient to patient. Although we have some templates for physical exams, everything else has to be keyed from scratch for each patient unless they’re a returning patient. I’d love to be able to bulk-copy these HPIs since they’re essentially the same. “Patient presents for employer-mandated testing, was exposed to a patient over the last two weeks who is now positive. Patient reports non-masked interactions at close range in a common break area and sharing of plates of food by co-workers.”

You might ask why I’m writing an HPI when the patient is just there for testing. Our new reality is that payers have gotten burned by the “sure, we’ll pay for COVID-related visits” policies and are now requiring documentation of medical necessity to support payment for testing. I thought this article from mid-June was over the top until I started experiencing “concern” from payer reps about our testing patterns.

As much as everyone is focusing on the struggles of the hospitals and the potential for overwhelmed ICUs, ambulatory practices (especially independent ones) are really struggling right now. Many are not performing testing because of lack of PPE and we’re still challenged to keep patients safe. Unlike larger facilities, small offices don’t have the luxury of being able to set up dedicated respiratory clinics within their footprint or to offer separate waiting areas for suspected COVID patients. The best they can do is to try to separate patients temporally, bringing in the well patients in the morning and sicker patients as the day progresses.

Many of my colleagues in this situation are using automated screening solutions to try to risk-stratify patients the day before, although the system isn’t perfect. For example, one of my patients who came in for food poisoning recently was actually COVID. It’s hard to triage that without doing a full telehealth visit up front.

I get a lot of direct to doctor emails from tech companies, and I’m surprised by the silence from the companies that have sanitizing technologies. There seemed to be dozens of booths at HIMSS for solutions to sanitize laptops and keyboards and otherwise keep technology clean. If anyone is in that space, I would be interested to see what business looks like right now and if you’re just overwhelmed or how things are going.

The push for telehealth technologies has also slowed. It feels like practices that jumped into the pool with Zoom or other non-healthcare solutions are starting to transition to telehealth solutions that are embedded in their EHR or otherwise integrate. I agree that expecting clinicians to work in two systems is daunting and no one wants to do it for long.

There used to be several players in the hand hygiene market. What’s going on in that space? Are hospitals going high tech to monitor staff compliance, or are they running out of money and worried about taking care of the basics? Any action on expansion of robotic healthcare assistants to reduce the need for humans to go in and out of exam rooms?

It seems like there are so many interesting technologies with potential, but I struggle to keep up with how other organizations might be innovating because I’m simply swamped seeing patients.

I hope that readers had a chance to recharge at least a little this weekend. Many people had Friday off in honor of the holiday or had modified work schedules. In many states where cases are rising, this is just the beginning of a long slog.

How is your organization helping workers recharge their batteries, or making sure they are holding up OK under the stresses of our new normal? Have you instituted new technologies to try to make an impact? What about the addition of recharge zones or stress reduction rooms? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/2/20

We had more craziness in the clinical trenches this week. Several of our sites ran out of COVID-19 testing swabs and we were told by vendors that shipments were being diverted to Texas, Florida, and Arizona. I’m not sure how we’re supposed to prevent outbreaks if we can’t test, but welcome to the world of supply chain shortages. It’s not like we haven’t had months to ramp up production, or that we aren’t unaware of the need to keep testing for the foreseeable future.

I’ve spent a good chunk of my professional career helping practices with capacity management as they transition from regular (long wait time) scheduling to open access scheduling, along with figuring out how to ramp up or down with EHR go-lives and upgrades. I’ve never dealt with anything like the capacity management needed to handle the unpredictability of COVID, so if anyone else has tips or tricks, I’m listening.

The New York Times also picked up on the issue of variability in testing capacity. One of the physicians interviewed mentioned lack of personal protective equipment as a reason why primary care practices aren’t taking on testing.

Many of the staffers at my practice gave up on having full PPE long ago and aren’t gowning up when performing swabs. Although we have an adequate but not ample supply, it’s a pain getting gowned up, and most of our staff members are taking their chances. Those of us who aren’t actually performing the swabs aren’t allocated gowns, so you just get in the habit of figuring you’re exposed and sprint to the shower when you finally arrive home.

CMS continues to blast out information like nothing else is going on in the world. This time it was an update that “2021 MIPS Self-Nomination Materials” are apparently are now available, so Qualified Clinical Data Registries and Qualified Registries can now start the paperwork for next year. I feel like I’m a million miles away from MIPS right now, and I’m betting 80% of the US healthcare folks share the sentiment.

The FCC continues to fund telehealth projects as more organizations enter the space. I have practiced on several of the major telehealth platforms, and all I can say is that they have a long way to go before they have the features that physicians really need to do a good job. My experience is that they’re clinging to their episodic care roots and there’s not much funding to create the kind of longitudinal health record that is needed for coordinated care.

None of the systems I’ve worked in have the ability to receive records from patients or providers (or at least I’ve never been trained on how or where to see them), so it’s like starting with a new patient every single time. They are also light on clinical decision support. Documentation is barely a step above Microsoft Word, with many providers keeping their own cheat sheets for copying and pasting.

A recent report from McKinsey & Company looks at the potential for a $250 billion shift to telehealth in upcoming months and years. That’s approximately one-fifth of what payers spend on ambulatory and home health visits. I’m not sure I’m quite that optimistic given the fact that in the month since the report was released, many patients are going back to brick-and-mortar visits. Since we didn’t ramp up remote provision of other services like blood draws for chronic condition monitoring, it’s often just as easy for a patient to go back to their physician’s office for labs and a visit than it is for them to do a telehealth visit and then have to go to a reference lab’s patient service center. In order for a seismic shift to occur, we have to figure out how to deliver other outpatient services remotely and how to practice telehealth in non-crisis situations.

Other care delivery paradigms such as Direct Primary Care (DPC) are also gaining traction. I was interested to see that Baylor Scott & White is including DPC as part of its health plan. Employers can choose to separate primary care from other fee-for-service offerings. There are a lot of different flavors of DPC out there, and in this one, the physician is paid a flat rate for all primary care services regardless of the number or type of visits. It’s much more like old-school capitation than true Direct Primary Care, which cuts out the middle layer between the patient and their health provider. Another typical hallmark of DPC is that the physician no longer needs software or staff to handle coding and billing processes, which leads to savings. I think the Baylor approach is going to lead to practices not realizing the benefits because they’re going to have one foot in the boat while the other is still on the dock.

From LegalTroubles: “Re: lawsuits from healthcare staff or unions around PPE and related issues. What are your thoughts?” Workers, including physicians, will have little recourse if they suffer illness, injury, or even death from inadequate PPE and unsafe workplace conditions. I’m a member of several COVID-specific provider forums and everyone is singing the same song about lack of PPE and being expected to work at a ridiculous pace in many areas. Any lawsuits will be defended by lawyers claiming that employers were doing what they could in a national health crisis. The reality is that that nearly 90,000 healthcare workers have been sickened by COVID-19, 600 have died, and there’s no end in sight.

I’ve worked in probably close to 100 facilities in my career. Healthcare workers have never had the level of oversight from the Occupational Safety and Health Administration that you see on most construction job sites. When is the last time you saw a “days since last accident” poster in the patient care areas of your hospital? Personally, I never have, except once on the loading dock of big-city tertiary care center.

The other day I refused to provide care to a thrashing patient due to the risk of a needle stick injury. I had to wonder whether I would be backed up by administration.

Even if employers operated with the level of diligence that they should, playing the “sorry, we just can’t get supplies” card is our new reality. The abject failure of this nation to fully leverage the Defense Production Act or other legislative actions or incentive programs to provide healthcare workers with the protective equipment they need (and deserve) is despicable. The reality is that each and every one of us, more so than the general population, wakes up each morning waiting for the other shoe to drop and wondering whether every cough or sniffle is the beginning of the end.

Do we have any MD/JD or DO/JD or legal folks in the room? What’s your take on the reader question? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/29/20

Back in the early days of Meaningful Use and the beginnings of the transition from volume-based payments to value-based care, I used to be knee-deep in politics, legislation, and regulation. Over the years I gradually spent more time with my nose to the grindstone helping organizations figure out how to transform and adapt to what were then final rules. From there I moved into more technology roles, helping vendors tweak their offerings and helping clients optimize their implementation.

I got away from following legislators and the courts, but the year 2020 has brought all that back on my radar. Understanding how closely tied the US healthcare system is with the US political system, especially through lobbying by powerful interests, I’m once again following the US Supreme Court and US Congress more carefully, along with various parts of government that are responsible for promulgating rules, policy, and guidelines. It’s a different place to be in, but still within the CMIO wheelhouse.

The US Supreme Court was busy last week, and although I thought I understood the meat of the DACA (Deferred Action for Childhood Arrivals) program situation, I failed to fully appreciate its ramifications on healthcare. When thinking of those impacted by DACA, most news stories feature high school students, college attendees, or young people in the workforce who are concerned about being deported after being brought here as children. An article put out by the AMA notes that approximately 30,000 of the workers impacted by the DACA decision are in the healthcare workforce.

What would our healthcare delivery situation look like with 30,000 fewer workers, some of whom have skillsets that are in shortage? Those impacted include physicians, nurses, and pharmacists. Looking at just the physicians and physician trainees, they have the potential to care for anywhere between 2 and 5 million patients during the course of their medical careers. Our nation continues to have a significant nursing shortage, to the point where we bring in travel nurses from around the world to staff patient beds in many parts of the US. Many of the lower-wage jobs in large urban health centers are staffed by immigrants, and I’m sure some of them fall under DACA as well.

The Department of Homeland Security will be re-visiting this issue and providing documentation to try to have the matter heard again, since the decision hinged on some specific details. If they do, I’m sure the more than 30 healthcare organizations that submitted a “friend of the court” brief for this case will continue to advocate on behalf of those impacted by an additional consideration of the program. In the mean time, hospitals and healthcare organizations should work to gain a better understanding of the immigration status of their workers.

CMIOs have historically been a lightning rod for complaints about physician burnout since EHRs were the vehicles used to add additional documentation burden and cumbersome workflows as part of federal incentive programs. In more than one client situation, I’ve been pulled in to use this expertise to try to address burnout that’s being exacerbated by the ongoing pandemic. I never sought to be known as “the EHR guru and burnout expert,” but that’s how I was introduced the other day. Although I’ve helped a couple of organization streamline their workflows, mostly around ordering and results management related to COVID, I’ve been doing additional work on the organizational development side to help leaders work better with clinicians who can only be described as shell-shocked.

I feel validated every time I see an article about this phenomenon. The AMA wrote about it recently in a piece titled “Four ways COVID-19 is causing moral distress among physicians.” I’ve worked a string of back-to-back shifts at urgent care, which essentially has become the emergency department because people are afraid to go to the hospital and come to us instead. I even had a gunshot wound the other night who required a trip to the operating room, which freaked my staff out, but given where I did my residency training, didn’t make me blink.

Already existing physician burnout is being exacerbated by not only a lack of effective treatments for the COVID-19, but lack of adequate personal protective equipment, which receives zero media coverage but is do-or-die for most of us. Now we’re dealing with either an extended first wave or a nascent second wave populated by patients who refuse to social distance or wear masks but desperately need our help when they find out they’ve been exposed at the neighborhood block party or their child’s sports practice. Frankly I’m tired of exposing myself personally while trying to help patients who just don’t give a damn or who are all about instant gratification.

Today I had every room in the center fully utilized, some rooms with 2-3 patients in them as part of a family unit, and was still 10-deep in the waiting room (which was actually 10-deep with people waiting in their cars in 90-degree weather.) Fortunately, I had my favorite physician assistant to help me fight the battle and we kept each other’s spirits up. We could only be described as “medieval warrior meets LL Bean” since I was wearing a modified welding face shield that looked like I meant serious business, and she was wearing a face shield with plaid trim. Based on our shifting case mix, I’m once again isolating in a corner of the house mostly away from others, and I guess if it continues to get bad, I could always go back to staying in a tent in the yard.

At least I’m a fully trained physician and making the choice to expose myself to this craziness voluntarily, which can’t be said of the thousands of resident physicians who are staffing hospital beds and clinics across the country. Earlier this month, residents in New York staged a walkout at their Brooklyn hospital, sharing a list of demands they want met prior to a potential second wave. During the peak of the surge, residents felt alone and abandoned by their facility’s leaders, forced to cope with a lack of supplies and little recourse. I found the statistics in the article staggering, including the fact that by May, a whopping 70% of the emergency medicine residents had tested positive for COVID-19. Residents also cited 160 patients in an emergency department that was 100 patients over capacity. Needless to say, this is not ideal.

A couple of readers have asked why I focus so much on the “in the trenches” experience lately rather than writing about healthcare IT. In addition to it being what I’m living on a regular basis, it’s something that all of us on the technology side need to understand. Organizations are trying to roll out numerous solutions to help solve problems and make things smoother for us, but I truly believe that to be effective in that effort they need to understand where we are, physically, mentally, and emotionally. We’re not going to show up on a web-based training session when we’re post-call and exhausted, and if we’re not focusing on what a trainer is saying because we haven’t eaten in 10 hours and really need to go to the bathroom, it’s something that should be considered.

I’d be interested to hear from readers on how your organizations have modified rollout plans for new solutions or how you’re addressing changes to functionality while your end users are on the edge. Are you making tweaks to try to streamline systems, or are you staying static to allow people to focus on other matters? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/25/20

This week has been absolutely crazy, with plenty of firefighting of both the informatics and clinical varieties.

A client that I did a quality project for last year is in the middle of an EHR go-live with “virtual elbow support,” but they had no physician super-users identified. Hard to believe, but there are still physicians out there who feel like they really need to learn it from a physician. For the client, figuring that out right before the go-live was a big miss. I’ve been playing WebEx Whack-a-Mole with a couple of physicians who won’t listen to the resources right in front of them and trying to convince them to get with the program. I’m always happy to help clients who are in a rough place, but it’s exhausting.

At the same time, my clinical practice has been having record-breaking days that make the “Flumageddon” season of a couple of years ago look like a cakewalk. They’re constantly pleading for people to come in on their off days, and I’ve covered a couple of times just so the physicians who are scheduled can have a break to sit down, eat, and have a minute to themselves. Still, it’s a never-ending revolving door of COVID swabbing, antibody testing, and processing of lab results as well as following up on infectious patients. Add in the usual summertime orthopedic injuries, lacerations from whacking the back of your head on a diving board while trying to execute the perfect cannonball jump, and a couple of ruptured appendixes in patients who were “afraid to go to the hospital” and it’s a recipe for disaster.

We’re leading the region with antibody (serology) testing, and I have to say I have mixed feelings about it. The visits take a tremendous amount of time, as we counsel patients to understand that having a positive antibody test isn’t the immunity passport that they thought it would be based on what they saw on Facebook. Many of the patients had respiratory infections in January or February and we have to explain that with that timeline, it’s much more likely that they had flu or bronchitis or one of the other garden-variety illness that was going on.

The rates of positive antibody results in my area are low, and although it’s good data from the public health perspective, it doesn’t do anything for the management of individual patients and it sure adds a lot of cost to the healthcare system. Since most insurers are covering it 100%, patients are eager to feel like they’re “doing something.” The American Medical Association continues to be vocal in spreading the word that antibody tests aren’t the path back to our old normal. We still know too little about what protection antibodies might provide or how long it may last, and there are risks for both false-positive and false-negative tests.

The traditional July 1 start date for new interns and residents is less than a week away, and I don’t envy them the weirdness that they’re walking into. I was glad to read this heartwarming piece about a mother and daughter who both graduated from medical school this spring and matched together for residency. The elder Dr. Kudji had been a registered nurse and a nurse practitioner prior to entering medical school in her 40s and matched in family medicine. The younger Dr. Kudji will be pursuing a residency in general surgery.

Another piece sent by a reader tugs at the heart strings: A pediatric cardiologist in Bolivia was challenged to find a machine to create implanted devices to fix heart defects through a non-invasive procedure. He turned to the country’s indigenous women to weave the amazing devices by hand, often using a single piece of wire. It’s worth the watch just to see the devices in action as they deploy.

Less heartwarming was the invitation I received from the American Telehealth Association for their virtual conference, a mere three days before the multi-day meeting was to start. They must be desperate for attendees because they offered a code for $350 off the regular $650 registration price. I don’t know of too many physicians who can clear their schedule with just a couple of days’ notice. InTouch Health did a must better job promoting their upcoming conference with more than a month notice. The July conference is free and features multiple tracks, including a COVID one.

This week, CMS announced the creation of the Office of Burden Reduction and Health Informatics. It’s designed to continue the “work of reducing regulatory burden to allow providers to focus on patients instead of paperwork and reducing healthcare costs.” It appears to stem from the Patients over Paperwork Initiative (with CMS stubbornly refusing to capitalize the O, for some reason).

The CMS press release touted its successes, but as a frontline urgent care clinician, absolutely nothing has changed as a result of this ongoing work. My staffers are still collecting plenty of data elements that aren’t helpful at the point of care for the conditions I’m treating in the majority of my patients. There may have been benefits in reporting and streamlining of conflicting initiatives, but that doesn’t help us in the exam room.

CMS Administrator Seema Verma was quoted as saying the new office will “increase the use of health informatics” and I’m as eager as the next person to see what they have in store. Perhaps we could start with a nationwide unique patient identifier, since CMS says that “fostering innovation through interoperability will be an important priority.” That will also help with their goal of “new tools that allow patients to own and carry their personal health data with them seamlessly, privately, and securely throughout the healthcare system.”

From Just Betty: “Re: BJC HealthCare. Check out this data breach notification letter from one of its flagship hospitals. The return address on the letter is for a construction company in Sacramento, CA. Do you think it’s a scam?” There’s nothing quite like following one unfortunate event with another one. In this case, some suspicious activity in employee email accounts resulted in an investigation that was “unable to determine whether the unauthorized person actually viewed any emails or attachments in the employee email accounts.” Compliance officers reviewed the contents of those email accounts and found patient information that may have been accessible, including patient name, date of birth, account number, diagnoses, medications, providers, treatments, and facility locations. It’s hard to believe people are still emailing files around that contain PHI. The return address does indeed belong to a construction company 2,000 miles away from the corporate headquarters. In addition to looking for some employee training to prevent phishing, I bet they’re also looking for a breach notification vendor.

A reader sent me a link to a paywalled article about a “recovery area” at New York City’s Mount Sinai Beth Israel hospital. Designed for healthcare workers who need to escape, it features recliners, music, and aromatherapy to reduce stress. They’ve opened more than 10 rooms at different facilities and note a self-reported reduction in stress after only a 15-minute visit. Since this was the week I was supposed to be volunteering at a camp which is instead holding “Virtual Summer Camp,” I’m de-stressing in my yard. Today’s challenge was to build a camp gadget or campsite improvement. I’m not sure what my neighbors think of my COVID-essentials dispenser, but my fellow virtual campers enjoyed it.

What’s your favorite knot or lashing? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/22/20

Former CMS Administrator Donald Berwick was featured in the Journal of the American Medical Association last week, writing about “The Moral Determinants of Health.” I was glad to see it, as I sorely needed a break from COVID-related literature and from the ongoing firefighting related to the pandemic’s many downstream impacts. Given the level of turmoil in our society right now, coupled with a disease that is disproportionately affecting various segments of the US population, it was just the read that I needed.

Many of us chose careers in medicine because we wanted to make a difference. Those of us who selected the realm of primary care knew we were taking on the challenge of being among the lower-paid and often less-respected subspecialties, but that was often balanced out by the knowledge that what we would be doing would be important.

For many of our patients, we would be the first member of the healthcare team they would turn to. Our training would help us be uniquely positioned to help solve their problems, through promotion of healthy behaviors or the recommendation of medication therapies or surgeries when needed. We didn’t choose to fight insurance companies or administrators, but as we left residency training for the real world of healthcare, it was obvious we were going to have to operate in an environment for which we were ill prepared.

Whether or not a patient is insured often dictates the care a patient receives, and that quickly creates a line between the haves and the have-nots. My generation of physicians didn’t learn about social determinants of health (SDOH) in our training, but SDOH always formed an undercurrent as we rotated through various clinics and offices in different parts of town. Depending on the ZIP code, the care we recommended varied widely and was largely tied to factors that led certain patients to be sicker than others and whether they could afford to have the care the needed. I had been in practice for nearly a decade before I ever heard a label for this phenomenon.

Berwick notes how significant these factors are, stating that “the power of these societal factors is enormous compared with the power of healthcare to counteract them.” He mentions the “subway map” view of life expectancy, where life expectancies decline for every minute of a subway ride between the “have” and “have not” areas of cities such as New York or Chicago.

Berwick describes the lack of logic in how wealthy nations address health. Although science can identify social causes for poor health, we spend our resources on “expensive repair shops” including medical centers and emergency care, rather than on prevention. He notes a lack of political will to date in shifting the focus of spending upstream, where a difference could be truly made. He mentions the concept of moral determinants of health, one of which is “a strong sense of social solidarity in the US.” In this construct, “Solidarity would mean that individuals in the US legitimately and properly can depend on each other for helping to secure the basic circumstances of healthy lives, no less than they depend legitimately on each other to secure the nation’s defense.”

He goes on to describe the foundations of a “morally guided campaign for better health,” which includes such concepts as the US catching up with the rest of western democracies on such topics as ratification of international treaties and conventions on basic human rights, action on climate change, and statutory support for healthcare as a human right. He notes that “no sufficient source of power exists to achieve the investments required other than discovery of the moral law within… the status quo is simply too strong. The vested interests in the healthcare system are too deep, proud, and understandably self-righteous; the economic and lobbying forces of the investment community and multinational corporations are too dominant; and the political cards are too stacked against profound change.”

Berwick ponders what it means for healthcare to stay in its lane and whether health leaders should take on these social challenges. He believes that the healthcare community needs to go beyond caring for illness, and that “it is important and appropriate to expand the role of physicians and healthcare organizations into demanding and supporting societal reform.” He calls on the healthcare community to spend less time lobbying for regulatory relief and improved reimbursement and more time lobbying for universal health insurance coverage. He calls for the healthcare workforce to use the ballot box to drive change. He closes with this:

Healers are called to heal. When the fabric of communities upon which health depends is torn, then healers are called to mend it. The moral law within insists so. Improving the social determinants of health will be brought at least to a boil only by the heat of the moral determinants of health.

The physician community is a microcosm of our society, and I know plenty of physicians who would rapidly align either for or against these ideas. I spent time this weekend with a surgeon who is “so over this whole COVID thing” and just wants to operate, and also with a psychiatrist who is helping others deal with the trauma they’ve experienced from having multiple family members die due to the pandemic. They’ve had dramatically different exposure to the downstream effects of the pandemic, even though both “healers” live in the same ZIP code and their kids go to the same school. We have to find a way to get past the polarization and to see things from other’s perspectives rather than just shutting them out because we have different experiences that may have driven different viewpoints.

I’ve learned of healthcare organizations that are tackling these issues head on and others that are trying to go back to the pre-pandemic, pre-protest era we lived in prior to 2020. It will be fascinating to see how strategies evolve and what organizations are willing to shift revenue upstream to public health and community projects that might just eliminate good portions of certain service lines.

Berwick has certainly given us food for thought, and it’s an ambitious list of actions he proposes. However, we just picked one of them, such as the idea that healthcare should be a human right, and figured out how we could come to consensus, we would still be in a much better place.

Is your organization addressing the moral determinants of health, the social determinants of health, or just trying to figure out how to get elective procedures scheduled again? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/18/20

More than 100 professional groups are lobbying Congress to create a safe harbor for COVID-19-related litigation. They are advocating protections against bad-faith legal action for primary care practices and physicians. The Coronavirus Provider Protection Act (HR 7059) would provide liability protection for services that are provided during the COVID-19 public health emergency period and for a reasonable time after the emergency declaration ends. It specifically notes issues around services that are provided or withheld in situations that may be beyond the control of physicians and facilities (e.g., following government guidelines, directors, lack of resources) due to COVID-19.

The threat of lawsuits hangs constantly over physicians. I’ve seen the toll it causes, both financially and emotionally, even if a case is dismissed. Some cases are filed well after the care was delivered, and we know that over the last six months, there has been quite a bit of care delivered that doesn’t follow published guidelines for a variety of reasons (including lack of guidelines, lack of appropriate personal protective equipment, lack of medical equipment, etc.)

Although some states have passed protections, it would be good to have a national standard, especially for providers who practice across state lines. There is also plenty of lobbying for protections in other industries, where workers might claim that their employers didn’t protect them adequately from the pandemic or that they were injured as a result. I see the waters becoming muddied rapidly and wouldn’t give the House bill good odds for passage. I would, however, give good odds on the US legal system becoming more entertaining if attorneys and judges started wearing wigs.

Since most of my summer fun has been canceled, I’ve used the time to wade through scores of emails that I intended to answer and were pushed down the inbox by the pandemic. I had missed the announcement of the newest tools from Athenahealth’s Epocrates division, one of which delivers consensus guidelines on drug therapies. The main data table includes not only the recommending bodies, but also the date of last update in a clean format, which is great for those who don’t want to try to sort out the status of multiple recommendations on a daily basis. There’s also a tool for drug therapy trial updates and a great listing of COVID-19 resources, including key points about clinical conditions that can be related to or mistaken for COVID-19.

As a consultant, I’m getting a little twitchy about the fact that I’ve spent three months in the same city without any travel. I’d love to get back on the road, spending time in other parts of the country and meeting people, but I’m not sure those days are ever coming back.

As much as I miss travel, I don’t miss being in a corporate office setting every day. As people go back to work, the CDC has recommended significant changes to US office settings. Recommendations to those returning to office jobs include temperature / symptom checks, distancing of desks (with plastic shields where spacing them out isn’t possible), and face coverings. All those organizations that spent money tearing out cubes and individual offices in favor of open-plan concepts are probably kicking themselves as they try to bring people back.

In a slap to the environment, CDC is recommending avoidance of mass transit or carpools in favor of solo transportation. Employee perks like communal coffee machines and snack stations are out as well, in favor of prepackaged, single-serve products. Not surprisingly, some companies are deciding that it’s better to keep workers remote and cut their office overhead. Even when I was in a corporate role, I was more productive on my “work from home” days due to the lack of interruptions and ability to frequently relax my brain with a distraction, even if it was moving laundry from the washer to the dryer between conference calls. We’ll have to see what productivity looks like over the long term.

It’s been a while since I’ve been up close and personal with concerns about my facility having Certified EHR Technology, so I enjoyed reading this recent ONC blog about the ongoing certification process. The 21st Century Cures Act requires the Department of Health and Human Services to establish Conditions and Maintenance of Certification requirements for the ONC Health IT Certification Program. There are seven Conditions of Certification that vendors will have to meet, along with ongoing Maintenance of Certification requirements. As physicians who have dealt with our own Maintenance of Certification pains, welcome to the club.

As tiresome as I found the Information Blocking requirement to be (everyone talks about it, no one does anything about it), I was intrigued by the Communications requirement. It prevents health IT developers from restricting or prohibiting communications about usability, interoperability, and security of certified health IT modules. I’m sure some vendors will continue to apply plenty of pressure to prevent such discussions, but would love to see some clients come clean about how awful their technology really is before others buy the same tired software.

Those who know me going way back know that I initially dreamed of being not just a doctor, but the first doctor on a long-term space station assignment. Needless to say, that didn’t work out (much to my parents’ relief, I’m sure), but I still enjoy keeping track of what goes on in the next frontier. I enjoyed the recent GlobalMed blog talking about the role of telemedicine in space exploration. It included discussion of the similarities between space travel and research in undersea environments and the need to to use data-driven approaches and technology to solve clinical problems when humans are hundreds of miles above the earth’s surface. If you’ve ever seen the story of the Antarctic explorer who performed his own appendectomy, it gives new meaning to crisis standards of care.

There is so much we have to learn about our potential to live and work in space and the role of technology in making it happen. For instance, we’re just figuring out how to bake chocolate chip cookies in orbit, which would definitely be on my wish list.

What did you want to be when you grew up? How close did you get? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/15/20

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/11/20

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/8/20

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/4/20

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/1/20

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/28/20

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/21/20

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/18/20

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/14/20

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/11/20

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/7/20

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.