EPtalk by Dr. Jayne 2/20/20

I’m all about the data, but I’m not happy to have been faked out by this year’s influenza numbers. We were lulled into a sense of hope by what appeared to be an early peak followed by a decline in flu cases, only to have a second (and higher) peak.

To date, there have been 26 million cases of influenza and 14,000 flu-related deaths, including 92 children. We’ve been seeing a lot of influenza pneumonia in the practice and I’ve just about washed all the skin off my hands. I hope we start to see the end of this soon. Everyone’s keyed up about COVID-19, but few average people are aware of how many people influenza kills each year.

I had a chance to connect with a colleague who lives in Taiwan and who was looking for in the trenches commentary on what people in the US think about COVID-19. He and his family have battened down the hatches for the most part and his children’s school is closed until the end of the month as a precaution. Fortunately, he telecommutes to a job in the continental US, so his livelihood hasn’t been impacted. He’s going to keep me posted from the man on the street perspective as the situation unfolds.

It’s definitely starting to get interesting at work, as we are having difficulty with supplies that typically originate in China, including masks, gowns, and other disposable sterile supplies such as staple remover kits. Fortunately, we have a good stock of standard surgical instruments that can be autoclaved for sterilization, so it’s just a question of shifting to that workflow. Nothing beats a good pair of precision surgical scissors from Germany, so I’m not complaining.

Based on the flu and COVID-19, I expect to see an increase in vendors at HIMSS selling supplies to keep the workplace safe, including washable keyboards, touchscreen covers, sterilization carts, and more. I haven’t received any mailings from them or invitations to any booth events, so if you’re in this part of the industry and you’re not strutting your stuff, you might be missing out. I enjoy touring all the booths that have practical items to promote and aren’t just full of buzzwords and the stuff of pipe dreams. If you have something cool for us to check out, drop us a line and let us know your booth number. We’ll do our best to make it by.

For a while, I was doing quite a bit of consulting around Patient-Centered Medical Home, so I spent a lot of time on the National Committee for Quality Assurance (NCQA) website. That business kind of died down and I drifted away, so I was happy to be drawn back by their involvement in the pursuit of Natural Language Processing. Their recent blog covers NCQA’s efforts to convene a NLP working group to help them explore how the technology can be used for quality measurement and reporting. The group includes representatives from Apixio, UPMC, and Wave Health Technologies.

The working group is focused on approaches to ensure that data generated from NLP is accurate. It plans to work toward developing a standard for validating NLP data. Since the working group is vendor focused, NCWA will be running parallel meetings with an independent advisory panel that includes NLP experts and researchers who will also weigh in on the potential validation model. I’ll definitely be keeping an eye on their work and how it might impact frontline clinical organizations.

I recently caught up with a vendor friend to talk about their strategy for the new Evaluation & Management coding guidelines that will come into play in 2021. The guidelines are designed to allow physicians to be paid without the onerous documentation they had to do in the past, which theoretically would allow vendors to tailor their clinical documentation to the actual clinical scenario rather than allowing physicians to bill at the highest level possible. I’m looking forward to not having to do more of a Review of Systems than is actually relevant for the visit and to writing notes that are closer to “Strep: Penicillin” than to the multi-page nonsense we generate today. I hope multiple vendors are looking at ways to make documentation easier as well as more coherent.

Time to “Ditch the Disk” in healthcare. Various tech leaders are encouraging the healthcare industry to move beyond CD-ROMs and make sharing images as easy as sending a text message. The task force meets every few months and looks at ways to improve the process. My organization burns an incredible number of discs every month and I’m sure they wind up in piles at patients’ homes, so I’m all for it.

I’m excited to report that readers are responding to my plea for pre-HIMSS shoe shopping tips. Apparently Jeffrey Campbell boots come highly recommended, with one reader noting “I have three of these…  I can even wear them with a broken toe.” That’s high praise indeed. I’m disappointed they don’t have them in my size in the red and blue snake pattern, because they’d be perfect for my upcoming trip to Washington, DC. A little bird told me you can sometimes find them on third party sites, so I’ll have to check them out. I definitely need something comfortable because I’m going to be hitting all the military memorials with a group of Honor Flight veterans.

Another reader recommends Irregular Choice, saying, “My artist sister is obsessed, and I am tempted to peruse their men’s section for the show floor.” I was completely blown away by their creations, especially the Muppets and Disney options. If I had an endless shoe budget, I could definitely go crazy there.

Good luck on your HIMSS prep. As usual, I’ll be on the lookout for the best reader footwear (both shoe and sock varieties). Will your shoes make the hall of fame or the hall of shame? What are your other favorite sites for awesome shoes? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/17/20

It was a wild and crazy weekend, as I got to experience what it was like to get rained on with 100,000 of my closest NASCAR friends. The race was postponed, so I get to do it again Monday, minus the presidential visit and military flyover since I doubt they’re going to send Air Force One and the Thunderbirds again.

I’ll be spending a lot of time in airports trying to get home due to the changes. When I fly, I usually try to catch up on continuing education or read something for my book club, because it doesn’t matter as much if I get distracted versus trying to do actual work. Most of my continuing ed journals are in the realm of emergency medicine or primary care, so I was happy to run across an interesting read in the healthcare IT arena.

A couple of days ago, a “published ahead of print” manuscript authored by some prominent clinical informaticists made some waves. Appearing in the online version of the journal Academic Medicine, it addresses the idea of commercial interests in continuing medical education, and how electronic health record vendors play a role.

Looking back 20 years, there was a great deal of continuing education that was sponsored either directly or indirectly by pharmaceutical companies. During medical school, pharmaceutical representatives would bring breakfast to a session with the not-so-subtle title of “Drugs and Donuts.” They would talk about their products and when they should be used, and I don’t doubt this led to heavy prescribing of the products.

A few years later, this evolved to a more subtle sponsorship of our Grand Rounds lunchtime lectures, where it was obvious who was paying for the steaming pans of sweet and sour chicken and what drug they sold. The reps no longer addressed the crowd, but were available to detail folks afterwards and hand out promotional items. At my school, some of these sessions were accredited for formal continuing education credits and the objectivity of the program was addressed, but others were much looser.

As the authors note, the Accreditation Council for Continuing Medical Education (ACCME) won’t give accreditation to commercial entities that produce, market, resell, or distribute health care goods or services used by or on patients. However, they will accredit academic institutions and other bodies who want to provide credit for courses they sponsor, and those institutions can accept pharmaceutical funding.

For now, ACCME doesn’t categorize EHR vendors as commercial interests and thus provides them accreditation to deliver continuing medical education. The authors note, “Like pharmaceutical company-sponsored CME events, EHR vendor activities, which inherently only focus on use of the sponsoring vendor’s EHR system despite its potential intrinsic limitations, can lead to physician reciprocity. Such events also may inappropriately influence EHR system purchases, upgrades, and implementation decisions. These actions can negatively influence patient safety and care.” They continue to “call on the ACCME to recognize EHR vendors as commercial interests and remove them from the list of accredited CME providers.”

I’ve had the opportunity to attend CME sessions put on by multiple vendors. They vary greatly in their content and how much general education is given versus how much it is really just a veiled training session. Some of the best sessions I’ve been to revolve around newer models of care delivery such as Patient-Centered Medical Home, Chronic Care Management, or Transitional Care Management. A good session will include an in-depth discussion of how the programs benefit patients, what they entail, how to bill for them, and what outcomes you might be able to glean from using them. Only a small percentage of the session is actually learning how to document the program in a given EHR. Bad sessions are little more than click-by-click directions for how to use the EHR, with CME provided to entice providers to attend when they otherwise didn’t participate in training.

I fully agree that being able to execute a workflow well in the EHR is beneficial to patients, as their data is more likely to be documented accurately and comprehensively. That doesn’t necessarily make a class worthy of continuing education credits, but I’ve seen it done.

The authors go on to explain why EHR vendors should be considered commercial entities. They note, “Even though the 21st Century Cures Act excluded EHR systems from the Food and Drug Administration’s (FDA’s) oversight they should be considered medical devices similar to pacemakers, insulin pumps, and CT scanners, which are all under the purview of the FDA. No other commercial device or technology is used more often by physicians and other health care professionals than EHRs.”

One of their major points is that when EHR vendors sponsor CME sessions, they focus only on the vendor’s system and its benefits without mentioning competitor options. “Because every EHR system has intrinsic limitations, attendees are not adequately trained on alternate ways to solve problems… Instead of learning best clinical informatics practices and challenging the vendor to improve its product, attendees are presented with only the vendor’s worldview, which may result in their suboptimal or inappropriate use of EHR products or services on patients.”

One of their comments particularly resonated with me: “EHR vendors focus physicians’ attention on future enhancements to their systems so physicians may miss opportunities to implement available solutions that are more congruent with the needs of their patients, organizations, and the community.” I’m still waiting for an enhancement I requested back in 2006, despite the fact that other vendors include the request in their core functionality. Because the vendor kept promising it, there was no way my employer was going to fund an alternative solution.

The authors made some outstanding points, which was to be expected since several of them are leaders in the American Medical Informatics Association. This fact prompted a statement from AMIA noting that the article wasn’t reviewed or endorsed by the AMIA board of directors. Regardless, the AMIA statement calls on the ACCME to “recognize and consider the potential for bias when HIT vendors offer education to health care professionals” and goes further to urge ACCME to define EHR vendors as “commercial interests” in the same way that pharmaceutical or device manufacturers fit the definition.

AMIA states that although education on the use of EHR products is appropriate and relevant, it may not be appropriate for continuing education credit. The AMIA board asks CME organizations to “establish rules and processes by which they may support certified CME in a manner that is independent and unbiased,” just like drug and device companies must.

Knowing what I know about the ACCME, it will likely be some time before they respond to these calls to action. I’ll be curious whether they make a decision or whether they take it under advisement for further review. For many physicians who stay current in their specialties, it’s not hard to accrue all your required CME hours without relying on vendor-sponsored hours. Many of my colleagues have two to three times the number of mandatory hours simply but doing what they’re already doing to further their knowledge for patient care. I’ve got a couple of friends on vendor CME committees, and I’ll reach out and report back on what they have to say.

What do you think about EHR vendor-sponsored continuing medical education credits? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/13/20

My HIMSS schedule planning is being hampered by some kind of bug in Outlook, where the time zones aren’t displaying correctly for HIMSS week. They are accurate the weeks before and after, but the week of the 8th is a mess. I suspect it has to do with the time change to DST, but it’s weird. I’ve asked a couple of other Outlook users and they’re not having the issue, which leaves me doing all kinds of shenanigans with my calendar to make sure I know when and where I need to be. If you have any tips on this, or are seeing it yourself, let me know. I doubt too many people run three time zones on their calendars, so it may be a fairly limited problem.

Signing up for events at HIMSS is becoming more complicated. Gone are the days when you could just attend vendor events as a mere HIMSS attendee. Citrix is requiring people to be “qualified” to attend and will get back to me in 48 hours to let me know if I’m on the list. Others such as Capital One / Ziegler are a little more accessible. One of the things I loved about HIStalkapalooza was that everyone was invited – there was a great mix of people which led to lots of interesting conversations. I respond to invitations with my real name and credentials, so I’m getting a feel for how the average attendee is handled.

I worked some unscheduled clinical time this week in order to cover a colleague with influenza. I was surprised that the EHR had been upgraded with no notification or explanation. Although the changes were minor, it created an unsettled feeling as you wondered what was different that you might be missing. Although some of the enhancements were nice, a few missed the mark in that they were only partial fixes to issues. Our vendor is going through some growing pains and I’ve heard good things are coming, so I’ll remain optimistic.

The lack of notification may be part of an overall change in communication patterns for the practice, and not necessarily for the better. I’d love for them to hire me to put on my standard “Effective Communication Strategies” workshop because they’re not doing a great job. In order to prevent people’s email from being inundated, they’ve gone from a “push” communication strategy to a “pull” one, and unfortunately, it’s not working.

When I do my workshop as a consultant, I walk organizations through the creation of a communications matrix, where they define the different kinds of communications, the audience, and how they should best be delivered. For some critical communications, such as how to handle the novel coronavirus (now named COVID-19 by the World Health Organization), you might want to communicate in multiple channels and blast the important items to people via text or email.

Instead, our practice leadership sent an email that essentially said, “So that we don’t send you emails that would quickly become outdated, we’ve put everything on a website that you should check daily.” Unfortunately, the website doesn’t have a clear section that spells out “what’s new,” which means providers have to read through the whole thing and try to figure out what has changed since the last update. It’s not a terribly effective way to communicate key information in a rapidly evolving situation. I can pretty safely predict that people will just stop looking at it, much like they stopped looking at a quality improvement website that worked in the same way.

Several of my clients have reached out for advice on how to handle various aspects of the COVID-19 situation. If you’re not already freaked out about being exposed to germs because you’re part of the healthcare IT infrastructure, you might be when you hear the latest data. According to the Journal of Hospital Infection, coronaviruses can survive on surfaces for up to nine days, although the majority die after four or five days. Low temperatures and high humidity increase the lifespan. I wonder if vendors whose products include solutions for disinfection and sanitation will see an uptick in foot traffic at HIMSS.

I was glad to see that National Coordinator for Health Information Technology Don Rucker called out the hospitals that signed Epic’s anti-interoperability rule letter. He notes that only three in 100 academic medical centers signed it. He went further to criticize one of the signers, saying, “One of the signers of the letter is known for taking thousands of patients to court. If you take someone to court, that information becomes public discovery. Their medical care is now public. It’s part of the court record… Looking at protecting privacy, we need to walk the walk here as we look at who is saying what and letter-writing campaigns.” It’s always good to look below the surface – sometimes what you find is pretty interesting.

In other news from ONC, the Health IT Advisory Committee (HITAC) is launching a new task force, the Intersection of Administrative and Clinical Data Task Force. It will focus on connecting data standards to improve interoperability, reducing clinician burden, and improving efficiency. Additional information on task forces is available on the HITAC website.

A recent article noted that little news has come out of Amazon, Berkshire Hathaway, and JPMorgan Chase’s Haven since its founding. It last issued a public statement in March 2019. We’ll have to see if there’s any buzz around or after HIMSS. If anyone has anything to share, feel free to reach out and we’ll keep you anonymous.

If you’re still doing your Valentine’s Day shopping, there’s always the Samsung Galaxy X Flip phone, which launches on February 14 in the US. It’s got a slick one-inch OLED display on the cover that shows notifications when the phone is closed, and when the phone is open, you can use it as a full-screen or split-screen display for different apps. The screen is rated for 200,000 folds, which based on the phone habits of some teens I’ve seen lately, might last a year. Is $1,380 too much to pay for someone’s undying love and affection?

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/10/20

I’ve had a crazy couple of weeks working on a big project that finally reached a major milestone. Now I feel like I’m operating in a bit of a vacuum. I’m taking a break from the clinical trenches for a while and will be doing some traveling.

I have to admit that I feel a little guilty about having a couple of weeks where I’m not operating under multiple timelines. I do pretty well with work-life balance, keeping track of how many hours I actually work compared to my capacity. It started as a way to make sure I could stay afloat financially without an actual employer, but I discovered it was also a reflection of how much non-productive time I had so that I could better reflect on what I was doing with that time.

When I applied for medical school, the majority of applicants went straight through from their undergraduate institutions to medical school. There were a handful of people in my college class who did research or something else for a year before applying, but often that was because they weren’t sure they wanted to go to medical school. The students I work with now typically take at least a year off between college and medical school applications. Many are doing research or looking for ways to distinguish themselves from the growing pool of applicants. Others are studying and prepping for the Medical College Admissions Test (MCAT) that they didn’t take as undergrads because they didn’t feel they had enough time to study. Still more are taking post-baccalaureate courses to make themselves look more competitive.

Most of my scribes fall into the “study and prep” group. We’ve had some thoughtful discussions about what it was like back in my day (I never thought I’d be saying that, but here I am) versus how it is for them now. Initially, I thought that having time before they went to medical school might make them more rounded and less stressed when they finally got there, but I’m finding that the extra year or two might be adding to the overall stress level as admissions become more competitive.

Many other things have changed in medical education. For example, work hour limits and other protections that were designed to try to make the process more humane for learners. Additionally, students are much more digitally enabled and technology savvy than we were when I was in school. I wonder what kind of impact the combination of changes will have on physician burnout down the line. Will they see the EHR and other systems more as tools or mere annoyances rather than as their arch enemies? Will technology be able to evolve with their expectations?

Expectations are so important when we consider how we perceive things. I recently had a phone interview with a potential clinical employer. He’s someone I know from a past employer and perhaps that made him a little too comfortable as we were chatting. He made some comments about some of the other candidates he had passed on interviewing, generally around what he considered a relative lack of work ethic compared to physicians of his age group. I’m a little younger than him training-wise, but not much.

I was floored by the fact that he was only offering two weeks of vacation plus three days of continuing education for his potential new partner, regardless of their experience. In our area, most of the health systems are offering new grads three weeks of vacation plus a full week of continuing ed time. He seemed unaware of the competition’s benefits, which again had me thinking about expectations and how they influence our thinking.

It was in that frame of mind that I read the recent JAMIA article on metrics for assessing physician activity using EHR log data. The authors believe that reporting standardized efficiency measures would help experts understand the environments in which physicians practice. I don’t disagree that data is important, but it doesn’t take into account data about the practice patterns that physicians had before and to which they continuously compare their current experience, whether consciously or unconsciously. We don’t have many measures of total charting / message time for each eight hours of scheduled patient time, except in practices that were forward-thinking and performed time studies and optimization exercises.

I’ve done operational efficiency projects for the better part of a decade, whether as part of an employed CMIO role or as a consultant. Many of the measures that the authors hope to manage are often best addressed by non-technology solutions. These have been around a long time, but practices continue to be resistant to implementing them:

• Time spent prescribing and managing refills. I still see physicians who only prescribe medications a month at a time, or who won’t even give enough refills through the next anticipated office visit. Experts have long advised year-long refills for stable patients, yet this is still a struggle for many. I also see people unwilling to delegate refill authority to other clinicians, insisting on reviewing each request themselves.
• Inbox time per eight hours of scheduled patient time. This is another area where operational issues can have an impact. Is the inbox overloaded because patients want appointments and can’t get them? Is the schedule double booked, or has the practice taken steps to manage its panel size so that those who want appointments can get them and aren’t forced to leave or send messages? Does the inbox contain remote patient monitoring information that could be handled by ancillary team members?
• Time spent writing notes. I often see physicians who used paper templates or dictation macros in the paper / dictation world who won’t spend the time to create provider-specific defaults or templates within their EHR. I still do not understand why it is so difficult to convince these providers that spending a little time will benefit them later.

Even though we may not have data on legacy work patterns, the authors pose some excellent research questions that are important for future research, including the impact of staffing ratios on various endpoints. They also note challenges with implementation of the measurements, including EHR idle time-outs, variable definitions of “work outside of work,” and the variability of prep work done prior to clinic sessions. They also noted that not all work is done in the EHR – clinicians spend time on the phone with patients and colleagues, have family meetings, complete FMLA and other paperwork, and otherwise interact with patients and the care team.

The authors are careful to note that data capture may lead to “unintended negative consequences” as physicians change their behaviors because they are being monitored. Perhaps they will write briefer notes or otherwise be less comprehensive than they might otherwise have been because they will be concerned about the appearance of inefficiency. They also are clear that they “do not suggest that these new measures be included as requirements in any federal reporting programs.”

As much as quantitative research is important, I’d love to see a greater focus on qualitative research with regards to clinicians’ perceptions and expectations. Do their past experiences and biases inordinately impact their use of technology? What level of impact do other forces have, such as documentation requirements, payer constraints on diagnostics and treatment, and government regulations? How much do various stressors impact our performance and our level of compassion for our patients? It would take time and resources to examine these questions.

What do you think about standardized metrics for assessing physician EHR activity? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/6/20

Apparently some Advanced APM payments are going to be slowed for some providers as CMS is missing the banking information it needs to send the payments. The profiles of nearly 2,800 physicians are lacking, but I doubt those folks are likely to see the entry in the Federal Register that includes links to documents where providers can verify if they are on the list. Providers have until February 28, 2020 to submit updated banking information. The bonuses are for the 2017 performance year, so some of those providers may have retired or otherwise left practice.

Missouri is apparently going to try to get it in gear this year, as the state legislature has introduced bills to finally try to create a statewide prescription drug monitoring program. It’s the only state in the nation without such a database, although the St. Louis County database is used by a good chunk of the state in an attempt to provide better care for patients despite the actions of previous legislatures. Several state senators have said they’ll try to block it with a filibuster, and if they do, I hope their constituents think twice about voting for them again.

My practice’s “just in time” ordering habits have bitten us, as there has been a surge in mask purchases due to the novel coronavirus outbreak. Masks are apparently on backorder and our supplier isn’t sure when they’re going to be getting any, so we’re no longer giving them to patients and some offices are out completely.

I find our administration’s response to the issue to be lackluster since influenza is still a big issue in the community, having killed more than 10,000 people in the US. Some leaders act as if contracting the flu is just a given, and many of our employees are allowed to stay at the office working even though they should be at home resting. Yet another reason I’m keeping my eye out for a new clinical gig. There’s always telehealth, where my risk of being coughed on by a patient or colleague is zero.

Speaking of telehealth, some of the opposition I hear with regard to that particular care delivery paradigm revolves around “giving Z-packs like water.” The telehealth organization I work with is very particular about antibiotic stewardship and providers are monitored to ensure that antibiotics are given appropriately. I was glad to see some recent analysis on how traditional practices fare in this regard. The study looked specifically at Medicaid claims data over a 10-year period and found that nearly 45% of antibiotics lacked a clear indication for their use. Almost 28% of prescriptions had no associated office visit. The data was from 2004 through 2013, before the rise of telehealth and long ago in the dim ages when patients simply called the office and relayed their symptoms. Of those prescriptions that had an associated office visit, 17% of them had a diagnosis that was not infection related.

The authors note that current strategies to reduce unnecessary antibiotic prescriptions are targeted at the office visit level. However, I would argue that EHRs could augment this by flagging visits where providers prescribe antibiotics with no associated visit. Although an actual warning might be annoying, it would be fairly easy to report on the data and present it for clinicians to review and see how they compare to their peers. Of course, as virtual visits occur, there would need to be further sub-categorization to review those virtual visits specifically for rates of antibiotic prescribing. Other feedback could include in-visit alerts that an antibiotic has been prescribed with no corresponding appropriate diagnosis.

Other beneficial interventions fall in the realm of public health, which as we know is underfunded. Greater patient understanding of when antibiotics are indicated and how to take them appropriately would be the best intervention. I still see too many patients who “took a couple of leftover amoxicillins” before coming to the urgent care for evaluation, which is a failure not only in the current situation, but also in the previous episode of care. Providers also need to know how well they are performing in this regard. I know many physicians who don’t have a clue what their metrics are for antibiotic treatment of respiratory infections, and that’s a shame.

As a blogger, I read a lot of other blogs and the best one I saw this week was Jacob Reider’s, titled: “When sponsored CDS is a crime.” His commentary on the Practice Fusion debacle sums up what he calls “the tension between better health and better profit.” Apparently he had a ringside seat for some initial exploration of the slippery slope of sponsored clinical decision support that led to specific elements of the 2014 Edition of the Certification Criteria for Health Information Technology. He recalls a lunch meeting with Practice Fusion’s then-leader Ryan Howard where they discussed some of the ethics around clinical decision support. Reider is clear that he doesn’t think the opioid situation happened on Howard’s watch, and gives us some visibility into the CDS that was actually in the application. It’s well worth the read.

I also enjoyed this brief Bloomberg Law summary of the HIPAA-related issues that prevent physicians and patients from texting one another. The reality is that it’s time to update HIPAA. The world has changed significantly since the law was passed in 1996. The internet was just a baby then (Netscape Navigator, anyone?) and many people could barely dream of email, let alone APIs and Netflix. In case you’re wondering, other notable things from 1996 include the debut of the Motorola StarTAC flip phone, Dolly the cloned sheep, Nintendo 64, and Tickle Me Elmo.

From Longtime Reader: “Re: app data. Concerns about what happens with our data as we sign up for apps are worthy. That being said, with respect to the big corporate health systems (whether ‘not-for-profit’ or not), the cat has long been out of the bag. We sign away our rights to control our data under duress or blinded by bureaucracy the moment we cross the threshold. Indeed, my primary care doc’s front desk has a signature pad, with no visual presentation of what one is signing for, that memorializes the act, with only some mumbling by the lovely front desk staff about its significance.” I’ve taken to signing those signature pads with something that either only vaguely resembles a signature, or is fully legible but not my name. I’m still waiting for someone to notice.

My HIMSS prep is in full swing as I continue the quest for cute shoes that are comfortable as well. They have to work from day to night as I transition from the expo hall to the afterparties, which is a tall order for any footwear. If you have any suggestions, let me know.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/3/20

I’m in the middle of a rough clinical stretch, with Super Bowl Sunday in the middle of it.

Most of the team members I am working with are young and relatively green. None had worked a Super Bowl shift before. I explained that we would be super busy until the game started, then it would get quiet, and then we would have a rush before closing for the people who stuck it out through the halftime show and then realized that they were sicker than they wanted to be and didn’t want to wait overnight.

I don’t think they believed me initially, but their worst dreams came true when we had seen nearly 60 patients in the first six hours of our shift. Influenza and strep throat were the main diagnoses, along with a smattering of strains, sprains, falls, and lacerations. As predicted, the patient flow dried up 45 minutes prior to kickoff, allowing us to catch up on the many incomplete charts that had accumulated.

I saw an interesting mix of patients, and for the first time, I had a patient who wanted to search my diagnosis on the internet right in front of me because she didn’t believe what I was telling her. I’ve had enough encounters with Dr. Google that it didn’t phase me, but she seemed surprised that what I was telling her was the same as what was on the internet. Eventually she came on board with the treatment plan, but we’ll have to see what she gives me as a rating or whether she leaves a review. I think she was expecting some other kind of care than what we deliver for her condition, but she didn’t say as much explicitly.

I much prefer when patients are clear with their expectations, and if they don’t agree with what you are proposing, that they say so. I asked my scribe for feedback and she said I seem accessible to patients and I am patient with their questions, so she’s not sure either why the encounter went the way it did. We want to empower our patients to be part of their care, but it’s difficult when there is a hidden agenda or when you don’t have all the parts of the story.

Speaking of patient engagement, I had several patients today who were trying to tell me about medications they had taken in the past and referenced their MyChart accounts. The medications were nowhere to be found, with only the current medication list displaying. The patients all said that they could see the older medications previously, which makes me wonder if the health system made a change to their display settings. The health system doesn’t include visit notes in the patient-visible record so that wasn’t an option either, and I couldn’t figure out the medication from what they described.

Regardless, it was frustrating for the patient. Trying to call the pharmacy on Super Bowl Sunday to validate a list of old medications just wasn’t going to happen. If this was the result of a software change, it would be nice for the health system to let patients know that the app would no longer display non-current medications so that they could adapt accordingly.

This is one of the core issues of interoperability. It’s not enough just to exchange the information, but if patients are to make sure of their health information, it needs to be in a format that is not only clinically useful, but understandable. Some of the things we as clinicians have learned to differentiate – such as the SNOMED-based problem list vs. the ICD-driven diagnosis list – are confusing to many non-clinical people. Information needs to maintain the original documenter’s clinical intent.

This is one of the reason I truly love the Intelligent Medical Objects solutions. They allow the clinician to document in words that they (and the patient) understand while still checking the box for the required underlying codes. Patients understand costochondritis a little better than they understand Tietze syndrome, which is just confusing. There also needs to be a way to differentiate episodic conditions that are relevant in an ongoing way (such as recurrent strep throat when parents are adding up the number of episodes that need to happen before their child’s tonsils can be removed) from episodic conditions that can often be just noise in the chart, such as occasional sinus infections, sore throats, or viral illnesses.

Some EHRs have made provisions for this. Providers can flag episodic conditions to move them from the diagnosis list to the problem list if they are pertinent, but that involves human intervention, reducing the likelihood that it will actually happen. Other EHRs require providers to retire diagnoses that aren’t ongoing, which is another step that may or may not actually occur.

Another favorite solution is Quippe from Medicomp, which allows users to highlight a finding and use it to identify encounters across the chart where related findings were documented, which is really cool. Maybe we can combine functionality like that with developing artificial intelligence solutions, marry it to a bot that will parse the chart intermittently and look for patterns that will identify what is relevant for ongoing documentation and what isn’t, and then display the data accordingly.

These kinds of solutions are what innovators should be looking for, not just creating better user interfaces for providers to mark up data. We need to be armed with great tools that look at our usage patterns and predict what we want to see next and how we want to see it. They need to understand our ordering patterns and dynamically create order sets that meet institutional rules, but that also allow us to do our work quickly and with a minimum of distraction. They need to look at how we’re prescribing and ordering and alert us if our behaviors are deviating from evidence-based best practices, especially if our organizations are scoring us against them, which many employers are. They need to be able to predict which patients are trending to higher risk and which can be managed in a more relaxed fashion, without us relying on potentially biased clinical experience or the Han Solo-like “bad feeling” about something going on with our patient.

As for me, the halftime show is wrapping up and we have zero patients on the board, so I’m headed to grab a snack and get ready for the rush.

What’s on your innovation wish list? What would really make your clinicians’ work lives better? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/30/20

CVS continues its transformation by opening Health Hubs in 13 of its Philadelphia-area pharmacies. The model was piloted in Houston and claims to “put patients at the center of their care” by offering services focused on health and wellness. Nurse practitioners staff the Hubs, along with pharmacists, to offer personalized care.

Although CVS leaders expect this to provide “integrated healthcare,” it remains to be seen how nurse practitioners who may have a limited scope of practice and pharmacists who are already in short supply will be able to effectively coordinate with primary care physicians and subspecialists. If they truly want to focus on controlling costs and delivering effective care, I’d like to see the focus on offering evidence-based treatments and avoiding nebulous “wellness” products, such as aromatherapy offerings. CVS plans to offer the model in 17 states by the first part of 2020. If you’ve had a chance to experience the Health Hub, let me know.

Elizabeth Holmes is in the news again as she represents herself in civil litigation, phoning in for a hearing in Phoenix. Attorneys apparently expect to be paid for their work, and since Holmes hasn’t paid her team in more than a year, her attorneys withdrew from the case. This litigation involves alleged personal injury related to faulty blood testing, with either missed diagnosis or unnecessary treatment as the outcome. Walgreens is a co-defendant in the case, and as the hearing began, Holmes stated that she will rely on the arguments made by her co-defendant’s legal team.

HIMSS is around the corner, and I’m missing Las Vegas. Even though I wouldn’t choose it as a personal travel destination, I much prefer it to Orlando for conferences. The access to restaurants and entertainment is much better in Las Vegas, and frankly, I’m just tired of Orlando. Las Vegas is mixing it up with a change to its marketing tagline, with “What happens here, only happens here” being the latest iteration. Supposedly the marketing agency has spent several years working on the new campaign, which seems like a long time.

I’m always looking for the next cool thing to see at HIMSS, and apparently Epic plans to debut “ambient voice technology” from Nuance at the show. I hope the Epic virtual assistant has a sense of humor like Alexa does, when she chides people who say sassy things to her. Supposedly the assistant, called “Hey Epic,” is being used by 20 organizations. If you’re using it, I’d love to report on your experiences (anonymously and confidentially, of course). Drop me a note if you have information to share. At HIMSS, they’re supposed to debut “conversational capture” along with automatic note creation, so it’s definitely on my booth list.

I’m starting to put together my HIMSS social schedule and have an opening due to one major vendor eliminating its client event this year. I haven’t gotten the backstory on why that happened, but it was always a fun party, with all the executives hanging out with the clients, so it will be sorely missed. I’ve already scheduled some lunches and meetings, so if you’re interested in having the HIStalk team report on your event, send the details our way. We’ll do our best to drop by, anonymously of course.

The Food and Drug Administration is warning healthcare providers and consumers about vulnerabilities in telemetry servers and clinical information stations that monitor patient vital signs. Security flaws can allow tampering with the devices to generate false alarms or silence genuine alarms on patient monitors that are connected to the systems. GE notified clients about the issue back in November, but posted additional information on its website this week. Although the FDA isn’t aware of any adverse patient events, GE is recommending that providers restrict access to the workstations, change default passwords, and isolate the affected devices from the wider hospital network. The interesting tidbit of this story is that the vulnerabilities were reported to GE by a third-party organization (CyberMDX) rather than by a client. It is unclear whether GE engaged them for routine vulnerability testing or how they came to be involved.

Precision medicine is a hot topic, but a recent article shows how difficult it can be to translate those results from the realm of research to the real world of patient care. From a panel discussion at the Precision Medicine World Conference, it appears that although the National Comprehensive Cancer Network offers guidelines on genomic testing, they are not regularly followed outside academic settings. Additionally, physicians and patients struggle to interpret the results of some tests. The results can impact not only the patients, but their potentially at-risk family members. Comparing what happens in community settings to the guidelines, only 8% of non-small-cell lung cancer patients and 40% of colorectal cancer patients received testing according to the guidelines. Panelists call for access to genetic counseling, along with a universal EHR, as potential ways to improve outcomes.

I’m intrigued by a new MyAnalytics feature from Microsoft that purports to give me visibility into my work habits. This week’s focus is on “wellbeing,” which it defines as the ability to “disconnect and recharge” as further quantified by “quiet hours” where I don’t have meetings, chats, or calls outside my working hours as set in Outlook. Apparently it knows that I worked on some documents outside my published work hours. Since this account belongs to a large health enterprise and I’m a contractor, I really don’t have work hours, but it’s fascinating to know that Big Brother is monitoring my work habits. I’ll have to see what the rest of my weekly reports reveal.

From Noteworthy: “Re: another tragedy in California. A vineyard spills 100,000 gallons of red wine. That could have satisfied a lot of thirsty HIMSS attendees.” It’s not only an oenological tragedy but an environmental one, as the wine contaminated the Russian River with the potential to damage water quality along its 110-mile route. The amount of cabernet sauvignon lost would fill eight tanker trucks. Officials note that about 20% of the spill was contained with the vineyard using vacuum trucks and a makeshift dam, but the effort ultimately failed.

What’s your favorite HIMSS beverage? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/27/20

The healthcare IT universe is atwitter (both figuratively and literally) about Epic’s opposition to the proposed HHS rules regarding information blocking. Although the rules are designed to speed sharing of patient data among hospitals, medical practices, and other care delivery entities, there are concerns that they don’t go far enough to protect patient privacy.

Opponents are claiming that relaxed rules will allow sharing of data with third parties that aren’t bound by HIPAA, resulting in patients losing control of their protected health information. HHS counters with the assertion that they “want the public to have computational right of access to health information so they can have control over apps of their choosing.”

Although choice is a lofty goal, the reality is that patients (and consumers in general) aren’t going to read the disclosures of how their data is used or what permissions an app might need to operate, which could open the floodgates of information sharing in ways they might not fully appreciate. On the other hand, data sharing is important for better healthcare – improved coordination of services, reduced duplication of testing, greater understanding of the patient’s whole condition, and more.

I see patients who regularly pull up their patient portal accounts and just hand me their phones, hoping I can make sense of their medication lists or what lab testing has been done recently. They know that the big health systems in town refuse to play nicely with independent providers, but they want us to have the whole picture.

It’s the digital equivalent of what the military did with charts for years. The patient would pick up their chart and take it with them to their appointments so that everything was at the provider’s fingertips. I used to love seeing those recently discharged military members in practice because it meant continuity in a way that I couldn’t get via fax or mail in the olden days before electronic data sharing.

I think it’s important for patients to understand that if they share their health information with third party apps that their data is no longer protected. This is the current reality for a good chunk of health data. Patients are giving their PHI freely to apps tracking fitness, fertility, calorie intake, sleep patterns, biometric factors, lab data, and more. They’re giving away their genomes to commercial testing providers without a second thought, mostly because they haven’t read the fine print.

I’ve heard the call for protection of health information regardless of whether it’s in the hands of a HIPAA-covered entity or not. That is starting to look like a good idea. Maybe it’s time to broaden the definition of PHI and hold everyone who handles it accountable for keeping it protected.

Maybe it’s also time for HHS and other agencies to fight information blocking in ways that don’t involve vendors. My state’s HIE is one of the most pathetic in the nation, with high costs to hook up to it and other barriers to participation. Although the big health systems are feeding it data, it’s cost prohibitive for small organizations or independent providers to connect. How about some grants to eliminate those barriers? Or how about tax breaks for providers who want to connect for better patient care? How about allowing individual providers to go through a credentialing process to be able to log in to see whatever patient data they need to get the job done, just like they do now for prescription drug monitoring programs? Why all the mystery about having to have a practice or institutional login? It drives me crazy, because when I moonlight at the hospital I can access the HIE, but when I’m out at the little practice on the prairie where the data would be most beneficial, I’m in the dark.

There are more pieces to the puzzle then just requiring vendors to jump through interoperability hoops. We need to require healthcare providers to actually comply with existing laws regarding records release and data sharing. Right now, there is little enforcement and little recourse for patients who are caught without their information.

Let’s also spend some money educating patients about their health and the importance of keeping track of their data, even if they have to do it manually. Sure, it’s cooler to do it on your phone or with an app, but even just keeping a file with copies of important labs is better than nothing. Three-ring binders aren’t sexy, but they’re cheap and you can still access the data when you forget to plug in your phone.

Patients don’t realize how important it is to keep track of their health when they’re healthy. I routinely have to restart people’s hepatitis vaccination series because they’ve lost the records of their immunizations and the pediatrician has long since retired. People become sick and realize they need “the binder” or “the spreadsheet” or whatever mode of data gathering they arrive at, but it’s too late.

Some argue that we shouldn’t put the onus on the patient. I would say that’s the only way to make sure their information is accurate.

I did a little View Download Transmit experiment on my own medical records at several different practices and found upwards of two dozen errors. There were diagnoses I’ve never had, medications I haven’t been on in years, and even a couple of lost pathology specimens. Managing that shouldn’t be entirely the patient’s responsibility, but there could be a better partnership between patients and providers to ensure that everyone had the information they need. There are simple workflows that enable this that very few practices do, such as sending the patient a copy of their health summary prior to the visit and asking them to bring any corrections to the visit. You could even (gasp) give the patient a printout of the information when they check in for their visit, ask for a markup, and then review it together. Seems easy, but there’s too often a lack of resources or lack of will to even make these small changes.

Although this is a hot topic for HIStalk and Politico and others, many people in the trenches have no clue. I had lunch with a CMIO friend today and she wasn’t even aware of the situation with Epic despite her role in an Epic-using organization. She works for the biggest information blocker in town, whose staff often refuses to talk to me after I refer patients to their hospitals. Go figure. I guess she wasn’t in Judy’s contacts list. Similarly, no one is fired up in my forums for women physicians or medical school alumni.

It has been interesting to educate people about this issue. I hope they start following what’s going on in healthcare beyond their daily survival routine.

Let’s put on our patient hats for a minute and reflect on what we think about the proposed HHS rule. Do you give it a thumbs up or down, regardless of how it impacts your working world? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/23/20

IBM has proposed measures to reduce concerns of bias in the use of artificial intelligence solutions. Critics have noted that AI technologies use data that can reflect past discrimination and may not accurately reflect health factors for women, minorities, the elderly, and disabled persons. IBM is urging industry and governmental agencies to work together to create standards to measure bias and prevent potential discrimination. It also calls on companies in the AI space to appoint ethics officials and to assess whether AI systems can cause harm.

I’m eagerly awaiting the arrival of useful AI systems in my clinical practice, since we perform primary readings on all of our so-called “plain film” radiology studies. (It’s been decades since I’ve seen any film, or smelled the delightful chemicals, and I certainly don’t miss it.) It feels like we sometimes over-call findings on chest X-rays, but without truly crunching the data it’s hard to tell, since we have an inherent bias because everyone who has a film is already pretty sick. It would be great to have AI backup or pre/post screening to make our lives a little easier and a little more evidence-based, while we wait the 30-45 minutes for a radiology overread.

I enjoyed reading this op ed piece about renewed efforts to combat medical errors. I’ve worked with a handful of systems recently that still struggle with the basics, including ongoing use of so-called “do not use” abbreviations. Some vendors seem to think that just because their product isn’t certified EHR technology that they don’t have to respect the standard conventions for safety and usability. The piece does treat a couple of issues too simplistically, blaming EHRs for physician burnout (I’d argue it’s not only EHRs but the mounds of regulations and data collection requirements that EHRs were designed to satisfy). There is also a lack of citations for key data points, such as the allegation that radiologists at one organization are viewing images at a rate of one every four seconds. I wonder if that state’s Board of Healing Arts has anything to say about that.

Applications for the CMS Primary Care First program closed this week, and I’ll be interested to see how many organizations signed up and ultimately what payers end up participating in the program. The initiative didn’t excite any of my clients, despite their detailed evaluation of the program’s different tracks and comparison of it to existing programs. The application process ran so far behind that they had to shift the program by a year, so I’m not sure anyone has too high of hopes for it.

I missed this newsy tidbit last week: The US International Trade Commission will be investigating Fitbit, Garmin, and other wearable devices following a patent infringement complaint by competitor Koninklijke Philips. At least in my community, interest in fitness trackers seems to have waned – no one talks much anymore about their steps or jumps up based on a prompt to MOVE! like they used to. I still use my Garmin watch to track my runs in addition to telling me the time, but I turned off the activity prompts and the display of texts from my phone, as I found them too disruptive.

My inbox has been overstuffed for the last couple of months, so I also missed this item: Hims & Hers telehealth is partnering with Ochsner Health System for coverage of conditions not usually treated through the Hims & Hers platform. They’re fairly small as a telehealth vendor with only 200 physicians, so I’m sure broadening their network will be a benefit. I’m not a fan of their sale of nonmedical consumer products such as beauty and skincare formulas, nor their sale of various supplements and alleged sex drive boosters. I’m not a fan of those in face-to-face practice either, as I think it’s hard to remain objective about pushing products if you profit from them, and I think the evidence on some of their products is thin at best. Apparently Ochsner isn’t worried about being on the slippery slope and they plan to launch the service first in Florida.

A good friend of mine has done significant work for tobacco quit-line services, so I was glad to see this article looking at EHR-based versus fax-based referrals to the quit lines. Long study short, the availability of EHR-based referrals produced referral rates at three to four times that of the current fax-based standard of care. EHR-based referrals were also more numerous for underserved populations. The key takeaway is that the easier the process, the more likely that clinical teams will do it – and if launching referrals from screens where the staff is already working does the trick, that’s a win for patients.

HIMSS is hosting a webinar on Monday, February 3 that caught my eye: “Monitoring Grandma: Adoption of Connected Health Tech by Seniors.” The objectives are to explore current tech trends in the older population, along with real-world experiences from clinicians using technology with geriatric patients. They also plan to discuss attitudes toward health technology at the community level along with how it should impact design and adoption. I’ve struggled occasionally with getting my Amazon Echo to do what I want it to do – maybe it’s my accent or maybe I’m just not using the right words. Or perhaps as I head farther away from the tender age of 29, I need to embrace the mythical Amazon Echo Silver.

Informaticists are discussing the recent surge in China of a novel coronavirus that has killed 17 people with more than 540 cases confirmed. Health systems in the US, especially those in major points of entry, are debating the addition of EHR screening questions similar to past outbreaks of Severe Acute Respiratory Syndrome (SARS) and Ebola virus. The city of Wuhan, with a population of nearly 12 million people, has shuttered local transportation systems, suspended outbound flights, and is asking residents to stay home. The new flu-like virus is suspected to have jumped to the human population from illegally traded wildlife at a Wuhan market. The World Health Organization will decide this week if this outbreak qualifies as a global health emergency, although airports are already screening travelers. Meanwhile, the United States has already seen over 9.7 million cases of influenza with 87,000 flu-related hospitalizations and 4,800 deaths (including more than 30 children) this season. Just something to think about.

Has your hospital added coronavirus screening questions to the EHR yet? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/20/20

On occasion, I’ve done consulting for groups who are trying to drive clinical outcomes through better patient engagement. Both vendors and healthcare delivery organizations have an interest in this, as they try to help providers capture incentives with value-based payment models or try to prevent unnecessary care. I’ve seen some unique and compelling apps that they expect patients to use, some of which try to gamify the healthcare experience. Other organizations are betting their money on patient portal functionality, and some are leveraging text-based solutions.

There’s a fine line, though, between trying to converse (whether electronically, face-to-face, or virtually) with patients versus using social medial platforms to try to reach specific clinical goals. I was interested to see this article in the Journal of the American Medical Association that looks at the potential role of social media in preventive health care. The authors start by noting Centers for Disease Control and Prevention data that indicates that more than 100,000 lives could be saved annually if patients in the US received clinical preventive services. These include basic elements such as vaccinations, tobacco use counseling, cancer screening, and blood pressure screening. They note key barriers such as access, cost, and awareness as factors that lead to inadequate delivery of services.

The authors note that “social media and other digital platforms that enable connectivity have unprecedented influence,” which to me is an understatement. The rise of social media “influencers” in many facets of life is somewhat surreal to those of us who have dedicated our lives to being expert in a field and trying to use evidence to guide what we say and do. In the world of social media, you can know fairly little about something, but if you present yourself well and have something catchy to offer, you can get thousands of people to begin following your every word. Sometimes notoriety is more important than knowledge or experience, and often consumers fail to understand the difference. With that in mind, I was skeptical about how social media could positively impact healthcare delivery. Not to mention, there are obvious privacy concerns where social media and personal health information intersect.

The authors specifically discuss the Facebook Preventive Health tool, which is available only in the mobile app. The app consumes sex and age data and matches it with guideline-driven preventive health services, also offering locations where users might want to receive them. The app uses a variety of guidelines from the American Cancer Society, American College of Cardiology, American Heart Association, and the Centers for Disease Control and Prevention. In looking at the app myself, they seem to pick and choose some of their recommendations, particularly where there are discrepancies between bodies such as the CDC and ACS. It’s also not very clear who is behind choosing the recommendations, and how they decided which set of guidelines to follow for any given condition. It’s also not clear how they decided what conditions to include or exclude in the tool. The app isn’t totally benign, as Facebook gathers user data about how individuals interact with the tool. Although the company claims they’re not sharing it with third parties, I’m skeptical.

The authors note that the Facebook Preventive Health tool suggests that users can share it with their networks. Although this can theoretically raise awareness of screening measures, it’s not clear whether such sharing actually drives health behavior change. They do cite a study on voting that showed that among 15 million Facebook users, direct messages encouraging voting influenced the behavior of individuals and their networks. However, they note that “a better understanding is needed in regard to whether information about preventive health propagates across users and how new users and influencers affect dissemination.” They also note some previous research that shows that “fact checking declines when information is presented on social media compared within an individual setting.” They cite the number of anti-vaccine “influencers” online and how misinformation can impact vaccine delivery. They go on to note that “for any health intervention on a social media platform, it will be important to determine how to assess the success of an intervention that includes vetted health recommendations on the same platform as misinformation.”

The authors note that privacy is an issue. While patients easily offer their personal data to apps, fitness trackers, and other platforms, they may not be aware how that data is used or that it can be combined with other data sources to personal data profiles that are beyond what they might normally share. I had a “wow this is scary” moment with one of my clients recently when they did just this – combining publicly available data that used only a name and email address to bring in demographic data, address information, and more, and ultimately created psychosocial profiles with specific predictions of income, educational status, political leanings, and other potentially sensitive data.

They go on to discuss the challenge of engaging populations that struggle to access health services – uninsured patients and those without primary care providers. Just making these patients aware that they need screening isn’t going to make family physicians create more openings for Medicaid or uninsured patients. The retail clinics mentioned in the app don’t offer a wide variety of services and the federally qualified health centers that are recommended might not have capacity to care for these patients either.

In the end, the authors leave us with more questions than answers. They note that it has always been a struggle when technology crosses paths with healthcare and there is typically skepticism of things that are new. Miasmas versus germ theory, anyone? They note the need for careful evaluation of the use of social medial platforms in driving public health needs, and the opportunity for partnership among healthcare delivery organizations, researchers, and the social media industry. These groups need to work together to enable studies of the interventions and definitions of a successful result.

This leaves me wondering, though – what would happen if specific social media influencers teamed up with reputable healthcare organizations to promote healthy behaviors? What if the Kardashians were hawking the concept of “eat less, move more” rather than “waist trainers,” which are essentially corsets? What if Goop sold “wellness” products that were actually based in science? What if famous rappers talked about taking their lady friend to get her pap test versus taking their daughter to get a “virginity test?” (Google it if you missed it in real life.) It has to go beyond getting former Surgeon General Vivek Murthy and HHS Secretary Kathleen Sebelius on Sesame Street.

What do you think about the role of social media in health promotion? Leave a message or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/16/20

Support of Windows 7 came to an end this week, and many organizations seem to be willing to take the risk that comes with not having security updates. My practice waited until the last two weeks to upgrade all the clinical workstations, resulting in countless hours being spent by end users rebuilding bookmarks, re-saving passwords and logins, and rearranging desktops as people try to get their computers to look and work “like they used to.” All of our staff rotates among a dozen or so locations, meaning they have to repeat the process multiple times because user profiles don’t sync across the organization. I think the most annoying piece was they didn’t announce they were going to do it, or which locations were going to be impacted, so every shift has been a little bit of a surprise.

The providers would have definitely preferred this be done in September or October, before the busy flu season hit. If I was wondering why I felt so beaten down after my last few clinical shifts, the month-end data explained it. My “patients per hour” metric was the highest it’s been since I’ve worked in the practice. Interestingly, even though patients had longer wait times and I had a couple of patients give me low ratings this month, my patient satisfaction score was the highest it’s ever been. I do enjoy being able to see data that explains what we’re feeling in the trenches, and being able to use it to improve how we work.

I’ve been reading reports from the recent Consumer Electronic Show. Many offerings have been over-hyped (“swim like a mermaid” had no tail) but others are kind of cool – the Mateo Smart Bathroom mat can track weight and evaluate posture while integrating with your phone, but the $179 price tag seems a bit steep. Withings has been in the health tech business for a while, and brings its clinically-tested ScanWatch, which is pending FDA approval. The cool part is its 30-day battery life. Kaiser Permanente is expanding its investment in a program using Samsung smart watches as part of a remote cardiac rehab program, with current technology showing promising results, so we’ll have to see what the next generation of tech brings.

Not all the technology that caught my eye was tech-related – the Juno Chiller can chill a bottle of wine in three minutes, but for $299 I think I’ll plan ahead instead, or just keep a bottle perpetually chilled. Other products on display are a bit much – such as Kohler’s line of Moxie showerheads, which include a magnetic Bluetooth speaker that fits in the middle. I shouldn’t be surprised, as Kohler already has a Bluetooth bathtub that features lights and vibration in addition to actual water. The LuluPet litter box uses images of feline stool and urine to monitor cat health, and can distinguish between different cats as well as weighing them. Get ready to have a discussion with Alexa about your cat’s waste, because it’s integrated.

Technology doesn’t always make things better and I’ve found that for many people, it has resulted in significant time-wasting as they struggle to keep up with multiple social media channels. The concept of “time affluence” being at an all-time low in the US was addressed in a recent Dropbox blog, which noted that 80% of 2.5 million people surveyed felt they did not have the time to do everything they felt they needed to do. According to the piece, people who feel like they don’t have enough time are more likely to be depressed and anxious than those who feel they have adequate free time. That’s been my experience in real life – you can tell the people who thrive on deadlines from those who feel overwhelmed.

The blog cites data from the Bureau of Labor Statistics that shows that people have more free time than they did 50 years ago, but for many people it doesn’t feel like it. It attributes this feeling to “the digitization of society,” along with information overload, and the fragmentation of time. Feeling distracted increases the perception of time stress. The blog also calls on companies to set protocols that enhance available free time, and practice them. I still see companies that don’t set appropriate rules for meetings and that fully support time-wasting practices such as double booking of meetings and not allowing people enough control over their calendars so that they can actually get work done.

Time is running out for anyone interested in the Primary Care First payment model and who hasn’t yet applied. Practices have until January 22 to apply. Modeling by the American Academy of Family Physicians “indicates that it should consistently work better than the Medicare Quality Payment Program’s Merit-based Incentive Payment System, even for those getting the maximum MIPS bonus.” They go further to say that the ideal successful practice will have at least 600 Medicare fee-for-service beneficiaries and should already be involved in value-based programs with Medicare Advantage or managed Medicaid.

Time is also short for those who are awaiting the ONC final rules on interoperability, which are expected late this month. The rules went to the Office of Management and Budget for review in September. The ONC annual meeting takes place January 27 and 28 and might be an opportune time for an announcement. CHIME recently wrote to members of Congress noting that the proposed rule doesn’t adequately address concerns about health IT security for third-party apps that are not created by organizations covered under HIPAA. They are concerned that without protections, third parties will be able to share or sell sensitive patient information.

From Jimmy the Greek: “I know you enjoy the outdoors, did Santa bring you one of these?” He had me at the headline: “This Floating Tent Offers You A Cool New Way To Die While Camping.” I don’t think I’ll be adding it to my arsenal, given it’s hefty $1,999 price tag or its equally hefty 75lb weight. The tent has a graphic of a campfire on its floor – although it’s the manufacturer’s logo, I hope no one gets the idea that it’s an indicator that you should build a fire on the base of the floating dome that is your home. I think I’ll stay with my standard issue REI on solid ground.

What’s the wackiest gadget you’ve seen, from CES or anywhere else? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/13/20

I’ve been thinking a lot lately about market consolidation. Mr. H always captures the movements: Teladoc Health is acquiring InTouch Health, SCI Solutions is acquiring Tonic Health, and MTBC is buying CareCloud.

Sometimes competitors buy each other, but the strategy can be somewhat murky. Are they trying to get better technology to improve their core product? Or are they trying to consolidate market share? Other times companies are buying specific pieces of technology that they lack in an attempt to stop the bleeding of customers going elsewhere for a more complete offering.

I’ve consulted for vendors during these acquisitions. My favorite type of engagement is helping the potential buyer to perform the due diligence around the potential purchase.

Usually the target company is keen on being purchased, so they are reasonably willing to get you dig around as much as needed. Sometimes, though, they may occasionally put obstacles in your way to keep you from figuring out how weak their product actually is compared to its marketing.

I worked with one vendor who thought they were getting a niche EHR that would complement their existing offerings. Unfortunately, they missed the part where that niche EHR really didn’t have a practice management system. Without the ability to bill for services, providers aren’t going to be thrilled with the fact that they’re going to have to buy a separate billing system and then try to mesh them together.

I say they “missed” the part where there was no billing system with some sarcasm. Of course they knew it was lacking, but chose to ignore it and hoped they could find enough gullible customers to come on board. Along with other members of the due diligence team, I was able to convince them they should take a pass, which hopefully saved them (and their potential customers) a good deal of heartache.

I’m interested to follow along as Teladoc Health purchases InTouch Health. I do believe that given our current culture and people’s desire for convenience, along with the need for providers to try to manage more patients more efficiently, virtual care is going to move to the forefront of healthcare.

The existing paradigms will continue to evolve. Hospitals that don’t have experts in a given subspecialty can contract with providers hundreds of miles away to provide care for their patients. Intensive care units can hire virtual teams to not only help manage patients after traditional business hours, but to review treatments and care plans as an extra set of expert eyes to make sure the best care possible is delivered. Patients can interact directly with their providers in a more efficient manner, saving the time needed to drive to an office and wait for care. Although these service lines already exist, more organizations are going to embrace them, and those that are already working in this manner will continue to evolve.

Teladoc Health already has the direct-to-consumer piece, and InTouch Health has a pretty solid institutional platform. The announcements focus on this, calling out the new company’s ability to manage patients longitudinally from the home setting to the intensive care unit. Regardless of their strengths and weaknesses, there will have to be a great deal of digging by teams on both sides to figure out exactly how their technologies might be able to work together vs. how much work will be needed to bring them together.

I worked with one vendor who had an EHR and a practice management system built on the same database platform but using different programming languages. As they tried to bring them together, they ended up halting all development on one side of the house while they rewrote the application to play nicely with the other side. The budgetary impact was significant, and it also caused the project to lose momentum. Eventually they got everything on the same page, but the product still died on the vine.

Many who have never been through the process of trying to bring disparate products together don’t realize what a long road it will be to seamless interaction between the direct-to-consumer offering and the in-hospital solutions. I love that kind of work – figuring out what can be kept, what needs to be refactored, and what might just need to be started over again from scratch in order for everything to work as intended.

In order to be successful, the various teams need to leave their egos at the door and focus on the end result, creating something new that will be greater than the sum of its parts. Sometimes, though, there isn’t enough budget allocated and the organization fails to address cultural issues, so what results is a shadow of what it might have been.

I have friends working at organizations that have struggled while trying to bring acquisitions together. One team worked for nearly two years to try to integrate the solutions, only to finally give up and demand that customers of the smaller vendor migrate to the larger vendor’s platform. Another team hurried to bring customers live on a shiny new tool they had purchased, not realizing that it wasn’t HIPAA-compliant until they started seeing unanticipated outcomes for what should have been routine workflows.

Of course, there is a negative impact on customers and their patients. These scenarios are also accompanied by declines in morale for the people doing the work. Sometimes key players will even leave because they don’t feel their opinions are being respected and they see their pride and joy being dissected during the process.

I hope that the companies involved in these acquisitions reach out to professionals to help manage the “soft” issues involved in bringing large teams together. From experience, they would likely benefit from an objective analysis and guidance in how to make everyone feel appreciated and to reduce the fear of being downsized or pushed aside. Most companies don’t do this, and they ultimately reap what they sow as the integration becomes increasingly difficult and the conversations more contentious. Some of the recent mergers and acquisitions in the healthcare IT world seem to be healthy, but others seem to be under a bit of duress.

Have you been through a merger or acquisition? Do you have advice for the impacted employees? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/9/20

Now that 2020 is here, CMS has opened the data submission period for the 2019 MIPS program. Eligible clinicians can submit their Quality Payment Program data until March 31, 2020. If you haven’t done this before, there are a variety of systems you have to register with to create your profile and submit your data, so be sure to visit the QPP website if you’re having difficulty. I’m exempt from individual participation and our group is opting out again this year, so that’s a relief. You can check the status of your favorite providers by using the CMS Quality Payment Program Participation Status Lookup Tool.

The new year also brings with it the California Consumer Privacy Act, with its provisions extended to the rest of us since big businesses aren’t going to have California-facing websites and others for the rest of us. It gives consumers expanded knowledge of what personal data is being collected, how it is being used, and the right to say no to its sale. It’s good for people to be more aware of how their data is being used, especially since so many people willingly give up their data without even thinking about it.

Even seemingly innocuous sharing using fitness sites can provide a wealth of information about people’s habits and movements. I’ve seen plenty of people overshare information about their children on social media, not thinking of how it might affect them when they’re older, but hadn’t thought about consumer-based genetic testing for children. A recent New York Times opinion piece addresses this, posing questions about parents sharing their children’s DNA profiles online. Apparently sending your kids’ swabs to 23andMe and sharing the results online is a thing.

I got a much-needed laugh during a clinical shift the other day. Apparently someone stuck a magnet to the inside door frame of one of our exam rooms. It wasn’t from the beach or something inspirational, but rather an ad for one of our competitors. Bold move and well played, but we did transfer it to the round file.

Less funny were the patients who came in with adverse effects of marijuana, given the recent legality of recreational purchases in Illinois. Not only did the patients get hit with nearly 25% tax, but also a hefty urgent care co-pay. As I’ve already put in several patient plans this year, lay off the weed, folks.

Amidst everything else going on in the world right now, this week the White House proposed guidelines regarding the regulation of artificial intelligence in healthcare, transportation, and other private sector industries. The general principles of “fairness, non-discrimination, openness, transparency, safety, and security” were mentioned, but in a general way. A memo from the acting director of the Office of Management and Budget warned about the perfect being the enemy of the good, stating that “Agencies must avoid a precautionary approach that holds AI systems to such an impossibly high standard that society cannot enjoy their benefits.” It remains to be seen how the principles will be specifically implemented or how much focus this will receive given other regulatory priorities.

Pet peeve of the week: use of the word “solutioning.” I’ve heard it three times this week in three venues, which makes me wonder if something is triggering increased use. Offending sentences included: “Let me work with the team to see what we can solution for you” along with “We’ll be doing some solutioning on this problem Friday and will keep you posted.” Sounds wordy and awkward to me, but I’d be interested to hear from others that think it’s a great word to use in this way.

Around the physician lounge this week: There was a study in the journal Pediatrics about the problem of “low-value care,” especially in the pediatric population. Researchers were specifically looking at whether children with public insurance (Medicaid) were more likely to receive unnecessary medical services than those with private insurance. They looked at data for over 8 million children across 12 states and found that one in nine publicly-insured patients vs. one in 11 privately-insured patients received so-called “low-value” services, meaning that they were either unneeded or unlikely to improve the patient’s situation. Either way, close to 10% of pediatric patients re receiving wasteful care.

The authors looked at a group of 20 low-value tests and treatments, many of which I see requested in practice: antibiotics for colds, unneeded x-rays, unneeded medications, etc. It’s difficult to explain to parents (and to the adults when they are the patients) that sometimes to do less is more and those explanations take precious time that providers often don’t have, so the cycle perpetuates itself. Clinical decision support rules and other technology can help us identify the low-value care, but they don’t do much to help explain why we’re saying no. Perhaps some brilliant developer could create a virtual reality game that tours through “all the bad things that can happen when providers give in to unrealistic patient request” that might make an impact. It should include a scary section where the player goes bankrupt due to wasteful spending.

Another potential game element could be the downward spiral that occurs when unneeded tests lead to a medical wild goose chase. This was mentioned in the Washington Post and I see it all the time when we order a panel of blood tests (because they all come on a convenient CLIA-waived cartridge testing system) rather than the single element we’re looking for. Something comes up out of the normal range, which doesn’t mean that it’s even abnormal, and more visits and consultations and tests are needed to work through it because everyone is worried about missing something or getting sued. The Post piece mentions unneeded testing done prior to cataract surgeries, which can lead to cascades of extra services.

I think this is one area where artificial intelligence might really be able to help – to assist us in learning what these not-normal but not necessarily concerning results truly mean across large populations, vs. us always having to go down the rabbit hole trying to figure out their significance.

The article has some gripping stories, such as the patient who had their kidney removed for what turned out to be a piece of fat, and then their remaining kidney failed. It also mentions the frustration felt by providers in these journeys. Physicians are also subject to cognitive bias (such as memories of when they previously “caught” something unusual) fed by anecdotal stories as well as personal experiences. These are exactly the elements that clinical decision support is designed to combat, but too often the physicians I spoke with are suspicious of the data behind such systems or whether use of that data would be defensible if they miss something significant and are sued.

The discussion also veered into the direct-to-consumer realm and some of the self-directed testing that is out there. Patients can now order large panels of tests, including genetic tests, without any kind of counseling or advice first. These can lead to significant anxiety along with the costs. There’s certainly variability in the services offered and the degree of physician involvement with some of these efforts. However, as long as there’s a buck to be made and patients are willing to pay for it, I don’t see them going away any time soon.

Do you think that healthcare IT can truly have an impact on the delivery of low-value services? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/6/20

An issue that is often cited as a cause of increased healthcare expenditures in the US is our fascination with technology. This is readily apparent as I see patients. They don’t want me to tell them that it’s highly unlikely that they have strep throat due to a well-validated clinical decision support rule. Instead, they demand an in-office strep test. They have been conditioned to expect technology to provide answers, even if it involves radiating a pair of totally clear lungs because the patient is concerned that they have pneumonia. The increased reliance on patient satisfaction scores as a marker of quality care certainly hasn’t done anything to improve this situation.

Earlier this week, I received a scathing review from a patient that triggered a phone call from the COO. She was upset that I suggested that she be sure to contact her primary care physician when she is ill. I had noticed that she is a member of a notoriously restrictive HMO and I wanted to spare her the denials and her physician the penalties. Instead, she took this as a statement that I “didn’t want her business” and that she was “not welcome at urgent care.”

Being interrogated by the COO about the patient encounter  — which was unusual enough at the time that I put several interesting details in the chart — was the last thing I needed during a busy clinic day when we literally had patients trying to die in the office. When I’ve talked to the emergency department charge nurse at the local Level 1 trauma center three times in the same day, that’s a bad sign for sure.

I would love to have bureaucrats and politicians in the room with me when I have to explain to a patient with a critical illness that they absolutely need to go to the hospital by ambulance and that no, you cannot go by private vehicle when you are actively having a heart attack. I had three different versions of this conversation during my last shift: one for the heart attack, one for a patient with multiple blood clots in the lung who was short of breath, and one for a patient with what appeared to be an evolving stroke. The fact that these patients were at an urgent care center and not the actual emergency department is a result of many factors.

In my anecdotal experience, the first reason is convenience. Patients want to be seen in their neighborhood by someone who can care for them quickly. They don’t want to deal with an office that can’t fit them in or a crowded clinic.

Second is cost. They don’t want a surprise bill from going to the hospital or a denial if their care isn’t deemed emergent after a hindsight review.

Third is a complicated health literacy issue. Patients often don’t understand what can be cared for at home, what needs to be at a retail clinic, what needs an urgent care center, and what needs to go to the emergency department or even a specialized emergency department. As an urgent care physician, I think sometimes we’re victims of our own successful marketing, but that doesn’t help your stress level when you’re urgently transferring a child with a coin in their airway or telling a patient they have advanced cancer that was blown off by their primary care physician.

Many forecasters thought that high-dollar deductible insurance plans would make patients savvier consumers and wiser spenders of their dollars. What we see in practice is that patients are paying so much for their insurance that regardless of the deductible, they want more and more services to get their money’s worth. I never thought I’d see patients coming in saying, “I think I’m OK, but I just want a CT scan to be sure.” They’re shocked when they say that we don’t have enough cause to order it, or that the insurance might not pay for it.

I try to use technology in some of those situations as a teaching aid, pulling up websites and providing information about why the patient is going to be just fine. Somehow it’s more believable when they see it on a website than when the doctor in front of them is saying it. I try not to take it personally.

There are also the times though that technology fails us. Recently, some patients who had undergone preventive mastectomies after concerning genetic testing results learned that the BRCA gene test may have been inaccurate. That was earth shaking for many patients, who have come to trust high-tech answers to their questions. I saw that article on the same day that I saw the Google blog piece about using artificial intelligence to improve breast cancer screening using digital mammography. Another win for technology after a stunning loss.

I was also heartened by the ultimate telemedicine encounter that occurred recently. Apparently one of the astronauts on the International Space Station developed a deep vein thrombosis (blood clot) in their neck, which was evaluated and treated remotely. The astronaut patient performed ultrasounds with guidance from an Earth-bound care team in order to monitor the clot. A pretty cool story, but difficult when you transpose it with the reality of many patients on the ground who can’t get an ultrasound for a suspected clot on two of every seven days, simply because they’re classified as “weekends” and facilities don’t have ultrasonographers readily available.

Being at the forefront of healthcare delivery is like being on a roller coaster. There are amazing highs (identifying the blood clot in the lung before it killed an otherwise healthy 25 year old) and devastating lows that are sometimes too horrific to put into words.

In my informatics practice, I work with people every single day who are committed to trying to solve the problems that we all are facing every time we, or those we care about, interact with the healthcare system. It’s a new year and hopefully a new opportunity for healthcare technology to really make a difference for patients around the world.

I’m excited to be a part of the future of healthcare. Who’s with me?

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/2/20

Regardless of what holidays you celebrate, everyone is impacted by medical offices that are closed and healthcare facilities that are running on modified schedules this time of year.

I’m in the middle of a streak of clinical shifts that have at times reduced me to a mound of quivering jelly. Influenza is definitely on the rise and I’m starting to feel like my mask is permanently attached to my face. Our urgent care group saw nearly 2,000 patients on December 26, breaking our city-wide record. Many patients reported trying to get in touch with their primary care physician only to find the office closed, with some offices being closed until after the new year.

Seeing a 20% bump in volumes, the IT side of my brain always wonders about scalability of the solutions we use. I’m happy to report that the EHR held up like a champ, but viewing radiology images in the PACS was another story entirely. Load times were running up to two minutes, which seems like an eternity when you’ve got a full house and need to know what’s going on with your patients’ films.

One of my patients happened to be an imaging rep, who asked how we were holding up this time of year. It was nice to see someone who understands that there are many factors behind keeping an office running, although he was less than amused that we couldn’t send his records to his primary physician.

As an independent organization, the large health systems in town aren’t too keen on sharing data with us even though it would mean they receive our work product as well. Just another example of information blocking that isn’t a vendor’s fault. In the meantime, I take full advantage of the features within Epic that allow me to access patients’ charts for a short time with their permission.

My operations brain is always challenged by these high-volume days. They make me wonder what “the system” could do differently to better manage these patients. Although many of those we saw had acute conditions that needed urgent treatment, like influenza or pneumonia or lacerations, many of them could have been handled by a nurse triage line or other lower-acuity situation.

Quite a few patients hadn’t tried any self-care, not so much as a decongestant or an over-the-counter cough medication, even though they were relatively young and healthy and didn’t have any reason to be concerned about medication interactions or worsening of chronic conditions. Several had been sick for less than a day. My favorite presenting issue of the day was, “My throat started with a tickle a couple of hours ago and I just wanted to see what it was.” This shows a lack of health literacy, even in the relatively affluent area in which I was working. What could we as a healthcare system do to serve these patients better?

I’ve also been able to put my telehealth hat on this week, due to a spike in volumes in my state. I only do telehealth visits sporadically since I don’t hold a lot of different state licenses. I was pleasantly surprised by the number of patients who weren’t specifically seeking antibiotics – who just wanted to make sure they were doing everything possible to treat their condition, or wanted validation of their treatment plan because they were making slower than expected improvement.

Back in the clinic the next day, I also saw the dark side of some virtual visit care as patients came in for face-to-face visits after having been prescribed medications that seemed unrelated to their symptoms. I saw three patients from the same physician who were each a bit concerning. It sounds like her practice has recently started using functionality within Epic that allows for patients to have billable asynchronous visits, and perhaps she isn’t in the swing with the fact that just because a visit is virtual doesn’t mean you don’t have to follow the standard of care. Maybe she doesn’t know the antibiotics she is prescribing aren’t indicated for the condition being treated, but there’s no good way to try to address that professionally when we see it.

Our volumes continued throughout the weekend, with record-breaking numbers of visits at several of our locations. I encountered a couple of primary physicians and one psychiatrist whose offices were not only closed during the holiday weekend, but also who had no after-hours coverage. Even other physicians received no response when trying to reach them. In my state, that’s tantamount to patient abandonment, and I hope those patients have some difficult conversations with their physicians (or perhaps soon-to-be-former physicians) about being left hanging.

I also heard some complaints from patients who just don’t feel like their physicians listen to them. It’s not only complaints about looking at the computer instead of the patient, but also complaints about physicians pushing additional procedures that are unrelated to their care plans. One patient showed me the brochure from her pulmonologist who was offering cosmetic Botox injections. These are just a small sample of the patients who wind up in the urgent care, where they’re trying to make up for whatever they’re not receiving in their usual setting of care, if they have one.

Santa must have been very good to a couple of patients, who presented with ICD codes in the F12 series: cannabis-related disorders. Cannabis-induced palpitations was one of the conditions, and I would have loved to have simply typed “lay off the weed” in my care plan. Somehow “reduce or eliminate cannabis use until cleared by cardiology” just doesn’t seem as festive. Nor does “your risk of recurrent vomiting would be lower if you stopped using marijuana.” These are the things they don’t tell you about in medical school, that one day you might find yourself dealing with in an exam room.

On days like these, I long for the relative lack of excitement found in a good lab interface build or some of the other work I do in my informatics practice.

For those of you who worked around the holidays, what kinds of adventures did you have? Any great stories? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/23/19

A student reached out to me recently, looking for a primary care physician willing to host him for a four-week clinical clerkship. I used to be a preceptor for both of the local medical schools but haven’t hosted anyone since I stopped practicing traditional primary care more than a decade ago. A call to the primary care clerkship office revealed that a computer glitch brought me back from the virtual dead, along with a number of physicians who are no longer able to host, and we were able to get it straightened out pretty quickly.

Still, I enjoyed chatting with the student, who had never heard of clinical informatics and had no idea what a physician might do besides conducting research or seeing patients clinically.

I was a little shocked by this since the medical school he attends is affiliated with a health system that just spent nearly half a billion dollars on an EHR overhaul. He’s already in the middle of his first clinical clerkship year, so theoretically he has been exposed to the hospital and countless resident and attending physicians complaining about the EHR or how it works. I would have hoped that the orientation to the EHR might have included an outline of how to request changes in the system, which would theoretically include mention of physicians serving on committees or in leadership roles who would have input into any requested changes. Apparently none of these things happened or were ever discussed, or my potential student missed the mention.

In hindsight, I think it’s more likely the former, since the hospital (and health system) in question still does not have a functional CMIO role. They have a number of clinical VPs and other titled people who are supposed to play a role in the governance of clinical informatics, but the reality is they have a number of other things on their plates that takes them away from actual informatics work. From what I understand from my peers, they don’t have functional governance structures and part of the IT team is devoted to just building what is needed to silence the squeaky wheels. The community physicians are up in arms about changes that are put in place for the academic faculty, and there’s a lot of duplicate work going on as they build different work streams without a unified approach.

I think the student enjoyed hearing about alternative careers for primary care physicians, especially once we talked a little about healthcare finance in the US and the high level of burnout among primary care physicians. His school isn’t doing a good job educating him on that topic either, since he had little understanding of Medicare or Medicaid or commercial insurance and the pressures felt by physicians as they try to navigate our healthcare non-system on behalf of their patients.

I suppose this might be one of the key goals of the primary care clinical clerkship, to expose students to such things since they’re probably not seeing it in the halls of the ivory tower. On the other hand, especially with the new push for premedical students to already have clinical experience before they apply to medical school, I was surprised by how little he knew.

He was also unaware of the salary limitations for primary care physicians. When I asked him if he had a ballpark idea what he might make in practice, he quoted a starting salary that was more than one and a half times that of an independent primary care physician with a well-established practice and an excellent payer mix with minimal Medicare and no Medicaid.

In my heart, I don’t want students to choose their specialties based on earnings potential, but I don’t want them to be surprised, especially when they’ll be leaving school with nearly half a million dollars in student loan debt. Granted, physicians still make a very good living, but many of us now in practice didn’t graduate with anywhere near that kind of debt. I was lucky with no undergrad debt, but still had to borrow the entire amount for medical school over and above what I had saved from jobs at the golf course, the donut shop, editing people’s term papers, and substitute teaching.

We talked a lot about how I came to be in clinical informatics and how I see the role. Usually I summarize it as being a translator or mediator – being able to work with clinical teams, operations teams, and the technology teams to identify ways that we can better the mission of patient care. Sometimes it’s process improvement work, sometimes it’s deep technology design work, and sometimes it’s just handholding for providers who are at their wit’s end. There are days when it’s sheer boredom (lab interface crosswalk build – if you’ve never tried it, you’re missing out) and some days are exhilarating (go-lives gone well). The rest of the time can be a roller coaster, but I wouldn’t trade what I do for a more traditional medical career.

I’m sorry I wasn’t able to teach him how to be a family physician, or to share how enjoyable it can be to take care of patients over time and to get to know them and their families. I like to think that he did learn something over the course of our conversations, though, even if it was just that he needs to do a little more investigation before he decides on a specialty. He has a few months left before he has to start applying for residency positions, when seems relatively short when you’re deciding how you want to spend the rest of your life.

I also gave him my standard advice: learn about the business of healthcare; learn about personal finances; don’t spend “like a doctor” when you get out of school; and find some non-work-related activities that will keep you company for the rest of your life. I was lucky to have learned many of those lessons along the way, but some of my peers, and many non-physicians as well, learned those topics the hard way.

I wonder how the medical school would receive the idea of a class covering these topics. Healthcare has certainly changed in the time I’ve been out of school, and not always for the better. There are driving forces that many in the industry don’t understand, whether they’re clinical or not.

On the other hand, isolating students from the reality of what they’re getting into might be useful to maintain the physician pipeline. I know quite a few of us who wouldn’t have done it had we known then what we know now. I see some of those former colleagues in hospital administration roles, industry roles, etc. You can always tell the people who really enjoy patient care because they often fight for the ability to keep their toes in the water, even if it’s only a couple of days a month. Of course, not all employers are sympathetic, and many more are forced to give up their clinical aspirations.

What does this have to do with the larger topic of healthcare IT? It’s food for thought to help us understand the force that shape clinicians and why they might act the way they do when faced with uncomfortable or unwanted change, or when some bit of technology puts them over the edge. Maybe if they were better integrated into the healthcare IT ecosystem earlier in their training, we would be fighting fewer (or at least different) battles. Maybe they wouldd feel more empowered to demand better usability and not just go along with what their hospital says they are going to use. Maybe they would see “the IT people” as less of a threat and more of a team working towards common goals.

How does your organization onboard medical students? Do they understand what the technology teams do? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/19/19

There’s a battle raging in Colorado over the Drug Enforcement Agency’s ability to access data within the state’s prescription drug monitoring program. In the course of investigating pharmacies, the DEA requested the data via a subpoena rather than a search warrant. The state claimed that the DEA request was indiscriminate, requesting six years’ of data for over 200,000 prescriptions. They offered to provide anonymized data and to comply with more specific requests with names.

The American Civil Liberties Union has entered the fray in Colorado district court, claiming that tight standards are required to protect privacy and requesting that patients should be alerted that the data will be disclosed or that the court should require a search warrant. The prescription drug monitoring databases have been a significant benefit for clinicians – it’s much easier to identify patients who might be inappropriately using controlled substances. This can lead to earlier interventions and improved outcomes. Let’s hope the legal battles have a favorable outcome that doesn’t take away from the important

A recent JAMA Network Open research letter looked at EHR usability, finding that progress is slow and sometimes nonexistent. The authors looked at 70 vendors who had participated in the Meaningful Use program over multiple years, finding that a good number fell short in usability testing. Only 27 vendors met the inclusion criteria, which included having a computerized provider order entry system, certification according to the safety-enhanced design criteria, and a reported System Usability Scale (SUS) for 2014 and 2015 usability requirements. They found that “there was no statistical improvement in EHR SUS scores between products certified according to 2014 and 2015 standards. One-third of 2014 products and one-quarter of 2015 products fell below the average benchmark SUS score.”

Despite the implications of EHR dissatisfaction on clinician burnout and patient safety, SUS scores decreased for 44% of vendors from 2014 to 2015. The authors note that the study has limitations, including that the SUS scores were vendor-reported and may not fully reflect EHR satisfaction. They go on to conclude that, “An increased focus on clinician end users during product design and development as well as optimized certification requirements are needed to improve usability.”

My personal, albeit anecdotal experience with usability is that for many vendors, it improves in fits and spurts. When they’re under the gun with certification requirements, they focus on it less, and when there is more breathing room, they seem to make a little progress. Given the amounts of money that health systems have spent on EHRs, they’ve created captive EHR users who are basically stuck with what they have. Even if it’s a failure, there’s little money left to make a change.

I enjoyed this Forbes piece on “Why Big Tech Companies Won’t Solve Healthcare’s Biggest Challenges.” Google and Apple are trying to disrupt healthcare, and both have the potential of significant earnings in the process. Still, it remains to be seen whether they truly understand the complexities of healthcare and whether they’re going to be able to set aside profit motive for altruism when it counts. There are also concerns about companies with obvious retail and profit motives having as much access to personal data as they might have moving forward.

The piece brings up some interesting points about whether patients should share in the profit from the use of their data. They point out the situation of Henrietta Lacks, whose cancer cells were used for decades of research without appropriate compensation. If you’ve never read it, “The Immortal Life of Henrietta Lacks” is worth a read. Hopefully we can all look back in a decade or two and see that good things have happened with the tech giants, but I agree that they’re not likely to find magic solutions for all our healthcare and technology problems.

I’m working on a project with a client where I’ve been asked to cull through potential technology solutions for a new service line they hope to take on. I’ve been sifting through websites, marketing collateral, and the pedigrees of various company leaders trying to determine whether the solutions are even viable. There are a lot of cool technologies out there, but some companies don’t look like they will have much staying power in the market.

We’ve moved into demos from some of the vendors, and I was shocked today to find myself on one where the demo data was not only nonsensical, but offensive. The patient scenarios used were degrading and it left me wondering whether they actually have any physicians on staff to guide them. Even if you’re a startup, spend a little money on physician expertise to ensure you don’t look foolish to potential clinical end users. If you’re not ready for a full-time physician on staff, there are plenty of clinical informatics experts who do contract work.

Despite the overwhelming coverage of impeachment proceedings, Congress is still getting other work done. The Telemental Health Expansion Act of 2019 has been introduced and referred to the Energy and Commerce Commerce. The Act would expand Medicare coverage for mental health services delivered via telehealth, and include the patient’s home as an acceptable “originating site” for services. This is much more useful to patients than having to go to a PCP or other office to receive telehealth services from another provider. There are several similar bills already working their ways through the halls of Congress, so perhaps one of them might be successful.

Tis the season of giving, and many of us are looking for ideas for our friends, family, and coworkers. I thought this piece on “Thoughtful and Useful Gift Ideas for Doctors” might be helpful. The first suggestion was a book on preventing burnout, which was a turn off. Much more interesting was their list from last year, which lead off with “caffeine and booze.” Some of the other items on the list were snoozers, although giving the gift of a defensive shooting class caught my attention.

In other holiday news, there’s support for why some of us dread listening to holiday music. There’s data showing that increased repetition of songs can lead to oversaturation and negative responses. Adding this to existing holiday stress and the effects can be compounded. According to data from Consumer Reports, nearly a quarter of Americans dread holiday tunes. I certainly enjoy holiday music in live performances, but the versions typically heard while shopping can be annoying.

Email Dr. Jayne.