EPtalk by Dr. Jayne 10/3/19

Fall is finally here in my part of the world, although areas of the US are still near broiling. October 3 marks the start of the last 90-day EHR reporting period for those of you playing the Promoting Interoperability home game, hospital edition. Those not reporting for a continuous 90 days in the calendar year will receive a downward payment adjustment. Hospitals must also respond in the affirmative for the Prevention of Information Blocking and ONC Direct Review Attestations.

Speaking of reporting, I somehow wound up on an email list for Greenway Health customers. Apparently, there is an issue with the Greenway Patient Portal and settings that allow providers to block sending laboratory data through the portal. Originally designed to keep sensitive information from being sent, if the setting is enabled then the entire site is unable to attest to certain MIPS and Medicaid measures. Providers were advised to adjust their settings prior to October 1 so that they would have data for the 90-day collection period ending December 31. Seems like something that should have been found earlier in the year, and I’m still puzzled how I wound up on their mailing list.

For anyone who has worked with hospitalized patients, we know how challenging it can be when patients are disoriented or at risk for falls. I was excited to read this case study about virtual sitters in the hospital environment. Mission Hospital in Asheville, NC piloted virtual sitters in its neuroscience unit. They noted a 23% reduction in falls and a 12% reduction in fall-related injuries during the 12-month pilot. Mission Health worked with Cerner to develop the virtual sitter system, using Microsoft Kinect technology to monitor patient movement. The solution included two-way audio, voice recognition, and customizable alerts. Technicians could monitor six patients at a time, and if patient movement occurred, the technician would be alerted to the specific feed. Similar to when an in-person sitter is used, the technician could use voice instructions to try to redirect the patient if needed. If the intervention isn’t successful, the technician can alert nursing staff to intervene in person. Large hospitals can spend millions of dollars on sitters, so this technology has the ability to significantly impact the bottom line.

Despite what the folks at Apple may have us believe, the iPhone isn’t the be-all, end-all of smart phones. I always cringe when a vendor launches a solution that is only available for the iPhone, as if those of us who use Android are some kind of second-class citizens despite Android having a slim majority of market share. I ran across a press release about a non-profit industry group that is working to create an open-source version of the Apple Health tool kit that can be used by Android users. Members of the CommonHealth project team include Cornell Tech, UC San Francisco, Sage Bionetworks, Open mHealth, and The Commons Project. The plans include robust governance to review partners and apps requesting to connect through the platform. UCSF is piloting along with other academic medical centers and health systems. I’d be interested to hear from anyone who is involved in the project.

From Incognito: “Dr. J – You are on to something when you note that switching back and forth between scribes and flying solo is a bit of a thing. I am convinced that EMRs bring a very different and intense kind of cognitive load than the analog world did, even without accounting for all the ‘little things’ that have been added to the physician’s thought process (because now, ‘they’ can). Adding a scribe is really just another piece of that cognitive load, even if it does reduce some bits. Switching back and forth flies in the face of ‘standard work’ in good processes. I’m sure that there are industrial design and psychology/perception experts who can tell us what we are doing to ourselves. They see it in fighter pilots and in air traffic controllers – and in Facebook ads.” Fortunately, I had a scribe all day today so things ran smoothly. Unfortunately, it’s probably the last time I’ll work with him since he’s getting ready to travel to residency interviews. Today’s scribe is a fully qualified physician, trained and licensed in another country. He’s been a delight to work with, even though his employment is a direct result of our broken health system that doesn’t always allow international medical graduates to perform the functions they might otherwise be able to. He plans to complete a residency in internal medicine so he can practice in the US, since he’s a dual national also holding US citizenship.

There was an article in my local paper about the explosive growth of urgent care facilities in the US, and not surprisingly several local physicians wrote scathing editorial letters claiming that urgent care providers are guilty of rampant overprescribing of antibiotics. The same claims are often made of telehealth providers, even though some have better data on others on how well they avoid unnecessary antibiotic prescriptions. It can be difficult to get data out of EHRs to run those types of reports, and even more difficult to try to use technology to limit prescribing, as one reader recently wrote:

“At my facility, we get fairly regular reports on antibiotic stewardship. Oddly enough the EHR is one of the roadblocks for doing what we want and need to do in this area. Tracking antibiotic use requires substantial pharmacist and infectious disease physician time where a well-designed EHR should have easy-to-use canned modules for tracking use as compared to the latest local microbiology profile. More importantly, there is no straightforward/easy way to restrict specific drugs to be ordered only by certain specialists, on certain floors or services, or with co-signatories or approvals by another service. Oddly enough, it seemed easier to implement such restrictions in the pre-EHR era. One issue is that we don’t want to block all direct prescribing of specific antibiotics since we are very mindful of not restricting initiation of a potentially life-saving antibiotic in an emergency situation such as impending sepsis. The issue of drug-specific prescribing restrictions is not just a problem with antibiotics – we have the same issues in trying to restrict rampant prescribing of other costly drugs.”

There’s no perfect system out there that can prevent all imperfect human behavior from happening. I know providers who consistently do sketchy things regardless of the education they receive, and probably the only thing that would block those folks would either be a hard stop in the EHR or a disciplinary action. Even though the organizations I’ve worked for take a dim view of such behaviors, there’s a delicate balance between admitting volumes, revenue generation, and tolerance for those who know where their bread is buttered.

Has your organization figured out how to effectively transform physician prescribing behaviors? Was it high-tech or high-touch? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 9/30/19

I recently wrote about Nuance and their efforts to create the exam room of the future, where charting is performed in real time as speech occurs. Several readers reached out with some detailed questions and discussion about the technology, which spurred me to dig a little deeper.

One reader commented about the concept of meaning as it relates to voice recognition technology and the need for systems to use pattern matching to correctly identify the content of the speech. I have a tremendous time getting my phone to recognize the difference between “pictures” and “pitchers” no matter how clearly I try to articulate, and regardless of context. Getting a system to recognize words when you’re actually trying is one thing, and having them accurately identify speech in an exam room conversation that is all over the place is another.

An article in the Journal of the American Medical Informatics Association looked at the difficulty in detecting conversation topics during primary care office visits. They used transcripts of the visits to look at whether machine learning methods could be effective in automating annotation of visits. The authors recognized the complexity of the average primary care office visit, noting:

Patients present multiple issues during an office visit requiring clinicians to divide time and effort during a visit to address competing demands, such as a patient could be concerned about blood pressure, knee pain, and blurry vision in a single appointment. Moreover, visit content does not solely focus on biomedical issues, but also on psychosocial matters, personal habits, mental health, patient-physician relationship, and small talk.

When looking at the content of visits to determine what material was covered, research raters can label each so-called “talk-turn” using codes intended to capture the visit content. This process can take several hours per visit, making it difficult to scale such an analysis. Being able to automate the extraction of these topics could not only help reduce documentation burden, but could also help identify providers who may not be following up on all the clinically relevant parts of the encounter. The authors wanted to build on previous studies that looked at human-labeled interactions and showed that machine learning systems can create annotations of those conversations.

Using 279 primary care office visits, they found that different models performed better at the visit level vs. the topic level, concluding that there needs to be additional study and larger datasets available to achieve performance that would succeed in the real-world exam room. It doesn’t seem as easy to move from the realm of natural language processing generation of discrete data as people might think. I’ve often thought about what it would be like if you could just record an office visit (both audio and video) as documentation. The pain would be in reviewing it later, unless there was a way to transcribe the information or make it searchable. Various vendors have tried to solve this problem, including leveraging Google Glass to do so.

Remember Google Glass, the tech industry’s darling way back in 2013? It’s been hiding in plain sight, as an “Enterprise Edition” that’s being used in a variety of manufacturing and heavy industrial applications as well as in healthcare. A quick scan of the website shows several big-name healthcare organizations on the client roster.

I recently had a chance to catch up with Ian Shakil, founding chairman of Augmedix, whose client roster shares some of the big names listed by Glass. He confirmed that Glass is far from gone, with around 30% of Augmedix customers using it as part of tech-enabled scribing services. The remaining clients use smartphones, which might be worn or on a stand in the exam room. It sounds like patients have gotten over the concerns that many of us initially had with Glass and privacy – he cites a 98% acceptance rate by patients, which is partly accomplished by education by the front desk or clinical staff.

It was interesting to talk to someone knowledgeable about a segment of the healthcare industry that I admit I know little about. Other than some excitement around Glass half a decade ago, and some acquisitions of scribe and transcription services by other vendors in the voice recognition and EHR spaces, I hadn’t seen a lot of coverage. We spend some time talking about the way various solutions tackle the problem, from what can be described as “dictation in disguise” to human scribes to remote scribes to attempts to use voice recognition and virtual assistant technology to create a true AI-powered scribe. Some vendors like Augmedix even offer services across the continuum, depending on where their clients are, from a human virtual scribe all the way to tech-augmented scribes who use a variety of tools to enhance their abilities to document visits.

I was surprised to learn that there is variability in what is done with the recordings of patient visits created during the course of visits. Depending on the vendor and the client, some want the recordings and video destroyed and others want it preserved. It may be used for training, quality assurance activities, or even in the future as a multimedia note or for access by the patient as a reminder of the visit. Given the plaintiff’s attorney whose branch is close to mine on the family tree, I wondered about the use of the video feeds in potential litigation. I’ve pored through enough bulky, EHR-generated medical records to know that it certainly would be easier to watch the movie than to read the book in this case.

I use a human scribe in the exam room about half of the time. Our office fully agrees with industry data that shows that such support leads to better notes, timelier patient care, and reduced clinician burnout. The biggest struggle I have though is going back and forth between having a scribe with me or not having one. When I have that support, everything I say is taken down or acted upon in the exam room before we leave, and I can just close that visit in my mind and move to the next exam room. The scribes watch for lab results or radiology tests to return and make sure I don’t miss going back to take care of a patient who is still pending disposition.

When I work a shift without a scribe, I’m pretty good at the follow up piece, but I sometimes forget to put in my orders or flag patients for discharge. I’m just so used to saying, “We’re going to do a flu swab and get a chest x-ray” and having those orders placed, my brain is on autopilot right past the need to enter them myself. It’s enough of an issue that I usually tell the rest of my clinical team that “I had a scribe yesterday and don’t today, so if you see me missing orders or discharges, just grab me” and they usually laugh, because apparently I’m not the only physician who does it.

Shakil shared a great piece with me that ran in The Lancet a couple of weeks ago, one where the author discusses “Empathy in the age of the electronic medical record.” It’s worth a read for folks who might wonder what physicians who struggle with the EHR are thinking as they try to see patients. I’m interested to hear what readers think on the topic. Where are we, and where are we headed? In the meantime, I’m mentally prepping because tomorrow’s schedule does not include a scribe.

What do you think about virtual scribes, natural language processing, and the exam room of the future? Leave a comment or email me.

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EPtalk by Dr. Jayne 9/26/19

It’s US National Health IT Week, as promoted by HIMSS. I’m working with several organizations right now and none of them is doing anything to “celebrate” the occasion.

The reality of things is that we’re all exhausted by our health IT endeavors. Back in the early days, and before Meaningful Use gummed up the works, it was exciting to be on the cutting edge (and sometimes bleeding edge) of things. As an early adopter organization, we had some pull with our vendor and could demand improvements in the software. Now that they’re just trying to keep up with federal regulations and satisfy shareholders, there’s no initiative to make the customers happy.

If your organization is actually doing something to mark the occasion, I’d be interested to hear about it.

CMS has updated the Medicare Plan Finder website for the first time in a decade. Medicare beneficiaries can access it on Medicare.gov and use it to compare Medicare Advantage and Medicare Part D plan. The upgrade is supposed to be mobile-friendly with enhanced readability. I asked one of my favorite Medicare beneficiaries to tell me what they think of it and he couldn’t find it, probably because he was looking in Google Play rather than the website. I gave it a peek myself and it was pretty vanilla. Apparently the coverage I’d want costs a pretty penny in today’s dollars, so I better work on my skills for retirement savings. Approximately 10,000 people enroll in Medicare every day, so who knows if there will even be any money left for coverage by the time some of us get there.

Most of us are familiar with the Google influenza tracker that used to be available. Although it has been sunset, it used symptom searches to try to identify flu cases. I was excited to see this article in the Journal of the American Medical Informatics Association that looks at internet search data as a way to predict emergency department volume. The authors looked at whether Google search data can be applied to ED volume forecasting to improve accuracy compared to existing methods. The data was from Boston Children’s Hospital, local public school calendars, National Oceanic and Atmospheric Administration weather data, and Google trends. As they added data sources, the model became more accurate. I wish my facility would get on board with this kind of big data, because right now our staffing model is very, very off.

From CliqBait: “Re: hit man. Definitely a head-turner, if not also a head scratcher.” A former University of Iowa medical student goes to prison for trying to hire hit man. The Gazette details the story of a man who wanted to kill one of the university’s associate deans after he informed the student he could no longer attend. The accused pleaded guilty to a firearms charge, but the murder-for-hire plot increased his prison sentence. Pro tip: Don’t hire people to kill other people, especially when your supposed hit man is an undercover law enforcement agent. And if you do make the mistake of trying to do so, don’t offer illegal machine guns as payment for the deed.

Surprise, surprise: a recent journal article notes that data found in EHR visit notes doesn’t always match the examinations performed by physicians. Reviewers compared real-time observational data to EHR documentation and found that they could only verify the Review of Systems 40% of the time and the physical exam only 50% of the time. Most of the discordant findings were in clinical systems that were less clinically relevant to the patients’ presenting complaints. For example, patients who presented with gastrointestinal or genitourinary issues had a small number (5.4%) of findings in those systems that didn’t match. For the same patients, there were plenty of unsubstantiated ear / nose / throat exams (81.8%). One could surmise this happens because of overly-detailed defaults or copy/paste, but either cause culminates in physicians not proofreading and correcting their own notes. The authors call for additional studies to determine how extensive these findings might be since the physician subjects were residents in training and a small number (180) of patients had their encounters observed. They also encourage payers to remove financial incentives that lead to physicians over-documentation.

New England Journal of Medicine Editor-in-Chief Eric Rubin, MD, PhD is shaking things up by saying that “thought print may not be dead, it might soon need palliative care.” He plans to continue to bring the publication into the current century by making it more interactive with a greater online presence. There’s even talk about relaxing rules regarding authors who post copies of manuscripts on preprint servers, getting information into the hands of other researchers faster than the typical peer-reviewed publication pathway. Times are changing and it’s difficult for traditional media outlets to keep up. Print media continues to struggle. In a neighboring corner of the Midwest, the St. Louis Post-Dispatch just moved out of their historic building in downtown St. Louis. The new tenant: mobile payment technology company Square.

Mr. H mentioned this earlier in the week, but Amazon has moved into the telehealth space with its launch of Amazon Care. According to the public-facing website, the service offers virtual visits, in-person visits at home or office, and “prescriptions delivered to your door.” Services will include both urgent care and preventive scope of practice, including contraception and testing for sexually transmitted infections. Nurses can provide vaccinations and collect laboratory samples at the patient’s location. Eligibility is limited to Amazon employees and their families who are enrolled in an Amazon health insurance plan and who are based in the Seattle area. Employees who are enrolled in Kaiser Permanente plans are ineligible. The service is available Monday through Friday 8 a.m. to 9 p.m. and weekends from 8 a.m. to 6 p.m. Medical services are provided by Oasis Medical Group, which hopefully provides a layer of privacy for employees seeking care. Since this is a pilot program, employees have to request an invitation to participate. It will be interesting to see how this plays out in the coming months.

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Curbside Consult with Dr. Jayne 9/23/19

I have a standing date every couple of months to meet up with the physician who replaced me at Big Health System. Usually we do something outdoorsy that allows us to stroll, decompress, and be somewhere other than a conference room, then follow it up with lunch or drinks depending on the time of day we manage to escape.

It’s been challenging to schedule for the last couple of months, with several last-minute cancellations on both sides due to travel and family issues. Today we finally made it happen, and it was a breath of fresh air, both literally and figuratively.

Usually we start with updates on what we’ve been doing the last several months. I tell stories of the wild and wooly world of consulting and all the things I see in the field, some of which you would think were embellished if you didn’t know the players in the industry. He in turn fills me in on the happenings at my old stomping grounds, which are usually pretty run-of-the mill.

They have been going through a major rip-and-replace system conversion that isn’t always pretty, with physicians from different hospitals jockeying for control of various committees and trying to make sure their interests are protected. We typically talk about strategies for trying to get these folks to work collaboratively and to consider the larger picture. I usually have some advice to offer since I’ve done similar work at health systems that are much larger and more complex.

Today, however, he had all the bombshells. There have been some political maneuvers leading to the loss or marginalization of two of the best folks I know in the industry. One was frankly pushed out. The circumstances are complicated, but the backstory involves making a place for the spouse of a highly-recruited subspecialty surgeon, and said spouse happened to want a particular role in the organization that was unfortunately occupied by one of my former colleagues.

Needless to say, a reorganization occurred, the position was eliminated, and the spouse was hired into a new position with a different title and reporting structure, but with the same responsibilities and direct reports. The hospital had to pay a large settlement to avoid a lawsuit. Although the downsized individual landed on their feet, the entire experience was traumatic.

The second situation wasn’t so pretty and involved some C-suite squabbles that left a second former colleague and informaticist employed, but essentially in job purgatory. He was unable to win a showdown between the informatics team and two feuding chief medical officers, and unfortunately became collateral damage. Someone had to take the fall for failing to please either of the CMOs, who were clearly out of line but politically prominent.

The first CMO had a penchant for forcing the informatics team to make every single customization his physicians wanted, going deep into the weeds where he didn’t belong. The second was just overcommitted and never showed up to meetings, then had a fit when his opinions weren’t considered.

The feud between these two was big enough that I had heard about it at a HIMSS chapter meeting, but I was surprised to hear that the clinical informatics director took the fall for their failure to get along, being “reassigned” from the flagship EHR project to another peripheral effort. It sounds like he would have preferred being let go. It’s sad to see someone with so much knowledge and potential becoming a casualty of a turf war.

Unfortunately, these are the stories that are all too common in hospitals and health systems today. Decisions are often made based on squeaky wheels or the perception of a problem without fully understand everything the underlying situation. Certain personalities are coddled based on their admitting habits or how much revenue they bring to the facility, regardless of the path of destruction they leave in their wake. Good teams’ projects languish because they’re not exciting enough or don’t generate enough revenue to get the attention they deserve. People are treated as expendable despite their long-term contributions to the organization.

These are the same reasons I left Big Health System. It saddens me to know that they are still singing the same song, just a different verse. It’s hard to drive past the billboards extolling the virtues of their care when you know what goes on behind the scenes, and what that care costs, not only in a financial sense, but in the unappreciated human efforts needed to make it happen.

Unfortunately, these two scenarios are by no means unique. I see similar situations across the country. When I try to analyze the “why” behind some of this, the only conclusion I can arrive at is that these organizations are being run from a big business perspective and not in line with the ethical and moral considerations that we expect from a not-for-profit organization. It would be one thing if this were a for-profit entity doing this, but I think we expect more charitable behavior from organizations that try to wear their caring nature on their sleeves. At least the for-profit hospital organizations are more overt about what they’re doing and why, rather than trying to hide behind some measure of community benefit.

It was good that we were “getting our zen on” in a beautiful public garden because my blood pressure tends to rise when I hear about people being treated unfairly. My friend plans to try to ride it out at this place since he isn’t terribly far from retirement.

Our conversation turned to the details of his current projects. Asynchronous e-visits are big on the list, although the primary care physicians are irritated that they are being completed by on-call nurse practitioners rather than the PCPs themselves. Patients love the turnaround time (less than an hour), which is significantly less than the time needed to leave a message at the office and get a call back. It’s cash on the barrelhead for the health system, which isn’t billing insurance for the visits and isn’t sharing the revenue with the PCPs. Since the PCPs aren’t likely to be able to turn those visits in less than an hour if they’re seeing patients in the office, and since they’re going to want the revenue if they perform them, neither of us see that paradigm changing.

Information blocking is also on the list. My friend readily admits that the health system is guilty. They won’t play nicely with the other hospitals in town and certainly won’t play nicely with independent physician organizations like my own, so they point the fingers at the EHR vendor and hope for the best.

Another hot topic is antimicrobial stewardship, although I laughed out loud when I learned his team is performing manual chart reviews to look at antibiotic use because they can’t get time allocated with the data analyst team. I was fighting that same situation before I left, but refused to perform the manual reviews because I didn’t have enough personnel to do it. Maybe it does make sense to pay nurse informaticists to painstakingly perform these reviews rather than having an analyst spend an hour a month running queries and pulling the data, at least as far as what the current leadership thinks.

It was good to get together and even better to spend an hour in a beautiful place contemplating the ornamental carp and the rock gardens. Given the time pressures we encounter during our work lives, you have to force yourself to carve out that time if you want it. We can each only do so much individually to combat the sheer madness we experience on a daily basis, but maybe if we stick together and support each other, or at least listen, we can make a difference.

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EPtalk by Dr. Jayne 9/19/19

Patient engagement is a hot topic in US healthcare, so I’m always interested to see how it plays out in other countries. A recent effort looked at the challenges of treating tuberculosis, specifically in ensuring that patients take their medications consistently during the six months needed to eradicate the disease. Patients in Nairobi, Kenya were enrolled in a program that delivered repetitive cellphone texts to encourage patients to take their medications. Those who participated had fewer negative outcomes compared to the control group. The texts ask patients to actively confirm that they have taken their medications. Those who responded were thanked and informed of their standings compared to other patients, including whether they made it to the “winners circle” for those with 90% adherence. Non-responsive patients receive additional texts, phone calls, and potentially in-person case tracking.

Stanford Medicine has launched a digital consult service to assist in diagnosis of challenging patient cases. They parallel the offering on the “curbside consult,” where physicians ask their colleagues about a case, hoping to draw from experience and past patients. The Clinical Informatics Consult solution has been in the works for more than a decade, and is currently live as a research project that can query data from millions of patients. Clinicians submit a clinical query and receive a report with summaries of similar patients in Stanford’s clinical data warehouse, including how they were treated and what outcomes resulted. The team has responded to over 150 consult requests from Stanford physicians. Developers hope that other academic hospitals may be able to use similar technology to help their own physicians.

I was recently asked to provide a reference for a former employee. The process was conducted using an online portal called SkillSurvey. The company claims to provide a data-driven hiring approach to assist employers in identifying job-related competencies along with soft skills. According to their data, 85% of references typically complete the company’s online survey and most do so within two days. Employers receive a report that claims to be predictive of a candidate’s chances for a successful first year on the job. The data shows how a candidate ranked across multiple references which sure sounds like more fun than trying to compare screening notes from HR staffers that don’t completely hit the mark, as I frequently experienced in a past life.

They didn’t go into the detail of how a potential employee likes to do their work, which I think would also provide useful data points prior to hiring. I recently had to have a “counseling” opportunity with an employee who thinks that trying to do the majority of your work on a smart phone is a good idea. Consultants are always busy, but they need to figure out what you can get away with doing on a small-format device and what requires you to just park yourself in front of a laptop or desktop. The biggest issues I tend to see with phone-related work behaviors are these: failing to see all of the recipients on an email before replying to all (especially when the reply is inappropriate for the entire audience); failure to see email attachments; difficulty adequately managing the calendar because of limited screen real estate; increased typos; and failure to read the entire email before responding, leading to comments that waste other people’s time. I’m all about being able to be mobile, but sometimes you just need to do your work on a big screen and with a keyboard.

A colleague of mine keeps trying to recruit me to the Medici platform, which offers everything from secure physician-patient communication and referral routing to billable audio/video consultations and ePrescribe services. Their marketing is straightforward, listing three simple steps to allow you to “get paid for texting with your patients.” Many physicians might not understand the nuances of what it means to begin using a service like theirs, particularly with regards to how those patient-physician communications get documented in the patient chart (or perhaps not) and whether the auto-translation features it offers are accurate. The company also offers texting with other professionals, such as veterinarians. The Austin-based startup has raised $46 million and has used analogies to identify themselves alternately as the Uber of healthcare or the WhatsApp of healthcare. I’m not sure of the origin of their name, but of course it reminds me of the Medici family, who schemed their way through Tuscany in the 15th and 16th centuries.

Speaking of telehealth apps, Planned Parenthood has entered the telemedicine space with the launch of their new app, Planned Parenthood Direct. It offers birth control options, including contraceptive pills, patches, and rings, along with treatment for urinary tract infections. The app is live in 27 states and the District of Columbia, with plans to expand to all 50 states by next year. It also allows patients to book in-office appointments for other contraceptive services such as IUDs, implants, and injections.

I recently encountered a situation where an elderly family member was receiving unneeded screening tests on the recommendation of their physicians. Knowing the physicians in question, I had a couple of suspicions. The first physician is part of a large medical group owned by a hospital system that sees itself as a major player in value-based care, and I wondered whether it was easier for him to just order screenings rather than exclude the patient in their crazily complicated EHR. The second is an independent physician who was ordering tests that would mostly lead for profit for his practice, which was particularly disturbing because the tests in question are invasive. A recent article in the Journal of the American Medical Association adds another scenario, which is the possibility that physicians don’t want to stop ordering screening tests because it will make them seem like they’re giving up on their patients. The decision to provide less care for older patients is a difficult one, and I hope more physicians, patients, and families are up to the task given the size of our aging population.

Sometimes companies don’t have the wherewithal to perform the difficult tasks that need to be done within an organization, so they bring in consultants. I’ve been on both sides as companies use consultants to downsize unwanted employees or deliver other reorganization strategies. It’s unsavory and has even been the stuff of movies such as “Up In the Air” with George Clooney. Having been party to horrific termination meetings in the past, I really enjoyed this piece about a New Zealand employee bringing an emotional support clown to his own firing. The clown mimed crying as the employee was fired and created balloon animals, even though they were a bit noisy. Kudos to the employee for having a sense of humor and being willing to spend $200 to give his former employer something to talk about.

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Curbside Consult with Dr. Jayne 9/16/19

This week was one of those where I question my life decisions, particularly the one where I chose to spend my clinical time in the emergency department.

Due to a perfect storm of maternity leaves, provider illness, and other factors, I ended up working entirely too many shifts in a row, which always leaves me feeling a little overwhelmed. Twelve-hour shifts are never only 12 hours, and once you get home, scare up some dinner, and deal with any urgent home issues, it’s time to hit the sack and get ready to do it again.

The mix of patients I saw this week says a lot about what is going on with our healthcare system (or lack thereof). There were too many patients who had put off care due to fear of excessive costs or high deductibles, which unfortunately led to even higher costs due to complications. Quite a few patients tried to receive care from their primary physicians, but were stymied by lack of available appointments (and sometimes by lack of someone even calling them back). There were also far too many patients who didn’t need to be there, those who hadn’t even tried a shred of self-care before deciding to come in.

As a clinical informaticist, times like these always make me think of whether there are viable technology solutions we could bring to bear on the problem. There are a host of solutions that can help, and some of them are already being employed across the country – patient portals, virtual visits, after-hours nurse coverage, remote patient monitoring, medical advice apps, and more. Sometimes these solutions do more harm than good, such as when test results are released to anxious patients before their physicians have contacted them regarding the results.

I cared for one of these patients this week. She received results through the patient portal on a Friday night and was unable to reach her physician. The results included an abnormal imaging study and some vague radiology references to “clinical correlation needed.” The patient, who already had a diagnosis of anxiety, began to have panic attacks after consulting Dr. Google, and those panic attacks manifested as chest pain. Since she had risk factors, we were obliged to work her up with an EKG and cardiac enzyme testing. Many hundreds of dollars later, she was sent home with a better explanation of her results and a recommendation to follow up on Monday with her primary physician.

Some hospital systems embargo their results until the ordering physician has contacted the patients, while others auto-release results after a predetermined delay. This particular facility releases its results on a delay, but apparently the ordering physician was much delayed in his discussion with the patient, leading to the situation.

Although technology can help the provider streamline his or her inbox and make more time for handling results such as these (as can delegation, improved office workflows, and more), there aren’t too many other tech solutions to this problem. It all boils down to capacity – whether the provider is able to care for patients in the manner in which they want to be cared for, on a timeline that is acceptable to them. The patient empowerment movement has shown us that what is acceptable to one patient isn’t always acceptable to others, and that we need to learn to meet patients where they are at if we want to deliver care that works for them. This is challenging for providers and organizations that weren’t trained this way and whose behaviors aren’t incented in this regard.

Despite all of our talking about value-based care, there are still too few organizations practicing what they preach. Patients also don’t always understand how to operate in these systems.

I had several community physicians yell at me recently because their patients were in my ED. These physicians, who are part of a notoriously controlling hospital physician group, were upset that their patients were in the “wrong” facility. I certainly didn’t go out and drag them in off the street, but I was on the receiving end of rants that were largely triggered by the fact that the whole system is broken. Now those patients are going to show up on some leakage report, and there will be many hours spent trying to build systems to try to make sure they go to the “right” facility next time.

Of course, my facility is part of the problem. Since our state has a weak HIE and there’s no easy way for me to access the patients’ records, I likely ordered unnecessary testing, which just further stresses the system. One of the docs suggested I just use the patient’s phone to parse through the patient chart, but that’s not a realistic solution either in a busy ED where it’s easier to just re-run the labs. I hate being part of the problem, but sometimes you have to choose the least of the evils in front of you.

There are so many cool tech solutions out there that I can’t keep up with them all – chatbots that help community health centers better communicate with their patients, apps to support chronic care management, telehealth platforms, virtual care, and more – but we’re still lacking in basic interoperability. We don’t even have a universal patient identifier to tie records to, even if we could tie them all together. What if each patient had a universal identifier card and we could query a master database for the patient’s record when they came in?

Some of the patients I saw during my recent experience with global healthcare described systems like that from their home countries. Our culture is different in the US, though, and it feels like patients wouldn’t be willing to accept something like that due to risks of privacy or having the government have their data. The reality is that a lot of our data is already out there anyway.

If you asked physicians and healthcare providers whether they would be willing to give up some level of privacy for the sake of better medical accuracy or a more complete record, I wonder what they would say? I certainly would, especially knowing the pitfalls of having inaccurate or missing data and knowing how much it costs to repeat studies that are already documented somewhere but just aren’t accessible at the time they are needed. Even when I can track down results, they’re almost always faxed to our front desk rather than being consumable within the electronic chart.

Since my state isn’t exactly a hotbed of data sharing, I’m curious how others operate in this environment or whether the grass is really greener on the other side of the fence.

Do you have a complete picture of your patients’ health? What would it take to make that happen? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/12/19

My attorney friends are always asking me about the sheer volume of information in medical records that they see for personal injury cases. It’s staggering – what used to be a manila folder full of records now might be a copy paper box when printed.

Many of the notes incorporate (or simply regurgitate) other data, which just adds to the overall length – whether it’s a copy-and-paste situation or whether it’s embedding diagnostic results such as CT scans or laboratories. Either way, it’s difficult to sift through the information.

So-called “note bloat” is a problem, and some EHRs are better than others as far as helping providers visualize key patient information. It’s not surprising that the EHR is cited in medical malpractice suits. EHR-related claims have increased from 0.35% in 2010 to 1.29% in 2018. EHR adoption has jumped from 15% to 90% across that same time period.

According to recent data from The Doctors Company, this trend continues. Issues frequently cited include system design and usability problems, which are typically cited as contributing factors to a claim rather than as a primary cause. Issues around alerts were cited in 7% of claims, while fragmented records were cited in 6%. User-related issues are an issue, from problems with copy/paste to entering incorrect information.

The Doctors Company, a medical liability insurance carrier, offers some tips for avoiding EHR-related claims: avoid copy/paste except with past medical history; contact IT if data is being inappropriately auto-populated; review entries selected from drop-down menus; and review information thoroughly before treating patients. The latter is easier said than done.

I’m always interested in new apps, so was excited to hear about Foodvisor, which claims to use photo recognition and AI algorithms to identify the food on your plate and offer personalized coaching around your eating habits. Many of my patients who have tried to use food journals get frustrated with the tracking part, even using an app which they often find tedious. If the photos can accurately be translated to discrete data, this would be a leap forward for patients who have been unable to track their eating habits.

Patients can also use the app to track their activities, either keying them in or by syncing them from the IOS Health app. (I guess Android users are out of luck in that regard.) The company launched in 2018 in France and this month in the US after the system learned how to recognize foods that are popular here. I like their avocado mascot and am looking forward to seeing how they do in the marketplace.

Perhaps the app might be of use to medical students, whose rates of hypertension are more than twice that of the general public, according to a recent presentation at the American Heart Association’s Hypertension 2019 Scientific Sessions. The student rate of Stage 2 hypertension was 18%, compared to 8% for comparable members of the general public. The study looked at over 200 first- and second-year students at the DeBusk College of Osteopathic Medicine. Participants completed a survey on tobacco, alcohol, diet, exercise, mental health, social support, and past medical history. The real surprise was that only 36% of students had normal blood pressures – the rest were either elevated, Stage 1, or Stage 2.

They might also want to take advantage of recent data from the journal Heart was published last month and indicated that daytime naps may be linked to a lower risk of heart attack or stroke. Researchers looked at 3,500 people living in Switzerland and found that those napping once or twice a week were better off than those not napping at all. Participants ranged in age from 35 to 75 years and were healthy prior to the five-year study. The study was observational, meaning it doesn’t show cause and effect; but I’m certainly going to take those results to heart.

Each year in September, EHR/PM vendors and clients scramble to make sure they have updated CPT codes since the new codes typically go into effect on October 1. This year’s 248 new codes include six for online services, three for physicians and other qualified professionals and three for communications with non-physicians. Two additional codes cover self-reported blood pressure monitoring. Just because the codes exist is no guarantee that they’ll actually be paid for if used, so providers should check their payer contracts to see how new codes are handled before they get too excited. There are also 71 codes being retired and 75 being revised.

Providers typically look to their specialty societies for information on how they’ll be impacted by the changes. They also look to their IT teams to make sure the codes are loaded and mapped appropriately anywhere they might be embedded within technology, so good luck to those of you responsible for the changes.

HIMSS launched registration this week for the flagship annual conference, with the coming year’s theme of “Be the change.” There’s also apparently a rebranding effort going on, with insiders being excited by their kicky new font and expanded color palette. I guess they’ll have to commission a new set of giant letters to adorn the grassy slope outside the Orange County Convention Center. The conference itself even got a rename – it’s now the HIMSS Global Health Conference & Exhibition. According to the marketing staffer who gave me the scoop, this complements their new vision and mission of being focused on the health and wellness ecosystem. The good news is that no one really used the full name of the conference anyway, so the rest of us can still call it HIMSS20 and be good. I booked my hotel a few months ago to make sure it was affordable so now I just have to book the flight.

Speaking of HIMSS, they’re hosting their annual US National Health IT Week event later this month. Its theme of “Supporting Healthy Communities” is designed to promote transformational activities to drive better health outcomes and health equity. Points of engagement include public health, population health, workforce development, expanding access to broadband and telehealth, and addressing social determinants of health. Several governors are expected to issue proclamations in recognition of the event, but it doesn’t look like there’s much going on in my neck of the woods.

How to you plan to celebrate Health IT Week? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/9/19

Lots of companies are talking about gamification as it relates to patient engagement and management of chronic conditions, but I never thought I would see an app designed to gamify strategies to reduce physician burnout.

The folks at the American Medical Association have released an app that tries to make a game of dealing with this serious issue. Titled “HealthBytes,” the app is designed to teach strategies to help physicians optimize their practice’s operations in an attempt to reduce physician burnout. The app can be played on a PC or smartphone. The AMA states “no matter how many times you play the game, you are bound to learn something new each time.” I’m not sure what kind of research they did to drive the creation of this game, but in my experience the last thing that burned out physicians want to do is experience anything office related if they don’t have to.

The AMA admits there is a time pressure element to the “Practice Master” game within the app. Players have four minutes to play through a physician scenario, including meeting the team, designing “my dream team,” optimizing documentation, conducting a patient visit, and creating a well-being plan for the physician and the team. Following that exercise, providers can share their score, play again, or consult AMA content designed to “offer innovative strategies to allow physicians and their staff to thrive in the new health care environment.”

After finishing my recent read of “Code Blue” by Mike Magee, which names the AMA as one of the principals behind the dysfunction of the US health care system, I find it only mildly amusing (but significantly distasteful) that they’re positioning themselves as experts ready to help solve the problem. One of my colleagues refers to the AMA (along with payer executives and federal regulators) as part of the Medical Axis of Evil.

The AMA is trying to be all over the issue of burnout, including offering the trademarked “American Conference on Physician Health” that will be held September 19-21 in Charlotte, NC. The organization is co-hosting with Stanford Medicine’s WellMD Center and the Mayo Clinic Department of Medicine Program on Physician Well-Being. The conference website lists of statement of need that “Physicians’ professional wellness is increasingly recognized as being critically important to the delivery of high quality health care.” It also notes that the meeting “is designed to inspire organizations throughout the country to seek ways to bring back the joy in medicine and achieve professional fulfillment for all our physicians.”

The sheer fact that presentations will include more than 70 wellness projects and programs illustrates the significance of the issue of burnout. I was surprised to see that the two-day conference costs $825 for AMA members ($925 for non-members), with a whopping $25 discount given to presenters who only have to pony up $800 to attend.

AMA is also offering a practice transformation boot camp immediately prior to the conference, at the bargain price of $279 for the day (although you do get a $100 discount if you register for both). Tack on an additional $214 per night for hotel accommodations plus meals and travel. Frankly, if I was going to spend that kind of money, I’d be heading to the beach since that is my proven strategy for improving my own physician well-being. I noted on the website that AMA recently extended the registration and now it closes a mere nine days before the conference, perhaps an indicator of what potential attendees think of the conference.

I frequently read articles about burnout, physician wellness, resilience, etc. and they often portray clinicians in the trenches (not just physicians – it’s all of us) as somehow being lacking, therefore we are subject to burnout. If we could just be more resilient, if we could just explore mindfulness, if we could just tweak every fiber of our practice’s operations, we would be OK. If we could just embrace the therapy dogs, take a walk in a grassy meadow at lunch time, or build the ideal care team, we’d be able to dodge the flaming arrows we encounter on a daily basis.

In the spirit of fairness, I gave the game a try. I found it simplistic and revealing only of the information that most of us already know. I made the leaderboard on the first try even despite being penalized for answers that were situationally correct but not what the game was looking for. It suggested hiring a scribe, which it refers to as a CDA (clinical documentation assistant – always great to add more acronyms), along with getting the IT team to restructure my EHR inbox. Good luck with that latter suggestion in a large health system environment where any changes to the EHR require the approval of three committees, a resource analysis, and endorsement by the person behind the curtain.

I admit I played it at work with the sound turned off, so maybe I missed out on some kicky soundtrack that might have made it more enjoyable, but mostly it just made me more aggravated than I already was about the situation.

An increasing body of research and commentary is describing “burnout” as the wrong word for the situation. Instead, they’re labeling this phenomenon as moral injury, the damage that occurs to an individual’s moral conscience as a result to the trauma we face in practicing medicine. The original definition of moral injury as coined by professor Jonathan Shay included three components: 1) when there has been a betrayal of what is morally right; 2) by someone who holds legitimate authority; and 3) in a high-stakes situation.

Although other definitions have evolved, I think this still holds for a large number of situations that healthcare providers face daily. One more recent definition from Brett Litz and colleagues describes that “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long term, emotionally, psychologically, behaviorally, spiritually, and socially.”

Tweaking the process for the office’s morning huddle isn’t going to do much to address the more deep-seated issues at play here. It is insulting for the AMA to put this in front of its physician constituents.

People often ask me how I cope with the craziness of healthcare, especially when you add the craziness of information technology on top of it. On some days, the answer is “barely.” Fortunately, I have a support system with friends and colleagues who understand what it’s like to work in this environment. I try not to take it too seriously and have modified my clinical career to one that is healthy for me. Being in traditional primary care was not, but providing episodic care is better. Doing clinical informatics work helps me feel like I’m doing something to help my fellow clinicians, regardless of the muck in which we operate on a daily basis. I also spend quality time on my treadmill watching utterly mindless shows on Netflix and there’s a smattering of time leftover for music, as well as my arts and crafts hobby. It’s a lot of work to stay sane in this environment.

What do you think of the response of the AMA and other professional organizations to the problem of burnout in healthcare? What would be a better answer? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/5/19

Telehealth technology in the news: Mayo Clinic has rolled out a cancer tele-rehab program, resulting in quality of life improvements for participants. The outcomes studied included pain and daily function, which were linked to reduced hospital length of stay as well as reduced need for post-acute care.

The technology used wasn’t strictly in line with what many of us consider telehealth. The 516 participating patients were assigned to either a control group that reported symptoms by phone or web-based survey, an intervention group that also received phone calls from care managers providing instruction on walking and exercise; and a second intervention group with the same interventions plus the addition of medication-based pain management. The number of hospital admissions was comparable, but the length of stay for the first intervention group was four days shorter than the control group. The second intervention group’s length of stay was about two days shorter. Researchers note that cancer pain is often undertreated and impacts the functional status of patients, so engaging with rehab services can lead to better outcomes.

More than a decade ago, I did some HIE work that we thought was pretty cutting edge, but now doesn’t even begin to scratch the surface for interoperability. Being able to access a patient’s full and complete medical information, whether provided by the patient or obtained from other sources, is the equivalent of the holy grail for some physicians. Having been in the clinical trenches for a fair amount of time, though, I wasn’t surprised by the statistics that nearly half of US patients are omitting significant pieces of their histories provided to their care teams.

Data noted in a recent survey of over 4,500 patients included issues such as domestic violence, sexual assault, depression, and suicidal thoughts. Patients are often uncomfortable addressing these issues with providers, especially during relatively brief medical encounters. They may feel they will be judged or lectured. The rate of information withholding is higher among women and younger patients. If the patient isn’t ready to share that kind of information, it’s unlikely to be available from other sources, but I hope that our efforts with patient engagement and empowerment will ultimately lead to patients who feel comfortable sharing information that will help us be better partners for health.

Flu season is nearly upon us, with recommendations to try to vaccinate all patients six months and up before the end of October. As the flu season becomes nearly year-round, the opportunities continue for patients (and staff) to contract the illness.

I once worked with a practice that did not provide employees any sick days and punished them for calling out sick. Their mantra was, “If you’re going to be sick, you might as well be paid for it.” It’s shocking to hear from a healthcare organization, so I was interested to see a recent study that looked at healthcare workers that continued to deliver care while suffering from acute respiratory illnesses. The authors looked at multiple flu seasons in nine Canadian hospitals from 2010 to 2014. At least 50% of participants reported at least one acute respiratory illness, and nearly 95% of workers reported working at least one day while they had symptoms. The relative risk of working while ill was greater for physicians and lower for nurses.

Study subjects were more likely to work with less-severe symptoms and were more likely to work on the first day of illness rather than as it progressed. Most people working while sick felt their symptoms were mild and 67% felt “well enough to work.” Not surprisingly, those without paid sick leave were more likely to state they could not afford to stay home. The authors conclude that “further data are needed to understand how best to balance the costs and risks of absenteeism versus those associated with working while ill.”

In related news, a recent study concludes that the N95 respirator is no better than a standard medical mask at preventing transmission of influenza to healthcare providers. That’s good news. Anyone who has ever had to wear the N95 knows it’s not much fun, not to mention the need for some people to shave beards to get it to fit correctly.

A related editorial notes that although the study was designed to address limitations of previous studies, the current study was somewhat underpowered and might be impacted by under-reporting of symptoms and delays in specimen collection. It also didn’t address the inpatient setting. It did, however, mimic conditions that are typically seen, including providers who may or may not wear the masks they are supposed to, or who may not wear them correctly. This makes the findings more generalizable.

Our flu vaccines are scheduled to arrive today. Personally, I can’t wait to roll up my sleeve since one of my colleagues has already been diagnosed with influenza.

I missed out on the groovy time that was the Epic User Group Meeting, but was intrigued to hear the announcement that they’re pulling together records of more than 20 million patients for medical research. As Mr. H noted, they’ve made this announcement before, so the real news is that clients are actually signed up. Cosmos is designed to gather de-identified data from Epic customers and make it available for evidence-based medicine research.

I’m sure it was a splashy announcement at the annual UGM gathering, but I question the ability for that data to be truly de-identified and how clean it is. Nine organizations have contributed more than 7 million patient records, with 30 additional customers being in discussions with the company. Participating hospitals and health systems agree to ensure data contributed is standardized enough to support research. Epic plans to dedicate resources to do terminology mapping to allow the platform to work.

The data won’t be available to researchers until there are at least 20 million patients in the data set and already people are salivating at the possibility of using it for rare diseases or difficult-to-treat conditions. Researchers will use existing Epic applications to work with the data, along with potential new applications.

There are certainly privacy concerns at play here, even with de-identified data. We’ve all seen how easy it is to re-identify that information. It’s unclear whether patients intended their data to travel far and wide and whether existing consents cover this kind of an aggregation.

I’ve seen half a dozen Epic builds over the years and frankly the lift needed to standardize some of the data might be the limiting factor. My own Epic patient charts are chock full of errors that I don’t have the time or energy to try to correct, so good luck to those who think this is going to be the answer to all kinds of research problems. There’s also the issue of data that lives in Epic that was converted from legacy EHRs, which after being converted and normalized, might not even resemble the original clinical intent.

I’d be interested to hear from anyone who has been involved in this project or who is closer to the details. What did you think of the announcement at UGM? Is it just one more shiny object for organizations to follow, or is it really a game changer? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/29/19

There has been quite a bit of discussion in the physician lounge about recent articles looking at health outcomes and social spending in the US compared to other comparable countries. The authors used data from the Organization for Economic Cooperation and Development spanning 1980 to 2015 and compared relative spending on social services and healthcare.

Countries in the dataset included Australia, Canada, Denmark, France, Germany, Japan, the Netherlands, Sweden, Switzerland, and the UK. They found that non-US countries spent an average of 8.8% of their gross domestic product (GDP) on healthcare, but the US spent 16.8%. In comparison, the US spent 16.1% of GDP on social services compared to 17% in other countries. When education was included in social spending, the US spent 19.7% of GDP compared to other countries’ 17.7%. The authors also found that in the US, a greater portion of spending occurs for the elderly.

The findings contradict the belief that the US spends so much more on healthcare because it doesn’t spend enough on social services. Previous analyses found that US healthcare spending is greater due to labor, pharmaceutical, and administrative costs, which shouldn’t be a surprise to anyone who works in the industry.

Several of my colleagues who are department chairs were also in a heated discussion about CMS star ratings on the Hospital Compare. CMS recently announced that updates to the methodology behind the ratings will be delayed until 2021, although CMS will continue to publish the ratings. Many hospital organizations are asking for the ratings to be removed or suspended until the updates are implemented.

Although the ratings are better than having no information at all, they’re difficult for patients to use when making decisions. For example, my local academic medical center has a lower rating than the closest community hospital, but if I needed anything more complex than removing my gallbladder or appendix, I’d be headed straight to the lower-rated facility.

CMS received 800 comments within 145 letters from various organizations, many stating that they feel the ratings are overly vague, they are too complex, and they oversimplify quality measurement. Submissions asked for greater precision in the ratings along with improved apples-to-apples comparisons. CMS will use the comments to develop the proposed rule for release in 2020, so the current methodology remains in place. A public listening session will be held on September 19 to further discuss the ratings and proposed changes.

Direct Primary Care was also a hot topic, with one physician noting he’d like to make the jump “to get out from under the corporate overlords.” The DPC movement might get a boost if The Primary Care Enhancement Act of 2019 (HR 3708) becomes law. The Act would update the US tax code to allow patients with health savings accounts (HSAs) to use those funds for DPC payments. Currently, DPC payments are treated as insurance premiums, so patients trying to use HSA funds incur a tax penalty. The number of primary care physicians considering a move to a more direct model is on the rise. A previous bill failed to pass in 2017.

Paladina Health and SSM Health are forming a direct primary care joint venture in St. Louis. There are many different DPC models, and this one is of the direct-to-employer variety. Employers will pay a flat fee to cover physician services, including office visits, some medications, and labs. I have a friend who works for Paladina Health and he enjoys seeing fewer than a dozen patients a day ,with office visits that are long enough to actually tackle patient problems and discuss non-pharmaceutical interventions like diet and exercise. He’s skeptical about the joint venture with SSM because one of the draws for him to work for Paladina Health was getting away from being employed by a hospital system. SSM Health plans to offer direct primary care to its own employees who are covered under its health plan.

The American Medical Informatics Association announced the keynote speakers for its annual symposium in November. CMS Administrator Seema Verma will keynote on Sunday, November 17, and patient advocate Peter Kapitein will speak on Wednesday, November 20. Kapitein hails from the Netherlands, and the part of his bio that caught my attention was his role in founding a fundraising bicycle ride up the Alpe d’Huez, one of the grueling highlights of the Tour de France. His bio also notes that his employer (the Dutch central bank) “facilitates him to work three days a week for the victory over cancer.” I can’t wait to hear more in person.

The Electronic Health Record Association (EHRA) has given its support for the new NCPDP SCRIPT version 201701 standard for electronic prior authorization (ePA) of prescription drugs under Medicare Part D. However, it did note some concerns around the deadline for implementation, recommending a full 24 months for implementation once the final rule is published. The standard is designed to allow pharmacies to communicate with practices using expanded electronic transactions, reducing the number of phone calls needed to complete prior authorizations. EHR and pharmacy vendors have to create updates and their clients will need to modify their systems, so it’s not a small undertaking. The current proposal requires implementation on January 1, 2020 and the new version of the SCRIPT standard isn’t fully backwards compatible, which could cause issues. EHRA is also recommended an update to HIPAA to reference the new standards since some individual states may be pursuing their own.

Individual state standards would be just about the worst thing we could interject into anything involving healthcare IT and especially interoperability. Clinicians practicing in cities close to state borders might be caught in the crossfire like they currently are with requirements for paper prescriptions, resulting in multiple workflows which doesn’t really help efficiency.

In my past life, we had to maintain multiple different paper prescription formats along with custom code to ensure the correct version was printed based on the patient’s pharmacy of record rather than the location of the practice. Our EHR vendor only supported script generation based on the latter, and contentious pharmacists across the state line refused to honor our prescriptions. In my current practice I have to deal with different local rules regarding controlled substances (you can purchase pseudoephedrine on one side of the street without a prescription, but must have a paper script on the other) and it’s a pain. It’s also probably one of the reason we dispense a lot of the drug from our in-house pharmacy, so patients just don’t have to mess with it.

I’ve also run into the differences in state standards in my recent foray into telehealth, dealing with different standards on reportable conditions ranging from sexually transmitted infections to dog and cat bites. For the latter two, most states require physician reporting, but the mechanism varies dramatically. In my home county, I can report via email, while in a neighboring county it has to be a phone call, and across the state line it has to be a faxed form. Thank goodness for Google, which helps me track it all down as the need arises.

What do you think about individual state standards for healthcare IT? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/26/19

I’ve received several post cards and also emails from Nuance lately, marketing their Ambient Clinical Intelligence product which they also describe as “the exam room of the future.” I’m pretty sure this is the follow-on to what many of us saw in their demo/theater at HIMSS.

The premise was this: the physician and patient interact in an exam room that supports speech recognition while also serving up EHR data to the provider upon request. The demo scenario was a 40-something woman with knee pain. The system helped the provider navigate to find information about previous visits as well as documenting the current one.

At the time, I spoke with some of the Nuance team and it sounded like they were really focusing on subspecialty situations where the workflows would be fairly standardized and/or predictable. In order for the technology to work, there needs to be a significant repository of data available as far as medical dictionaries, codified discrete data, etc. Then on top, you have to layer the typical exam findings, questions, and possible answers for different conditions, to ensure the system will be able to recognize what is being said without having to “train” the speech recognition portion. Beyond that, components of EHR historical data t have to be served up to help answer questions the clinician might ask, such as when a medication was first prescribed, etc.

Although the orthopedic demo was pretty flashy, it was obvious that the participants were actors and that they were working from a script, especially when the real-time-looking demo on the screen didn’t 100% match what had been said. Still, it was attention-grabbing enough to send me to speak to one of their reps about where they really were in development for other specialties. It sounded like they were a bit of a way out for what would be necessary to support workflows in primary care or urgent care, which can be the exact opposite of predictable. With the mailings and email ads, I figured perhaps they had made more progress and decided to follow up.

One piece on the website that caught my eye was something they’re calling “integrated machine vision” and is designed to “detect non-verbal cues.” I’d be curious to learn more about how they’re doing this, and what it might entail to create a library of non-verbal information that could be parsed to add context to notes. I’m also curious whether this applies only to the patient side or whether it’s skilled enough to pick up non-verbal input from the clinician. Would it be able to interpret the complete absence of a poker face that I exhibited recently when seeing the largest hernia I have encountered in my career? Could it interpret the glassy-eyed stare of my patient to determine whether they just weren’t paying attention or whether I should be asking more deeply about potential substance abuse? For clinicians caring for teens, I’d think that ability to quantify teenage eye-rolling would be the gold standard.

Another major component of the system is the virtual assistant piece, kind of like Alexa, Siri, or Google. “Hey Dragon” is the wake word to access information in the EHR, and as this technology evolves, it gets us closer and closer to what many of us have seen in the “Star Trek” universe over the years. Having toyed with a virtual assistant over the last couple of years, I know there are nuances in how the questions are asked to get the data you want to get. Somehow in “Star Trek” they don’t have to ask the computer three different questions to get the desired output. I’m hoping Nuance has been able to figure out the secret sauce needed to translate how physicians think and speak and adapt the system to match.

I was also intrigued by their “intelligent translation and summarization” comments on the website, where they note that it “turns natural language into coherent sentences.” That sounds a bit like physicians might have trouble being coherent, which probably isn’t far off the mark for many of us, especially at the end of a particularly long and brutal shift. I know I lean heavily on my scribes (when I’m fortunate enough to have one) to translate my often-wordy home care instructions into a bulleted list that patients will be more likely to follow once they get home.

Although some of us are skeptical about the power of AI, I was intrigued by some of the numbers presented on the website. The company claims 400 million consumer voiceprints, with 600 million virtual and live chats per year powered by their AI technology. Although I’ve used speech recognition in the past, I didn’t realize the growth in speech-to-text and the fact that they have 125 voices in 50 languages. If they could somehow work with Garmin to integrate the “Australian English Ken” voice I used to have with my stand-alone GPS, I’d be sold. I could listen to him all day, even if he was continually telling me to make a U-turn at the next safe intersection.

This type of technology could really be a game-changer for physicians, perhaps reducing burnout, decreasing medical errors, and making visits more efficient for patients and clinicians alike. I’d be interested to hear from anyone who is actually employing these types of features in practice, whether it’s a comprehensive suite as Nuance is promoting or whether it’s freestanding elements such as a voice assistant for chart navigation, data retrieval assistance, or something else.

I wonder how much research is being done in this arena outside of the vendor space, whether any of the institutions that have strong informatics programs are getting involved with similar initiatives, or whether it’s so expensive that the work is typically vendor-driven.

From a patient perspective, I’d love to see a voice assistant functionality that could make it a reality for me to simply ask it to “make me an eye appointment after November 3 using one of the open slots on my calendar” and have it connect with my provider’s practice management system and get the job done without two phone calls, a patient portal message, and a two-week timeframe like it took me to make my last appointment. Now that would be something, indeed.

What is your most sought-after voice assistant functionality? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/22/19

Time is ticking for practices that haven’t completed the full transition to the new Medicare Beneficiary Identifier numbers. Claims submitted with the previous numbers will be rejected starting January 1, 2020. At this point, the new MBI is only being used for 77% of Medicare fee-for-service claims. Given the duration of the transition period, I’m surprised to hear that nearly a quarter of claims are still going out under the old numbers.

Telehealth is of interest to many young active patients, but clinicians are concerned about how well it might work for older patients for whom technology might be a challenge. A recent research letter details findings on video visits that were used with homebound geriatric patients. Physicians in New York state piloted the program from June to December 2018 as they sought to identify cost-effective ways to care for older adults. The authors labeled the program as “not yet ready for prime time” even though most patients and medical social workers involved in the study felt that when a video visit was successful, it met their needs and was preferred over long wait times for in-person visits. The difficulty apparently stems from inability to successfully complete the visits, with only a 49% completion rate. Installation of the telehealth app was performed by researchers after patients were identified from a pool of enrollees in a home-based primary care program.

Of 500 eligible patients, only 56 were enrolled. Patients were assessed to ensure they were cognitively and technologically capable of conducting a visit and that there was a family caregiver willing to participate as well. Even with those controls, there were a number of technical and equipment compatibility issues, with only 39 patients completing at least one video visit with their medical social worker. The average visit length was 18 minutes. The average patient was 85 years old and issues cited included failure to remember their Apple ID or passwords. Another issue involved two-factor authentication, where patients had to receive a code to access the app before they could enter the video conference.

There are significant shortages for home-based primary care for the frail elderly who want to remain in their homes. I’d argue that even with the challenges, if we could manage a percentage of patients via video, that might be better than the current state of affairs. Using technology that doesn’t require an Apple ID (especially since Apple is no longer the darling many people once thought it was) and relaxing the need for two-factor authentication might increase the percentage of successful visits. The authors next plan to pilot a device that connects via a patient’s home television and allows use of a TV remote, which might be a better option for the target population.

There are so many publications from CMS and other governmental entities that I occasionally miss something interesting. Apparently deep within the interoperability proposed rule is a provision that requires hospitals to inform primary care physicians about patient admissions, transfers, and discharges. Although Accountable Care Organizations want access to the data, hospitals are pushing back. One stumbling point is the need to inform physicians of these activities electronically.

Another is the requirement of this notification as a condition of Medicare participation for the hospital. It also would require hospitals to determine which physician might be the most appropriate to notify. I’ve worked with the attribution issue for several of my clients and it’s never straightforward, especially when patients might have recently changed primary care physicians or when they might be admitted for a problem that is primarily under the care of a subspecialist. Patients and patient advocates are also wading into the discussion, claiming that notifying physicians without express patient consent is a violation of privacy. The comment period on this particular proposed rule closed in May, so we’ll have to see what changes might be made.

For those of us who closely monitor Medicare spending, not only professionally but personally (hoping there will still be some money available when we get to the magic age), take a look at this piece on wasteful drug spending. One of the tricks commonly used by pharmaceutical manufacturers to extend their revenue streams is the creation of drugs that are nearly identical to existing drugs, but that are different enough to have their own patent. A recent study looked at spending on these drugs and found that Medicare could have saved nearly $17 billion from 2011-2017 by substituting 12 older drugs for the newer agents. There is little clinical evidence that these newer drugs deliver better outcomes than their older generic precursors. Researchers used the Drugs@FDA database to identify drugs that had been approved and analyzed both Medicare and patient out-of-pocket spending on the drugs. The out of pocket spending by patients could have been reduced by $1.1 billion on top of the Medicare savings.

Healthcare IT could be positioned to help educate prescribers and patients about this issue through a variety of strategies. One might be displaying relative cost at the point of prescribing. Another might be showing therapeutic equivalents as a part of clinical decision support. Payers are already trying to stem the tide by putting the higher-priced drugs on higher formulary tiers, which are easily identified in some EHRs. I wonder if the development of some of this functionality in current EHRs is being stymied by the vendors’ engagement with pharmaceutical companies, since several are selling patient data behind the scenes.

Another option would be to use clinical decision support to prompt lifestyle interventions before prescribing some of the drugs and enrolling patients in care management programs to ensure they can be successful with lifestyle change. Those are more high-touch options that are less popular in our US culture, however. It’s easier to take a pill and many patients find taking the latest and greatest drug to be desirable regardless of the cost.

Mr. H scooped me with his report on the Patient Record Scorecard, which grades hospitals on how effectively they respond to records requests from their patients. I had heard about it in a different context, when a reader clued me in to a site called MedRxiv (prounced “med archive”) which describes itself as “The Preprint Server for Health Sciences.” Essentially, the site is publishing manuscripts that are preliminary in nature and haven’t yet been through a peer review process. The site was founded by non-profit Cold Spring Harbor Laboratory, Yale University, and BMJ and operates as “a platform for researchers to share, comment, and receive feedback on their work prior to journal publication.” I hope the authors of the Scorecard can ultimately get their findings published since they seem consistent with what many of us are experiencing.

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Curbside Consult with Dr. Jayne 8/19/19

I wrote back in 2017 about the All of Us research program, sponsored by the National Institutes of Health. Originally they were trying to build a cohort of 1 million patients to help them look at genomic, clinical, and lifestyle data over a 10-year period. The New England Journal of Medicine recently published an update on the program’s progress.

Following the original beta program that I wrote about, All of Us opened for general enrollment in May 2018. Elements of the program include health questionnaires, EHR data, physical measurements, and the collection of biospecimens.

As of last month, more than 175,000 participants had contributed biospecimens, with more than 80% of those participants being from “groups that have been historically underrepresented in biomedical research. That’s a pretty big deal, since it’s difficult to recruit research subjects from certain subsets of our population. They’ve also collected EHR data on more than 112,000 participants from 34 recruitment sites. Should the researchers meet their goals, the robust nature of the data would allow researchers to explore factors related to individual lifestyle differences, socioeconomic factors, environment, and biology in order to better understand how we can prevent, diagnose, and treat diseases.

Having historically underrepresented patients join the program is great since those populations often have inadequate access to healthcare. Although some conditions can be linked to race and ethnicity, they’re only pieces of the puzzle. Other factors influencing health include age, sex, gender identity, sexual orientation, disability status, access to healthcare resources, income, educational level, ZIP code, and more. Researchers are prioritizing those underrepresented populations for physical measurements and biospecimen collection.

Unlike other data-gathering programs, All of Us doesn’t focus on any particular set of diseases like cardiovascular conditions or cancers. It seeks to create a broad data set that can be used for a variety of investigations, including outcomes research. Although they’re currently only enrolling adults with the ability to participate in an informed consent process, they’re looking at protocols for enrolling minors as well as adults who might be cognitively impaired. The materials are only available in English and Spanish, so it’s not a true cross section of the population, but the program is moving in the right direction.

The program has launched a web-based data browser where you can search concepts for some of the conditions and statuses being tracked. Although patients can only see their biometrics and survey responses, the researchers are working to build protocols to share genetic, laboratory, and EHR data back to participants. Priority will be given for actionable genetic information and pharmacogenetic results, delivered to those patients who have elected to receive that information.

Since the database is intended to be longitudinal, it will be interesting to see how many patients continue to participate over time. Since its inception, Congress has allocated $1.02 billion to the program, including funding for genome sequencing and setup of genetic counseling resources for participants receiving actionable results. The 21st Century Cures Act authorized funding through 2026 in the amount of $1.14 billion.

Another element that they’re still trying to work out is the incorporation of wearables data. Patients can share data gathered from Fitbit devices and investigators are looking at collection of data from other sources. Given the number and diversity of devices out there, they would need to support quite a few platforms to be able to get a good sampling. My extended family’s affinity for devices ranges from Garmin to Fitbit to Apple. Even with concerns about the validity of data from wearables, it’s interesting to note that simply having a wearable health tracker of any kind says something about a patient’s socioeconomic status and awareness of health issues.

One of the challenges noted by the authors is the incomplete nature of some of the EHR data, along with variability in that data. They are working to harmonize the data that they bring in from EHRs at recruiting institutions and are discussing ways to incorporate data from patients receiving care in rural settings. Health Information Exchanges might be another data source for those patients.

A quick tour through the online data browser illustrates some of the challenges of managing the data. The concept of diabetes can be rendered as the presence of disease, as a factor leading to adjustment of other lab values, and as a status identifier. There are also issues with EHR data in that it’s not always going to be complete enough to have the statistical power that you might find with data collected as part of a prospective trial. Still, it’s better than some of the current options, and I’m eager to see how things develop.

The biggest challenge they’ll have to face, however, is recruiting the more than 800,000 patients they still need to create their target population. It’s likely that in the early days of the program enthusiasm and awareness were high, resulting in the enrollments they already have. They’re going to have to stay on pace at the recruiting centers they already have up and running or dramatically expand the number of locations that can assist in the recruiting process.

Another option is to expand what they call direct volunteers, which are patients who come to the program from outside the designated recruiting centers. Reaching those folks who might be in rural areas or who just don’t come into care and are therefore less likely to be recruited requires different kinds of efforts. I haven’t personally heard anything about the program except from healthcare IT sources, and I’m constantly in and out of medical centers across the country. I’ve seen more signage about Ebola virus than I’ve seen about the program.

Given the size and breadth of our reader base, I’m hoping someone has first-hand experience with All of Us, either as a researcher or as part of one of the recruiting institutions. What has your experience been? How enthusiastic is the team? What can the rest of the healthcare community to do help you meet that million patient goal? Leave a comment or email me.

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EPtalk by Dr. Jayne 8/15/19

EHR vendors, get ready to make some updates: The US Preventive Services Task Force (USPSTF) plans to recommend screening all adults for illicit drug use, including inappropriate use of prescription drugs. The draft recommendation statement is open for public comment through September 9. As an EHR client, we expect these kinds of recommendations to play out in our EHR as soon as they’re published, but for many vendors it’s a long road between when a recommendation is issued or a guideline is updated and when it actually is in the hands of the majority of their clients. I’d be interested to hear from vendors how they approach these types of updates and how quickly they can get them to the point of care.

Speaking of recommendations and regulations that never become reality, here comes yet another delay for implementation of the Appropriate Use Criteria for advanced diagnostic imaging that was initially passed in 2014. NPR reports that the delay will continue, with 2020 as a “testing” year where Medicare will not block inappropriate scans. CMS won’t make a decision until 2022 or 2023 on whether (and when) penalties will begin. The reality is that Medicare and other payers continue to pay for unneeded diagnostic exams. These exams are often ordered because patients demand them, even though they show low clinical utility. Physicians increasingly worrying about being “dinged” on patient satisfaction scores that go along with it, often under duress. Advanced imaging services are a profit center for many medical institutions and physicians chafed at the idea that they’d have to log additional keystrokes in the EHR to document compliance with the criteria.

A friend of mine who used to work in corporate IT has recently moved into the world of healthcare IT. I’ve been enjoying his reactions as he learns about all the crazy stuff that we have to deal with, including managing claims, handling capitation payments, and more. He recently visited a practice that was processing data using stacks of papers to trigger the workflow and track who was doing the work. I’m thinking about prescribing him some muscle relaxers to counteract the ill effects of all the head shaking he’s probably doing. It’s always amusing, but sad in many ways, to watch someone experience the dirty underbelly of healthcare. It’s a mix of shock, disbelief, and outrage. Those are the same emotions I’m feeling while I read “Code Blue: Inside America’s Medical Industrial Complex” by Mike Magee. I had started it prior to my international medical adventures and resumed the read after hearing from my fellow volunteers. Hearing from them about how healthcare is delivered with lower cost and higher quality in their countries just makes my blood pressure rise. I sold any stock in EHR vendors long ago, but will be divesting some remaining pharma investments shortly. Shareholders are part of the problem, not the solution.

Corporate profiteering is everywhere, and I experienced it in another conversation today. One of my residency colleagues went to work last year for a group that does Direct Primary Care as an employee benefit. She’s been enjoying the work, especially the part where she has an hour for new patient visits and 30 minutes for regular visits, and feels like she actually has time to partner with her patients to improve their health. She wanted me to know that her company is expanding to my area and to see if I was interested in a referral to their recruiter. Since that’s a major aspect of primary care that I miss in my current clinical practice, I said I was game.

She proceeded to tell me a little more about the company, including that they were recently purchased by a PE firm and that there has been the addition of a good number of VPs that don’t seem to do anything but have titles in sales, marketing, and operations. That’s part of why and how they’re expanding; the PE money is an infusion but also increases the need to create some revenue from the system. Although their profit is largely driven by the difference between what the employers pay and the services the patients use, she agrees it’s only a matter of time before the nature of the practice changes. For providers in the trenches, though, it’s a difficult balance between practice paradigms that have good elements but some features that are unsettling. Her final thought was that it’s still better than the HMO she used to work for, so I guess there’s that.

I’ve always wanted to visit Spain, and I wish I was still doing a reasonable volume of lab work so I would have justification to attend the upcoming LOINC Conference outside of Barcelona. Both the Laboratory and Clinical LOINC Committees will be at the same meeting for the first time, and the conference fee is low compared to other organizations. For those of you heading to the sun-drenched Mediterranean, enjoy!

The next couple of months are full of meetings and functions. ONC is hosting an interoperability forum  August 21-22 that has a good-looking agenda, but there are too many parallel tracks – I wouldn’t be able to pick just one to attend. There’s also a symposium on September 6 around patient matching for prescription drug monitoring programs. This also starts the User Group meeting season, beginning with the Aprima User Conference from August 22-25 in the Dallas area. I hear that’s a fun one, but have never been able to make it work with my schedule.

New Hampshire becomes the latest state to expand telehealth services, with Governor Chris Sununu signing a bill expanding the scope of services covered under Medicaid. Previous regulations limited telehealth services to specialists, but the new law mandates coverage for virtual primary care, remote patient monitoring, and substance abuse disorder treatment as long as the patient has already established care face-to-face. The definition for “originating sites” for those face-to-face services has been expanded from medical offices to include “the patient’s home or another nonmedical environment such as a school-based health center, a university-based health center, or the patient’s workplace.” It’s not as expansive as providers might like, but it definitely helps the state move forward. The law also creates definitions around asynchronous telehealth for non-urgent issues, which will help provide services when video visits might not be realistic.

I skim a lot of journals and publications, but have to admit I wasn’t aware of the Renal & Urology News before a reader sent me this snippet: A recent study looked at referral patterns at Wake Forest School of Medicine and found that patients with rare genetic conditions might be more likely to refer themselves to an academic medical center based on information they find on the Internet. The authors noted that primary care physicians might not be aware of certain rare conditions, so “If patients suspect a rare disorder that is undiagnosed by their physicians, actively pursuing self-diagnosis using the Internet can be successful.” Dr. Google, take note.

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Curbside Consult with Dr. Jayne 8/12/19

I had lunch with an old friend today and was surprised to learn that he has engaged with a telehealth client. Although he’s a database guy at heart, he’s also got a mind for developing solutions, and that’s how he wound up in the space.

He’s working for a group that is developing chatbot technology for health systems that want to incorporate asynchronous visits into their offerings. Rather than just script out various scenarios, however, they’re working to leverage existing data to design responses and offer care to patients, so I was intrigued. Right now they have some flexibility since they aren’t billing for the service (it’s being offered as a perk of being a patient in the practice) and don’t have to worry about checking boxes for claims and billing. It will be interesting to see where things go.

Telehealth is definitely at the forefront of many organizations’ strategic plans. Whether you’re a dedicated telehealth vendor or a practice looking at it as a solution to reduce revenue leakage, if it’s not part of your plan, you need to be thinking about it.

Physicians are looking at telehealth as a way to improve their work-life balance. Although many have been doing the equivalent of after-hours visits for free for decades, they’re now looking to be paid for their services and compensated for their time away from family (or away from sleep, in many cases).

Patients are also highly interested in telehealth from a convenience standpoint, although they’re not always well versed in whether the services are going to be covered. I’ve seen some backlash from patients concerned about being billed for a visit that they didn’t really consider to be a visit, since in the past they had talked to their physician after hours for free. There will definitely need to be education on what services are truly telehealth vs. phone calls after typical office hours.

As a physician who has started to deliver telehealth visits, I’ve found it challenging. You have to use different skills than you might in a face-to-face encounter, even if video is enabled. There are subtle differences in the interaction, and I feel like I’m drawing a lot on my experience as a physician in making sure I’m not missing anything.

As residency programs issued their new graduates at the end of June, I’ve heard of several new grads that are going straight to telehealth without ever having had a face-to-face practice. I remember how uncertain I was as a new grad in solo practice and didn’t have colleagues to bounce things off of. I would think that feeling would be magnified for a new grad, especially if their residency program didn’t really prepare them for telehealth. I don’t think there are that many programs that do, at least not in family medicine. If there’s any mention of telehealth, it’s as an adjunct to the traditional physician-patient relationship, not as a standalone.

Physician specialty organizations are eager to push back at the idea of standalone telehealth. The American Academy of Family Physicians recently highlighted a study about the value of the physical exam. The group describes the physical examination as “central to the relationship between physician and patient for millennia,” but notes recent “skepticism about tis role in patient care.” Researchers looked at a very small (16) set of family physicians to understand how they perceived physical examination experiences and what those physicians identified as objective and subjective benefits of the exam as part of patient care. Some described the actual examination as critical, with one saying that providers who don’t conduct exams are not good doctors. Others said they used the exam to confirm or disprove their suspicious after discussing the history of the present illness. One physician said there was an expectation to perform an exam, and therefore doing it helped build the relationship.

I have a different take on exams after staffing the World Scout Jamboree. Our exams there were entirely dictated by physician preference and the patient’s presentation, with no consideration given to billing, body systems, or bullet points. Some of our patients were healthy teens with self-limited problems that dictated a minimal exam, while others were diagnostic dilemmas that required more.

On the world stage, at least in that environment, I don’t think that doing more vs. less made a difference to the patients. One of my Swedish colleagues at the Jamboree noted that physicians there do a minimal exam. The focus is more about sitting down and talking through things rather than the laying on of hands, at least in his experience.

The study authors also note the emotions felt by physicians during the physical exam, especially when assessing sick patients. They also reveal their own emotions by saying that “we should not dismiss physical examination as nostalgia” in favor of technology.

I suspect that physicians that perform minimal exams in the face-to-face setting are doing so because it’s clinically appropriate. I too often see people examining unrelated body parts just out of habit or because they think they need to, regardless of whether it will affect the care plan. This is difficult to address when precepting students, but an important topic as we look at evidence and data-driven approaches to care.

I had a teacher once who insisted that no physical exam was complete without a rectal exam. He legitimately expected the interns to perform that exam on every single inpatient. Several of us refused, citing the odds of finding an incidental rectal cancer as completely out of balance with the invasive nature of the procedure and the discomfort caused to patients. That’s an extreme example, but I also see students and new grads that examine thyroid glands on every patient, just because it’s habit and regardless of the chief complaint.

Mysticism and romanticization of the exam aside, sometimes you just don’t need to see the patient, let alone examine them, and it’s entirely possible to deliver quality care without laying on of hands. That’s going to be difficult for many audiences to accept.

Pediatricians are also coming out with concerns about telehealth, particularly regarding over-prescription of antibiotics. That’s not been my experience as a telehealth provider, where the degree of antibiotic stewardship is highly visible and frankly much more strict than my face-to-face practice. I’m sure there are bad actors out there, but painting everyone with the same brush isn’t ideal. I also see plenty of traditional family medicine docs who call out a Z-Pack for upper respiratory infections even if the infection is most likely viral. I see those patients in the urgent care setting when they complain that their antibiotics didn’t work, and get to spend plenty of time counseling them on the differences between bacteria and viruses and exactly why their antibiotics didn’t work.

It’s important to also note that not all telehealth is direct to consumer. Some services are offered as part of a traditional practice, others are arranged by an employer, and still others are funded by insurance companies and other payers looking to keep costs down. It’s a complex solution that isn’t one size fits all and doesn’t always fall under similar models. The only thing I know for sure is that telehealth isn’t going away anytime soon.

How aggressively does your organization track antibiotic stewardship? Leave a comment or email me.

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EPtalk by Dr. Jayne 8/8/19

I’m once again in the middle of a billing dispute with Big Medical Center, so I was excited to see this article about tech giants teaming up with healthcare companies to share claims data. One of the proposed applications is helping consumers avoid paying erroneous bills, which would apply in my situation. The group is using CARIN Alliance specifications and testing should begin first with Apple, which appears to be farther along in the process.

The goal is for patients to have broad access to their data rather than having to look at how they use health services across providers. This may enable patients to better understand how they utilize services before having to select health coverage each year. The same thing can be done using the paper Explanation of Benefits statements that most of us receive, although a fair number of people don’t seem to read them or keep them.

It’s been a week now since I called to complain about my erroneous bill and was bounced from the faculty practice billing service to the hospital billing service to the office, which doesn’t understand how I have two receipts for my payment even though one is from Epic and the other is a credit card slip. They declined my offer to scan copies to them, claiming they can only interact through the patient portal and patients can’t add attachments.

I have no hope of getting this straightened out anytime soon. The last time I had a billing dispute with them, they sent me to collections even though the aging on my patient balance was less than a week old. Apparently the fact that it took them more than a year to actually generate a bill during their Epic transition wasn’t a mitigating factor, since the system just saw it as way overdue.

Up until I studied for the Clinical Informatics board certification in 2013, public health informatics wasn’t something I knew much about, let alone practiced. A lot has changed since then given the availability of rich data sets and the ongoing commitment by health organizations to try to reduce costs. Healthcare delivery organizations are also looking at outbreaks in an expanded way, from influenza to measles.

I was glad that we didn’t have to put the measles containment protocol into place during my recent gig at the World Scout Jamboree. The only suspected case turned out to be the relatively harmless Pityriasis rosea rash. Still, we were ready. Recent data from the Centers for Disease Control show more than 1,170 cases of measles this year with no end in sight.

One of my clients recently asked me to create a measles reporting package for them, looking not only at vaccination status among patients, but also to prepare to gather data for measles-related complications such as pneumonia and encephalitis. I spent entirely too much time immersed in ICD-10 finding all the right codes to look for, but hopefully it will help them be prepared if and when the time comes for them to need to do regular reporting. Kudos to them for being proactive even though they’re in one of the 20 states that hasn’t yet experienced a measles case.

Speaking of cost reductions, I was intrigued by this New England Journal of Medicine article that looked at ACO model participation with respect to levels of Medicare spending. Specifically, the authors found that ACO providers in rural or underserved areas had lower spending compared to non-ACO providers, at least during the first performance year. It’s important to note that the primary outcome of the study was spending – secondary outcomes were utilization-focused, including inpatient admissions, emergency visits, days in skilled nursing facilities, and inpatient readmissions. Key outcomes measures, such as mortality, were missing from the study.

I don’t disagree with the need to reduce Medicare spending so that there is some money left when the rest of us reach that age, but I think patients and physicians would be more likely to adopt new payment and care models if they are shown to make a difference in patients’ lives, either through quality of life or quantity of life. Medicare spending is seen by many patients as “someone else’s money,” so there isn’t as much incentive to go along with changes as if the money was their own.

Another article about cost savings also caught my eye, primarily because it was talking about blockchain’s ability to save the healthcare industry $100 billion over the next half decade. Areas of potential cost savings include IT operations, personnel, and health data breaches. Other potential areas of savings are for drug companies using the technology to track medications and reduce counterfeiting.

I love some of the general statements in the associated report, including that blockchain can help solve widespread interoperability problems and non-standardization along with “overcoming the shortcomings and challenges associated with legacy systems.” The devil is always in the details when any technology is positioned as the ultimate solution to a multitude of ills.

Another proposed area for blockchain in healthcare is in physician credentialing, with an estimated 80% savings over the time it currently takes to complete the process. We could save some money without adding additional technology just by making physician credentialing rational. There’s no reason why I should have to provide my high school transcript to credential as a physician, even though I was recently told by someone that the state of Illinois requires it. I hope the requestor enjoyed reading the legitimate but decidedly sketchy document from the 1990s that I provided following a quick phone call to my high school registrar. The finished product looked like it could have been drawn up by anyone who owned a dot matrix printer and a photocopier.

I’m an avid reader, so of course have to mark the passing of Nobel-winning author Toni Morrison. Morrison also received numerous other awards, including the Presidential Medal of Freedom and major awards from France. I didn’t really appreciate her work until some parents in my local school district tried to ban it, and I wish I had found it earlier. I leave you with her comments from a graduation speech in 2005:

Of course I am a storyteller and therefore an optimist, a firm believer in the ethical bend of the human heart, a believer in the mind’s appetite for truth and its disgust with fraud… I’m a believer in the power of knowledge and the ferocity of beauty, so from my point of view your life is already artful – waiting, just waiting, for you to make it art.

May each of us find the art within.

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Curbside Consult with Dr. Jayne 8/5/19

The 24th World Scout Jamboree has come to a close. I’m finally back in the world of hot showers where you don’t have to pull a chain to get the water to run.

The World Organization of the Scout Movement pulled out all the stops on the closing ceremony, including former United Nations Secretary-General Ban Ki-moon as guest speaker. The scouts were challenged to build upon the friendships they created at the Jamboree to work together to tackle major global issues as reflected in the United Nations Sustainable Development Goals: poverty, inequality, climate, environmental issues, peace, and justice. Having now worked with scouts from around the world, it’s clear that on the world stage, scouting is about a great deal more than camping and the outdoors.

The closing ceremony was capped by an outstanding fireworks show that also incorporated lasers and the Novus wristbands I mentioned last week. The wristbands were synchronized to the show, strobing in various colors to match the mood of the music and fireworks. There was music from “Star Wars,” “Pirates of the Caribbean,” “Mario Brothers,” and various world artists.

The only “miss” on the show was the failure of musical guest Pentatonix to deliver a version of “Take Me Home, Country Roads,” which was the unofficial anthem of the West Virginia gathering. It was performed at most of the other shows, including the “basecamp bash” events, which were like going to a nightclub without the alcohol and with the addition of neckerchiefs. It was phenomenal to see young people holding hands and swaying to the music despite the fact that their governments are hostile to each other.

Following the show, many of them pulled all-nighters getting their campsites packed into the three crates that were onsite when they arrived, turning the city of nearly 45,000 campers into a field of pale green squares where tents once were. Then came the parade of nearly 1,000 buses to carry the scouts either back to their homes or to tour the US before returning home.

The Charlotte airport had experienced weather delays the day prior and was quickly overwhelmed by the number of scouts trying to clear through security, particularly at the American Airlines terminal. I was lucky to be on Southwest and had smooth travels, but heard many stories of scouts sleeping on piles of luggage outside the terminals and airline agents who refused to allow scout units to check in as a group, adding to the congestion as they issued baggage tags one by one.

As I waited to board, I received my final email from our medical leadership delivering the tally of medical encounters. More than 13,000 patient visits for issues ranging from sore throats and blisters to fractures to myocardial infarctions and cerebral aneurysms. The Listening Ear mental health providers saw more than 660 visits as well, and we were grateful to have their input on scouts whose stomach aches and headaches were likely a manifestation of homesickness or interpersonal conflict.

I was glad to close the book on the Jamboree’s EHR, which as a clinical informaticist, seemed to me to be over-engineered with simplicity as a goal, but in ways that made it difficult to use if you are technology savvy. One of my colleagues continued to curse it (literally) until the end, even though this was his third jamboree using the system. I suspect he’ll never fall to the adopter side of the equation.

We worked through many technology quirks, including two days with wifi outages that made it unusable and no downtime plan in sight. Not even a printed form we could use. I can’t imagine a modern medical office without even a SOAP note template they could bust out in such an occasion, so that’s an improvement they need to make before doing this again at the US National Jamboree in 2021.

We also ran out of printer ink multiple times, making the required workflow of a discharge document impossible. I quit creating the discharge documents at one point, knowing we couldn’t print them and no one would ever read them, so I wasn’t going to waste the clicks when scouts were queuing for two hours to be seen by a provider.

We also worked through a variety of operational quirks that I hope are addressed in the future. The most major problem at my particular facility was lack of attention to creating the care teams. One of my colleagues even asked, “What’s a care team?” which was not an auspicious beginning. The providers were assigned to teams randomly without regard to their specialties or to their skills or abilities, which were not assessed in advance.

As you can imagine, the pool of providers willing to take off work for nearly three weeks is small and results in a large proportion of clinicians who are either retired or who have been out of practice for some time. Our facility was no exception. I had to teach a neurosurgeon how to treat strep throat as well as how to order meds in the EHR even after he attended more than eight hours of training. I had to remind 18-year-old medical volunteers that they were not licensed in the state of West Virginia to dispense meds or administer IV therapy. As a busy emergency doc who works in facilities that are optimized to the extreme with a staff that is topnotch, it was a struggle.

The Cerner team assisted the medical leadership with analytics, and hopefully they will look at the data for the types of visits seen and supplies used to better provision the medical facilities for the next US Jamboree on this site in 2021 as well as for the next World Jamboree in Korea in 2023.

They are already soliciting medical volunteers for both. Based on some of the challenges as well as the cost (volunteers paid more than $1,700 for the experience, plus travel and lost work time, and the event in Korea is going to be upwards of $6,000) I don’t think I’ll be signing up anytime soon. It truly was a once-in-a lifetime experience and working with the scouts from other countries was priceless. I had return patients from Sweden, Portugal, and Nepal that made sure to follow up when I was on shift so that I could deliver their care, and that was truly an honor. I enjoyed learning about other cultures, scouting around the world, and various healthcare systems in both developed and developing nations.

I am appreciative to my consulting clients who humored me during this hiatus and took my brief and infrequent emails for what they were (exhaustion, lack of connectivity, and being in the middle of treating roughly 1,000 scouts a day at my medical tent). Thanks also to my HIStalk family and to our readers for sharing this adventure.

Email Dr. Jayne.