Curbside Consult with Dr. Jayne 12/14/20

I’ve written a couple of times recently about some healthcare misadventures. The first story involved a delay in care due to COVID-related office shutdowns and the subsequent fallout when a close friend of mine ended up with an abnormal cervical cancer screening test. A couple of weeks later, I mentioned a glitchy pathology results interface that failed to send out results in a timely fashion, leading to delays in notifying patients of their results and subsequent delays in follow up for abnormal findings. I had the physician’s perspective for that one, feeling my colleague’s angst as she had to notify her patients of their delayed results. I also felt her frustration at her healthcare IT team’s poor management of the situation and the potential impact on the patients whose results were delayed.

I had hoped to not encounter any further stories like these in 2020, because heaven knows we’ve had enough stress, challenges, and outright disasters this year. Unfortunately for my friend the patient, her story has continued, and not in a good way. Although we’ve been talking about it on a daily basis in text messages, emails, and screenshots of her MyChart account, she has given me permission to write about the episode as a cohesive story.

Although I’m glad that I’ve been able to provide support and help her navigate the system, the reality of this is that none of it should have happened, and there should have been better systems in place to protect the patient.

Following the initial abnormal test, she went through an office-based biopsy procedure and waited more than two weeks for her results. The delay which was attributed to a continuing backlog in the hospital’s pathology department following some COVID-related furloughs. Although her surgeon expected some degree of abnormality, the result revealed a significantly worse problem that required further surgery and additional biopsies.

The scheduling process was frustrating due to ongoing games of phone tag and the perceived need for real-time communication rather than using email or text to schedule. My friend voiced her frustration: “I don’t know why they can’t just text me the open times. I’ve given them permission and it’s not like they’re talking about anything medical. It’s about as confidential as scheduling to rotate my tires.” Throughout this, her sense of humor has stayed largely intact, but reading statements like that gave me a hollow feeling in my gut as I had a ringside seat to watch the brokenness of the US healthcare system play out.

Instead of sending pre-procedure instructions and patient education via MyChart, the office sent them via postal mail. They were delayed by issues with the postal service that were likely related to the run-up to the US general election. When they finally turned up two days before the procedure, she was glad to confirm what she had already read via Google, but was still baffled at why the health system can send her bill through MyChart but not other items: “I mean seriously, they send me a bill in MyChart two days after the visit before insurance has even paid, but they can’t send me the important stuff like patient ed?” I agreed with her assessment, but didn’t know how much this statement would come into play later.

Finally, procedure day rolled around. Although I was able to drive her, due to COVID, she had to go by herself with no support person. Many in healthcare overlook the impact this has on our patients. She was definitely a little off when she got back in the car, and apparently she’d had an atypical reaction to one of the medications and was having some lingering effects from that. Although I understood as a physician why the rules are the way they are, as a friend, it didn’t seem to be the best thing for the patient to let her leave the facility the way she did. I went through a similar solo experience at my recent colonoscopy and they at least called my driver to pick me up at the door and made sure I got into the vehicle in one piece.

Her surgeon told her that pathology was still backed up and to expect a two-week turnaround for the results. She describes those two weeks as “eternal” from the patient side and joked that they should have tracking on the pathology specimens like online shopping: “Imagine it! You could get an email that said we’ve received your order, then we’ve received your biopsy jars, and it could just go through the whole process. We’ve prepared your slides! You’re next under the microscope! We’re writing your results! We’ve sent your results to your doctor!” It would be funny if it wasn’t so true that patients have more understanding of the flow of goods through Amazon then they do with regards to critical tests affecting their health. Putting on my vendor / consulting hat, I’d love the opportunity to write those messages, if anyone is interested.

She also lamented the fact that during those two weeks, she received numerous messages in MyChart about “complete nonsense that has no bearing on whether I have cancer or not.” Apparently, there were two more billing messages, along with several broadcast messages regarding COVID screening and the availability of telehealth visits at the university medical center. She had a good point: “Why can’t they set this up with a different notification if it’s something important versus something generic? All the emails just say there’s a new message in the chart. It could still be HIPAA friendly – ‘you have a new message in your patient chart’ means it’s about you, and ‘you have a general message from Big Health System’ means your heart can stop racing.”

We joked about taking it further to modify the notification sound on your phone, to a gentle “whoosh” for regular messages, an alert siren for the big stuff, and a cash register noise for the billing messages. We also thought about the ability to snooze general messages for 30 days just like we can snooze annoying Facebook friends.

Almost two weeks to the day, she received a text from her doc: “Path back, margins clear, all good, will send in MyChart” which she forwarded to me, followed by a copy of her doctor’s note and the report. I saw something odd on my first reading of the report, and after re-reading it half a dozen times, I knew I had to call her. It wasn’t in fact all clear, but there was a mismatch between the summary portion of the report and the actual microscopic description of the slides. The translated version is “all the cancer is gone, but cancer is present.” She messaged her doc, who agreed to call the pathology lab to have the slides and report reviewed.

Cue more waiting time, as the lab was vague on how long it would take for a repeat reading. As a good friend, and without naming any names, I reached out to a pathologist who works in the same health system to ask about the process. She was shocked that the report went out, since there was supposed to be a human review of all reports to make sure nothing like that was released. She also told me that re-reads are supposed to be done the same day.

Three days had passed and finally it took another phone call from the surgeon to get things moving. According to my friend, “that lab is in shambles due to COVID cases and quarantines.” She also noted that errors have been on the rise across her system since they replaced the human transcriptionists with voice recognition software, which is why they instituted human review. Although I sympathized with the quarantine and technology issues, I was still shocked at what a mess was going on within the healthcare organizations that we rely on.

After the surgeon’s second phone call, an amended report showed up at 11 p.m. Fortunately, my friend’s doctor was still up working her inbox when it hit, and my friend was still up as well. I was up too, and she texted it over. We chatted the next morning, and although the amended report was reassuring, she still didn’t know if she should trust the lab “since after all, this is just my life, right? They can’t even proofread?”

It’s a good point, and I encouraged her to ask for the samples to be sent to an outside pathologist for a second read, which she did. The overread took another two weeks. Personally, I think the first lab should absorb the cost of the overread since it was their error that triggered it, but I’m sure she’ll be getting a bill. At least though she has peace of mind that the reading is accurate.

Although she has received a reprieve for the next several months, there is still more testing to come. Even if all is good, she will be looking at ongoing followup for a few years. I hope that by the time she goes through this again that the systems have recovered to the point where she doesn’t have to endure anything near what she went through last time.

Many of the factors influencing these outcomes can be laid at the feet of the relentless cost-cutting that is everywhere in healthcare. As a clinical informaticist, this story is going to haunt me for a long time, because some of the work we’ve been collectively involved in is designed to prevent incidents like this debacle. Although we push hard to try to make things more patient-centric, money always gets in the way, not to mention the impact of a global pandemic. There are lessons to be learned here:

• Patient self-scheduling can be an OK thing as long as there are guardrails around it, even for procedures. I’ve helped clients do it, and they’ve not only survived, but thrived.
• It is unclear why a practice would send paper patient instructions to a patient with an active MyChart account, especially during a time of elevated concern about the US Postal Service.
• COVID is going to be with us a long time, and we need to think out of the box on how to get patients the support they need when they’re engaging with healthcare institutions. Asking them to go it alone isn’t the answer, even if they appear young and healthy.
• Hospitals are penny-wise and pound-foolish, and that’s not likely to change.
• Amazon does a better job communicating about the status of a laundry detergent purchase than hospitals do regarding life and death matters.
• Voice recognition software may be cheaper than human transcriptionists, but cost isn’t everything.
• No matter what the technology is, human error still occurs, and multiple people missed the mismatch in the report including her surgeon. Not everyone has a friend who is a doctor to provide an additional line of defense.
• Communication is EVERYTHING.

No matter where you are in this industry, please think about this story and think about how it impacts you professionally and also personally. If this patient were your mother, your sister, your daughter, or anyone you care about, is this how you would want it to play out? Regardless of who we work for, our ultimate customer is the patient, and doing what’s right by them should always be in front of us.

How does your organization tackle some of these missed opportunities? Leave a message or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/10/20

As COVID-19 ravages large swaths of the US, CMS continues to push a strategy to enhance hospital capacity that is somewhat slow to start. It allows ambulatory surgery centers to provide inpatient care when needed. However, the problem is that most clinical staff at ambulatory surgery centers aren’t used to ongoing management of very sick patients. Just because there are more beds doesn’t mean there are more people to staff them. Our area has a surplus of beds but limited staff, which makes for some interesting spinning of hospital capacity rates.

The strategy also allows certain patients who would normally be admitted to the hospital to be cared for in their homes. Although many academic centers are gearing up programs to make this a reality with high-quality coordinated care following the CMS guidelines, some organizations are forcing greater at-home care by just discharging patients as early as possible even though they may not meet conventional discharge criteria. It will be interesting to see how this impacts readmission rates down the road. Analytics gurus, start your engines.

With all the clinical shifts I worked in November, I missed out on a telehealth-related bill introduced in Congress that would penalize states that aren’t part of the Interstate Medical Licensure Compact. I’m fully supportive of anything that makes it easier for us to practice across state lines. I live fairly close to a state border and can have a telehealth visit with some patients while they are at work in my state, but it becomes illegal if they start their visit from their home across the river. HR 8723 would give states three years to join the Compact or risk not receiving funding from the Bureau of Health Workforce, which rolls up under the Department of Health and Human Services. State licensing boards would also be blocked from some federal grants if they don’t have a “public awareness campaign to encourage specialty physicians to practice telemedicine.”

The Interstate Medical Licensure Compact was launched in 2017 by the Federation of State Medical Boards and now has its own governing board. Its goal is to create a more streamlined process for physicians to gain licensure in other states. Currently 25 states plus Guam are live with five more states scattered throughout the process.

When I started practicing telehealth, my mentor encouraged me to apply for multiple state licenses. I quickly found the process to be arduous and expensive just for the applications, with some states requiring bizarre documentation such as high school transcripts that are largely irrelevant to the competency of a physician who has been in practice longer than some high schoolers have been alive. Once the licenses are approved, there is then annual maintenance of those licenses, and the risk/benefit equation quickly tipped to the former.

I’m deep in the final stages of a product launch this week, and this is the first one I’ve done in a totally remote environment. I’m used to working in a command center with everyone under one roof for rapid troubleshooting and hotfixes, which just isn’t realistic given the current pandemic conditions. Nearly all the resources are working from home, which has created some interesting situations, including a toddler attending one of our final checkpoint calls. The organization is doing a great job trying to foster togetherness and support the team during this high-stress situation, including sending gift cards for take-out and delivery meals.

Although I miss the feeling of togetherness and the satisfaction of working as a team, it’s just one more element of the new normal that many of us will be working in for the foreseeable future. I’m also glad for some time away from patient care so that I can refresh and recharge. Of all the go-lives I’ve supported, no one has ever tried to get me to look at a Ziploc bag full of their stool sample, which happened to me three times during my last few days of patient care.

Nearly 100% of the chatter in the virtual physician lounge this week surrounds whether the Pfizer COVID vaccine will be approved on Thursday and how quickly organizations can start administering it. The lack of a national vaccine strategy has created vast disparities across states with regards to how it will be administered to frontline healthcare workers. Over the last couple of weeks, our area’s major health systems have announced their plans for employee vaccination and public health organizations have started to talk about their plans for vaccinating high-risk patient populations. However, it didn’t seem like there was any plan for vaccinating frontline healthcare workers at non-hospital entities.

After getting an unsatisfactory update from my employer, I felt like I was on my own and connected with a group of independent physicians who are in the same situation. They’ve been making phone calls to various county and state agencies along with hospitals and health systems for weeks, and each entity seems to point fingers at someone else who “should have been responsible” for including us in the planning. Just talking to the physicians in the group, our respective organizations deliver over 500,000 patient visits each year and represent close to 3,000 COVID tests each day. It doesn’t begin to reflect the amount of care delivered by independent physicians across our city, let alone the state.

My contribution to the effort has been reaching out to state and local professional societies and elected officials. Although many of the individuals we have collectively contacted are sympathetic, none of them are willing or able to take the burden from us and carry it forward. This has been such a long, hard slog and the emotional impact of knowing that physicians who don’t even care for known COVID positive patients will be vaccinated but we won’t, just because of who we work for, is enough to push us over the edge.

The best comment of the day came from the physician advocacy rep at my state professional academy: “It is truly unfortunate that something so important is so difficult to achieve.” It’s not like we haven’t had months to plan this, or in the worst-case scenario, could have just copied from the “smart kid” state next to us that seems to have a fully formed plan.

How is your state or community handling vaccines for non-hospital frontline healthcare workers? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/7/20

My adventures as “just another physician” continued this weekend as our urgent care suffered a crippling EHR downtime.

My location had all of its staffed rooms full, several patients checking in, and a waiting room queue of nearly 20 patients when the EHR began to sputter. At first, it was only certain parts of the system that weren’t working properly, but they were some of the most critical – assessment and plan and medication orders. This of course created havoc in the discharge process. Because the EHR was merely sputtering, we were hopeful that it was a momentary glitch, so we kept trying to execute our workflows.

Eventually the EHR started spitting back truly unwelcome error messages, such as “server disconnect” that progressed to the hated “no servers available.” The dysfunction then spread to the practice management side of the house, with check-in and check-out grinding to a halt. For the staff members who had kept kept their systems up rather than trying to reboot, they at least had access to the tracking board to see what patients were physically in the exam rooms. For those of us who had tried to “turn it off and back on again,” the system was dead in the water and we were unable to access Citrix. (My staff often wonders how or why I even know anything about Citrix, and I must say I owe it all to one engineer who decided to take a young clinical informaticist under his wing.)

As expected, the IT emergency phone line was jammed, leading staff to call other locations to see if the outage was just our problem or everyone’s. We were all in the same unfortunate position, but when asked about instituting downtime procedures, the IT team told us to hold because they were already contacting the vendor. This led to wasted time and frustrated patients as we were trying to discharge patients so that we would have open exam rooms to use for those milling at the check-in desk in a non-distanced fashion.

I asked for a paper prescription pad to expedite discharges, but there was some confusion about where it lived and whether it was in the regular narcotics cabinet, the back stock narcotics cabinet, or the administrative office. One clinical tech started phoning prescriptions to the pharmacies and documenting them on Post-it notes while we waited for our site leadership to get their act together.

We were 15 minutes into this veritable goat rodeo with no update from our leadership when I directed the team to go ahead and pull out the downtime binders so we could start moving patients forward again rather than spinning our wheels over what we should be doing next. It took nearly 10 minutes to pull the binders, and then staff had to read the instructions to try to figure out what to do. There was some disagreement from our site leader about whether we should start the process, which added yet another delay.

Fortunately one of my clinical techs took the initiative to run from room to room and collect names and dates of birth for each patient, which we wrote on Post-it notes that were then attached to two old-school clipboards propped up at the physician work station. The list of physically present patients didn’t fully match the list of patients on the remaining tracking board screens, so we decided to make the clipboards the source of truth. Everyone updated the Post-its with as many facts as they could remember about the patients, and we queried our laboratory devices to provide duplicate results for anyone who had testing recently performed.

That provided enough facts to cobble together the information needed to discharge several patients, although we still had some confusion at the check-out desk as far as collecting payments. I was just happy to have exam rooms in which to install the remaining patients that hadn’t gone back out to their cars to wait, as they had been treated to a bit of a show as staff ran around trying to figure out what to do.

Nearly 30 minutes into the event, which felt like an eternity, we still didn’t have an update from leadership. Having come from a big health system where we lived and died by the strength of our downtime plan, I found that surreal. All the other IT systems were up, so there was no reason they couldn’t be sending email or text updates to each site or to the physicians since they already have groups set up for bulk notifications.

I continued to see patients, Post-it by Post-it, until the clipboards began to clear. Eventually, the system came back up, but not in its entirety. Restoration came in the reverse order of it going down, with medications, assessment, and plan lagging behind. The only way we knew the system was improving was by constant trial and error as opposed to an “all clear” notice from the practice.

Since our downtime policy requires manual entry of all data into the system rather than entry of critical or longitudinal data and scanning of the paper downtime forms for non-critical data, the staff immediately became even more stressed, wondering how they would catch up with a continuing flow of patients coming in the door. All told, it took us almost two hours to fully recover and get everything caught back up.

I don’t know whether this was a vendor failure, a hosting failure, an infrastructure failure, or what. but it’s clear that if there was a fail-over system for downtime, it didn’t work correctly. It’s also clear that we don’t practice our downtime protocols enough, or educate on them enough during training. Of the eight staff working at my site, only two of us have ever been through a downtime, and the others were generally unfamiliar with what needed to happen. Since I don’t play any role in the organization other than as a physician, I’m going to keep my thoughts to myself, but make sure my IT clients are better prepared than what I just worked through.

Experiences like these should be rare, and although they cannot be prevented, they can certainly be mitigated in a way that was better than what happened to us. It’s a good reminder of how critical it is to continue good IT practices, even in a pandemic. The patient experience was certainly less than optimal during the episode, and I hope there wasn’t any compromise in care.

When is the last time your organization practiced its downtime routine? Has anyone tested their backups lately? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/3/20

I’ve received quite a bit of feedback and comments on my recent Curbside Consult that addressed ongoing usability issues in EHRs. Some of the comments came with questions, so I thought I’d answer them here because the answers raise other interesting items for discussion.

The first question was around why my organization controls access to the vendor’s documentation and/or why I cannot access it because I’m a physician informaticist.

In my clinical practice, I am not a physician informaticist. I’m a frontline ER/urgent care provider, just like the other 100-odd providers who are employed by my organization. I play the role that the majority of physicians and healthcare providers in the US also play – we are simply gears in the machine. It has been made abundantly clear that our collective role is to see patients, follow organizational directives, and not ask a lot of questions. This is not unique to my organization, but also applies to many emergency physicians around the country, a good portion of whom are employed by third-party companies and not the hospitals or facilities they serve.

Back in the days before COVID, I made a couple of suggestions about the EHR – implementation of features that I know must exist because they were required for 2015 CCHIT Certification and this is a Certified EHR – and was told that it was not my concern and that leadership needed to focus on operations and not chasing down issues with the EHR. They apparently don’t see the links between happy users and productivity or good workflows and patient safety. Like many other mid-sized organizations, they do not see value in paying a physician good money to perform non-clinical work. Our EHR is maintained by a paramedic who is “into computers” with occasional input from the chief medical officer. I see this mindset all across the US, including at a major academic institution where I was on faculty.

Many institutions still do not see value in clinical informatics. This lack of understanding is the primary reason I became a consultant. Don’t think you need a CMIO? Fine, hire me for an engagement and I’ll convince you why you need one more than ever. To those who work at hospitals and health systems that place value in clinical informatics leadership, be thankful. It isn’t like that everywhere. Culturally, my organization would rather curl up and die than bring in a consultant that might tell them they’re not perfect, because they think they are the best and most tremendous care delivery organization on the planet and say it regularly in pep talk emails to the staff. Hyperbole is alive and well there, as is penny pinching.

Another question addressed why I won’t name an EHR when I talk about its flaws.

As a consultant who has seen the good, bad, ugly, and downright horrific, I am reluctant to throw a vendor under the proverbial bus for the sins of its clients. I used to do subcontract consulting work for a major EHR vendor. They would send me out independently to troubled clients. My only responsibility was to figure out what the issues were and craft recommendations that would help get the clients to a happier and more productive place.

Invariably, shadowing one or two patient visits would reveal a poorly-configured EHR that didn’t take advantage of the vendor’s latest features. Some clients were so far behind on upgrades they were no longer able to receive support, but they were unprepared to even consider an upgrade for various reasons. Operational and leadership pathologies contributed to never being able to optimize the EHR. I’d love to be able to get a demo-grade copy of our EHR to know how good or bad it isn’t, but until I know it’s the EHR’s fault and not that of my myopic leadership, I’m not going to blame the vendor. If I had unfettered access to a general release copy of the EHR that I knew had not been butchered or gutted by a client, I would be more than happy to name and shame.

I enjoyed David Butler’s comment about “God came in and created Intelligent Medical Objects.” IMO is one of my favorite add-ons for EHRs that don’t already have it. My current EHR as implemented does not leverage IMO. There is some kind of mapping among ICD-10 and SNOMED and ICD-9 (which we still have to use for certain work comp cases), but it’s mediocre at best.

I also enjoyed the comment from AnInteropGuy talking about systems that still ask if someone has had overseas travel, since that’s currently a somewhat moot point. I recently had to take a family member for dental care and assisted them in filling out their COVID pre-screening. Question #1 was, “Have you recently traveled to China or traveled on a cruise ship?” I kid you not. Those questions are so March 2020 and indicate a vendor who can’t be bothered to stay current or a client who refuses to upgrade.

Thanks to all who commented or reached out by email to either Mr. H or me. I enjoy hearing from readers and being able to understand where you’re coming from.

Many of my physician colleagues are taking all kinds of unproven supplements — including aspirin, melatonin, zinc, and vitamin D — in an effort to either stave off COVID or reduce its severity should they become infected. To be honest, healthcare providers in my area are dropping like flies. I strongly suspect lack of appropriate PPE. Some nurses have been wearing the same N-95 masks since February because their hospitals say their role doesn’t demand anything more than a surgical mask even for COVID-positive patients, and even the best-provisioned of us may get one new mask a week despite the fact that the new CDC recommendation says masks should be discarded after five “donning” cycles, which equals one day if you eat lunch and hydrate a couple of times during your shift.

A few of my more fringe colleagues are also taking prescription drugs like ivermectin (which will also keep them free of heartworms and cat scabies) because there are a couple of papers that say it might be a good idea. I’m personally on board with a new study that links consumption of chili peppers to better midlife survival.

The research was presented at the virtual American Heart Association 2020 Scientific Sessions. It concludes that higher intake of any type of chili pepper was associated with fewer deaths from all causes (including cardiovascular disease and cancer) during a seven- to 19-year follow-up in middle-aged adults. As any good student of the middle school science fair can attest, correlation does not equal causation, but at this point as a physician looking down the barrel of a rampant and seemingly unstoppable pandemic that many in the US still believe is a hoax, I’ll take any positive thoughts I can get.

Having spent time pursuing my studies deep in the heart of Texas, I became a fan of the chili pepper. Since then, I’ve been on enough camping trips to know that a splash of hot sauce can help overcome many a bad meal. As an added bonus, daily consumption will also tell you if you still have your sense of taste and smell and whether you need to take your “essential worker” self for a COVID test, since many of us are exposed regularly but never tested.

What’s your COVID prevention regimen? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/30/20

A recent study looked at the idea that including a patient’s headshot in the EHR could reduce order entry errors. Although providers typically place orders on the correct patient greater than 99.9% of the time, researchers wanted to address the remaining 0.1%. The study was performed in the emergency department at Brigham and Women’s Hospital over a two-year period. They concluded that “wrong patient” orders were 35% lower for those patients who had a photo in the EHR compared to those who didn’t.

Although I’m supportive of the concept, I’d like to offer my own shortlist of solutions for error reduction in the EHR. Unfortunately, all of these were scenarios I’ve encountered in the last few weeks seeing patients. For the ones that are specific to the EHR (as opposed to operations or staffing), I’m not sure if the issue is truly caused by the EHR or by my group’s implementation of it. Because they so tightly control access to the vendor’s documentation, I have no way of knowing.

Medication Order Entry

Formularies should be configured to only support appropriate routes of administration. For example, in my EHR, if I select a medication to be prescribed to a pharmacy, I’m limited to the routes that are appropriate for the drug. Eye drops only display “ophthalmic,” oral medications only display “oral,” skin creams display “topical,” etc. It’s physically impossible for me to accidentally tell a patient to take their amoxicillin tablet topically unless I personally type it in the free text notes to pharmacy box, and even then, the pharmacy is going to catch it. For our in-house medications, however, some of them have options that aren’t appropriate, such as an IV push route of administration for drugs that should never be administered that way. It’s easy to click the wrong button, but removing the button would make the error impossible.

Similarly, doses should be hard coded so you can’t goof them up. If the office protocol is to prescribe famotidine 20mg IV every single time and to never use a different dose, why are we presented with a free-text field where we have to hand type it every time? We also have an issue where the in-house prescribing screen has navigation issues. You can’t tab from field to field, but rather have to move your hand back and forth from the mouse to the keyboard, which increases the chances that you might accidentally type “30” or “10” rather than “20” in the field if you’re in a hurry.

Orders should also be linked to avoid errors of omission. For example, if I’m ordering a liter of normal saline for IV hydration, I shouldn’t also have to order an IV catheter. I guarantee no one is going to try to do a straight venous injection of saline – of course they’re going to use an IV catheter. The system should also default timed infusions where appropriate. If the practice requires all infusions to be administered for at least 31 minutes in order to play the CMS coding game, then why not default 31 rather than making each of us type it every time?

Discrete Data Fields Should Be Appropriately Discrete

I cringe every time I have to document vital signs in our EHR. Blood pressure is a single field and requires the user to type the “/” in the middle and has no limitation on the field size. If my tech is having a bad day, I can get things like “180/1000” and the system doesn’t bat an eye (although it does flag it in red, at least). Someone at the vendor must have missed the memo on usability and not having a color change be the only indicator of an alert, though, because there is no other flag on the screen.

Especially for something like a blood pressure that you might want to graph or trend, the numbers should be captured separately, and the fields should be limited to reduce the risk of nonsense data entry. We have similar issues with height fields that aren’t configured to block nonsense entries. If someone doesn’t notice there are separate fields for feet and inches, you end up with patients that are 67 feet tall rather than 5’7” or 67 inches. Don’t get me started on our lack of use of the metric system with pediatric patients, which is the gold standard trained at most academic medical centers.

Use Technology to Assign Diagnoses That Make Sense to Both Provider and Patient

I’m a huge fan of systems that map ICD codes to patient-friendly and clinician-friendly terminology. Patients don’t want to see “R42: Dizziness and giddiness” documented on their charts. They want to see “vertigo” or “dizziness” or “lightheadedness” as appropriate with the ICD code behind the scenes. This is a pretty straightforward example, but there are dozens of wild and wacky codes and descriptions out there. Physicians hate it and I’m sure other clinicians do too. Patients end up with the wrong diagnosis on the chart when the provider struggles to find the correct one. Kudos to the IT folks who installed “the good stuff” technology wise to prevent this issue.

Use Technology to Keep Up with the Times

My EHR still does not have patient instructions for COVID. It’s ridiculous at this point. I diagnosed my first patient eight and a half months ago.

Reduce or Eliminate the Need for Multi-tasking Behaviors

This isn’t an EHR issue per se, but it’s the root of many of the errors we see. Clinicians need to be supported by their organizations and not expected to see patient volumes that are unsafe. Looking back to the pre-COVID world, my organization placed constant pressure on us to make sure that more than 95% of our patients were treated and released in under an hour. Sometimes that meant having one provider trying to juggle care for up to 15 patients depending on the number of rooms at the clinic. This can only lead to disaster depending on the experience of the clinician and the acuity of the patients’ issues. All staffing is driven by dollar signs, however, regardless of where you work.

One good thing that has come out of the pandemic is that they’ve capped the number of patients that can be roomed at a time based on the number of support staff, which means I rarely manage more than six patients at a time. It’s been a godsend and I can’t help but think it’s helped reduce errors, but at times it can still be unrealistic, especially when the patients are really sick and have a lot of labs and tests to manage. I have no idea whether those caps will stay in place as the pandemic eases, but I’m hopeful.

What error reduction strategies has your organization employed, or what seems obvious but hasn’t yet been implemented? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/23/20

The Center for Medicare & Medicaid Innovation (aka the CMS Innovation Center) announced the list of participants in the Primary Care First initiative this week. The program was delayed due to a variety of issues prior to the pandemic, which really pushed it back. It’s finally slated to start on January 1, 2021.

I wonder how the selected participants feel about having roughly 40 days to get everything in place? Most of them have been working on other initiatives that share the same goals as this program for some time, but it’s an entirely different thing to actually get a new program ready to launch in your organization. Trying to do so in what most people are experiencing as the largest peak of the pandemic is yet another level of pain altogether.

What is Primary Care First? It’s been so long since I talked about it that many of us have probably forgotten. It was designed as a voluntary alternative payment model slated to “reward value and quality by offering innovative payment model structures to support delivery of advanced primary care.” The program is supposed to last five years. More than 900 primary care practices were selected and there are 37 identified regional partnerships with commercial, state, and Medicare Advantage plans. Practices had to be in an area with a regional partner in order to participate, which excluded a good chunk of the country.

The program changes the payment structure for patients in participating plans, with the idea that even though not all the patients in the practice may be covered by one of the partner payers, that the practice would effectively up its game in delivering the same level of high-quality primary care services to all patients.

In exchange for performance-based payments and reduced administrative burdens, practices agree to assume financial risk as they try to reduce the total cost of care. There is also a so-called “seriously ill patient” option for practices that treat high-need, seriously ill patients who don’t currently have a primary care provider.

Overall, the model is supposed to revolve around patient-focused care and a high level of care coordination. The reduced administrative tasks are supposed to free providers to spend more time with patients. The program is also designed to “foster practitioner independence by increasing flexibility for primary care, providing participating practitioners with the freedom to innovate their care delivery approach based on their unique patient population and resources.”

Practices are scored based on clinical quality and patient experience measures which include: a patient experience care survey, controlling high blood pressure, diabetes hemoglobin A1c control, colorectal cancer screening, and advance care planning.

I’m sure the practices that applied many months ago had no idea where we would be come January 1, and I wonder if many of them might try to opt out. The final selection of 900-odd practices is quite a way off from being representative of the roughly 210,000 primary care physicians in the US. I’m not even sure, given some of the other variables that were involved in selecting the participants, that the cohort will be able to generate the statistical power needed to prove whether its outcomes (clinical and financial) are truly better than other care delivery paradigms. These practices have been at least dipping their toes in the waters of value-based care for years, with many of them being mostly submerged.

The list of payer participants is dominated by Humana, with a handful of other plans and a sprinkling of Blue Cross / Blue Shield players. Looking at the practice list, it’s a little tricky trying to tell who is who because the participants are mostly listed by the name of their brick and mortar entity, which may not portray the health system ownership behind them. I learned about these naming relationships the hard way: when I was employed at a practice owned by Big Hospital System, they were keen on each practice having its own brand, which wasn’t always the greatest idea when they upcharged you for customizing various things with the practice name versus just being able to say “BHS Medical Group” in your outbound reminder messages, etc.

A couple of the big players show up with a handful of practices each: AdventHealth (formerly Adventist), Ascension, Baptist Health, Beaumont, Cambridge Health Alliance, Cedars-Sinai, Cleveland Clinic, John Muir Physician Network, Temple Physicians, Virtua Primary Care, and Warren Clinic. The University of California has the most participation with 39 sites, and OhioHealth is the runner up with 26 locations. My state isn’t part of the identified Primary Care First regions, so I won’t be able to get very many in-the-trenches stories from regional peers, but I did see at least four of my former clients on the list. Hopefully my contacts are still working there and are willing to keep me posted on how things are going.

Even for the practices with the most value-based care experience, trying to launch this program during a surging pandemic will be key. Colorado is a participating state, and recent reports estimate that 1 in 49 Coloradans are COVID-positive right now. Practices that are reeling with those kinds of numbers are going to be hard pressed to spend time preparing to embrace prevention and management of chronic diseases, which are certainly being exacerbated by the pandemic.

In the urgent care space, I see so many patients who either can’t get in to see a primary care physician or whose physicians have frankly abandoned them. My friends in telehealth report dramatic increases in the number of patients requesting visits for COVID-like symptoms. There’s even a surge in people who have had COVID tests at drive-through clinics but who are struggling to reach their primary physicians and are reaching out to telehealth providers to get documentation that they meet CDC guidelines to return to work.

I wish the best for the Primary Care First practices. We need to bolster our primary care and public health infrastructures – of that, there is no doubt.

We had a conversation at urgent care yesterday around what the health care system will look like in the US after it’s been completely decimated by COVID. This was right after we were notified that four providers had been diagnosed the day before, including the one who had been sitting at my workstation less than 12 hours previously. The nearly 100 patients I saw have no idea what kind of bills are coming their way, especially if they are positive and need hospitalization. I see a tsunami of medical bankruptcies on the horizon. If the Affordable Care Act is repealed and more people have to pay out of pocket for preventive services, I don’t see them having tremendous cash reserves to do so, and this could drive even greater healthcare expenditures down the road.

I’ll continue to follow the adventures of Primary Care First and report back with what I find. If you’re involved in the initiative, I’d love to hear from you. Until then, stay healthy, stay safe, and stay six feet back.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/19/20

Although telehealth has certainly been helpful for many organizations trying to boost patient access during the COVID pandemic, a recently study shows that it was not fully able to offset the loss in available patient care slots. Overall, telehealth was able to help organizations recoup about 40% of the decline in ambulatory office visits. Not surprisingly, patients from low-income ZIP codes and racial / ethnic minorities were less likely to use telehealth services than those from more affluent areas.

The study looked at more than 6 million private payer claims, but there’s still a gap in understanding visits for patients with public payer coverage (Medicare, Medicaid) as well as those telehealth visits that may have occurred but not been billed since providers were struggling to understand how to get paid for telehealth.

Office visits were most dramatically affected, but vaccine administration, mammograms, colonoscopies, and HbA1c tests were also reduced significantly.

I have to admit that I was part of that mammogram cohort and didn’t end up getting my semi-annual imaging until August. The facility where I usually have my mammogram didn’t bother to send me a reminder that I was overdue or let me know when they had resumed services, so it was completely on me as a patient to make sure I caught up. Good thing I did before COVID spiked and services were limited again.

Sometimes the titles of articles say it all, and this piece in JAMIA definitely caught my attention: “Unveiling the silent threat among us: leveraging health information technology in the search for asymptomatic COVID19 healthcare workers.” The article reviews the National Institutes of Health Clinical Center’s approach to rolling out an Asymptomatic Staff Testing System. The Center is the 200-bed hospital arm of the NIH that delivers patient care and research support. Due to the type of research being performed, over 60% of the patients admitted are immune compromised either from an underlying health condition or an experimental treatment. This underscores the need to deliver continuous surveillance of healthcare workers and prompt identification of those who may be positive for COVID-19.

One of the program’s goals was to deliver weekly testing for eligible healthcare workers. They used existing EHR and other systems to identify workers and allow them to self-schedule their testing appointments. Automation was prevalent throughout the process, including check-in, specimen tracking, and laboratory interfaces. As the process was designed, they “identified the difficulty in following the organization’s formal software development process under the time requirements” and mitigated this by using existing systems where possible. The whole process from task identification to early adoption was only four weeks, which would be a near impossibility for many healthcare organizations.

To determine how successful they were, the team looked not only at the primary outcome of identifying infected workers, but also surveyed the healthcare worker customers on the process as well as the facility process owners. I wish I saw more organizations follow this approach with a 360-degree evaluation where they pay attention to all the feedback, not just internal customers such as infection control departments or human resources. One of the findings was a need to ensure that patients / workers set up accounts on the patient portal, which is a common challenge among healthcare organizations.

I always get a kick out of articles that cover poor password management habits, and this year’s list shows that the more things change, the more they stay the same. Review of data from hacking forums and the dark web revealed that the most commonly used passwords in the US include “password” and “123456.” The latter (and the multiple variations similar to it) shows that it’s not just users behaving badly, but vendors who should have logic behind their password requirements that would disallow such sequential numbers. Humorous options in the top 20 include superman, iloveyou, football, and letmein.

Although some vendors may be complicit, the other side of this coin is the vendors or entities that make ridiculously complicated password requirements or rules for frequent changes. These approaches have been shown in some studies to actually increase security risk, as users may be more likely to write passwords down.

One of my clients falls into this bucket. They make you change your password every 30 days, and the requirements include upper case, lower case, numbers, symbols, and a length of at least 10 characters. Maybe their goal is to push people to use randomly generated passwords coupled with a password manager, but that’s not always practical when using shared workstations. Regardless, I wasted half an hour of their tech’s time this morning (and a billable 30 minutes of my time) dealing with an expired password after I missed the prompt to change it.

Big thanks to the gals in my life who sent a couple of recent care packages. Jenn knows my love for putting my feet up with a good book and surprised me with the world’s softest socks, along with energizing foot lotion and an Amazon gift card, which I promptly swapped for a new read. There were also some addictive gummy bears, but I’ve had to tuck them in my snack drawer lest I eat the whole bag. My favorite revenue cycle informant, Bianca Biller, sent the famous “Bionic Apple” from Merb’s Candies in St. Louis. Let me tell you, this thing is a Granny Smith apple covered with the smoothest caramel you’ve ever seen and rolled in chopped pecans. Did I mention it was the size of a softball? It made an excellent lunch while I enjoyed a webinar presented by some of my favorite folks.

For your friends and colleagues at the tip of the clinical spear, the next few months are likely going to be some of the worst times they’ve ever experienced professionally. I’m thankful for my friends and their support. Hopefully my newly energized feet will give me a bounce as I head back to the trenches tomorrow.

What are the best pick-me-ups you’ve ever received? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/16/20

We’ve officially crossed into COVID hell in my part of the country.

The largest health system just announced the rescheduling of elective surgeries at all 15 of their hospitals, starting Monday and extending for the next eight weeks. Employed physicians have been instructed not to travel and must be ready to return to the hospital within 24 hours when summoned. Operating room capacity for scheduled cases is being reduced by upwards of 30% to allow for redeployment of staff to other areas. Another system has redeployed their operating room nurses to the medical/surgical floors and has brought in travel nurses to staff the ORs, but not everyone can find enough travel nurses even if they can afford them.

I imagine this is what it felt like to be in New York City in the spring. It doesn’t feel like we learned anything from their suffering because we’re now officially in the same boat.

Our urgent cares have tried to reduce volumes by limiting the number of COVID tests we do for patients who are asymptomatic, but it’s not much help since we’re in a phase where nearly every patient has symptoms. Schools are moving from in-person and hybrid models back to fully virtual, and parts of the state are headed back towards stay-at-home and safer-at-home orders.

My staff is working harder than ever, but they are most definitely at the breaking point. Sometimes I feel guilty about being only part-time for in-person care, and then I remember the work that I’m trying to do with my clients to better manage patients without the need for in-person encounters and their associated exposures.

Here are my free consulting tips for practices trying to figure out how to manage patients in the outpatient space more efficiently, since we’re all trying to do more with less. These are things that I have been recommending to practices for years, but for some reason, they still are trying to do things the hard way:

Refill management

If your system has technology to help with refill management, use it. If you don’t, consider a solution like Healthfinch to help tame the beast. If you don’t have technology, consider creating a policy that allows delegates to manage refills on behalf of physicians.

I still work with a lot of physicians who can’t let go of the idea that only they can manage refills, and their inboxes are flooded with refill requests. These are usually the same people who aren’t giving refills to their patients to last through the next scheduled visit, let alone to last through the year. I recommend that physicians who struggle with this idea start with one or two health conditions where medication refills are the lowest risk, and let their staff dig in. Make a list of the criteria for refills – this may include a visit within the last 365 days and no overdue labs – and start letting your support staff support you.

Inbox management

I’m a big fan of the “touch it only once” mantra. Use your technology to help you sort your inbox and then work it deliberately by section. If you only have a minute or two, select a lab result to manage or a refill request to manage, not a patient phone call. Don’t go through your inbox looking at things and trying to re-prioritize it over and over. You’ll waste a ton of time along the way.

Set up dedicated time during the day to manage the inbox, or plan to work it before or after seeing patients. Even if you’re used to calling your patients with results, consider leveraging the patient portal or secure texting if patients have opted in for these services. They’re much more convenient for patients and will save you time.

Invest in technology that can free your staff

Practices are still using humans to call patients and ask them COVID screening questions. If your organization has the ability to screen patients through a portal or other tools, use it. If not, there are many cool technologies out there such as Asparia that not only manage appointment reminders, but can help provide a safe arrival experience and triage patients who may need to avoid coming into the office.

You should also maximize the use of digital check-in or other workflows that might be available in your patient portal. For my most recent new patient visit, I uploaded copies of my insurance card and photo ID on my phone before even walking in the door, resulting in a contactless visit. When you save those minutes for your staff, it adds up, and those resources can be redeployed for use with patients who need real-time or face-to-face contact, or to better support you as you embrace telehealth visits.

Don’t be afraid of telehealth visits

With everyone being concerned about COVID and the availability of inexpensive devices for home biometric assessments, you would be surprised how many patients can provide a full suite of vital signs for a telehealth visit. Blood pressure cuffs and thermometers are plentiful, and pulse oximeters are becoming a regular part of the home first aid kit for many families courtesy of Amazon, Target, and other major retailers. Of course, this may vary depending on the patient population served, but I think physicians might be pleasantly surprised if they ask about access to these devices. If the patient doesn’t have one, they might have a neighbor or family member who does.

I’ve been practicing telemedicine for a while now and I’ve found it useful for picking up factors that I might not pick up at an office-based visit, such as fall risks in the home. I’ve also seen full ashtrays on the coffee tables of patients who claim to have stopped smoking, so you never know what you might find. Learn the rules for telehealth billing for your specialty – many specialty societies have published cheat sheets for their members.

Leverage your staff for telehealth visits

Staff can meet with the patient prior to the visit and update histories, document vital signs, flag medications for refill, etc. All too often I see the physician trying to do all these tasks even though they would have allowed support staff to do them in the in-person world. Sometimes the technology doesn’t make this easy, but there are ways to work around it to maximize the physician’s time.

Many of these elements go back to something that is so hard for some physicians to learn, and that is that they need to run their practices with everyone working to the top level of their licensure. If you’re lucky enough to have a registered nurse in the office, make sure you’re truly using them to deliver nursing services and not to do things that could be done by a medical assistant, patient care tech, or receptionist. I’ve been hearing the same arguments from subsets of physicians for decades, and if there’s one thing 2020 has taught us, it’s the need to break existing paradigms because “business as usual” is effectively over.

How has your organization tried to streamline the ambulatory paradigm in 2020? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/12/20

My inbox has been bountiful this week, with so many good stories that link to healthcare IT that I just kept flagging items to come back and read later, only to find my entire screen full of flagged emails.

My urgent care is swamped with patients wanting COVID testing, and although there are enough supplies to go around, there simply isn’t enough staff. Since most of our payer contracts require patients to see a physician to document medical necessity for testing, and there’s only one of us at a site, it’s just an endless parade of testing visits. That is, until something acute comes in, and then there is an adjustment as we remember how to see “traditional” urgent care patients again.

I was excited to see this article in Nature Medicine looking at how fitness trackers might be useful to detect biometric changes associated with COVID-19. I know patients will always want testing “to know for sure” as well as to make sure they can take advantage of workplace policies that require a positive test for paid time off, but it would be nice to have other tools that patients could use to help risk stratify themselves. That way they could figure out if they really need to stand in line for hours for a test at an urgent care center or if they could do a video visit with their primary physician and arrange testing at the health system’s drive through tent in a day or two.

The study Digital Engagement and Tracking for Early Control and Treatment (DETECT) study looked at data from more than 30,000 individuals from all 50 US states. They found that adding sensor data to symptom-based models improved their accuracy. Regional health officials in my area are lamenting the inability for temperature- and symptom-based screeners to identify infected patients, so at this point anything would help. Our schools just went back in person, and within 24 hours, were sending people home to quarantine due to exposure. The idea is that using device data could help identify clusters before infection spreads. That would have been useful in the aftermath of a recent parent-approved Halloween party thrown by some local teens, where over 200 high-schoolers attended.

A recent article in JAMIA looked at the advantages of human scribes compared to other options, particularly looking at patient safety aspects. They used a multidimensional sociotechnical framework to look at how different health systems use scribes. The dimensions were technical, environmental, personal, and organizational; 81 individuals were interviewed, including scribes and clinicians. They were asked about why they chose to use scribes as well as the background and training of scribes, along with pros and cons of their implementations.

One interesting finding was that since many health systems rely on college students for scribing, that geography is a factor in whether a practice can find a good scribe or not. That would definitely underscore why virtual scribe solutions are popular, since not every town has college students, let alone highly-motivated pre-medical or nursing students who would make good candidates.

Respondents did note a preference for real-time scribes versus using voice recognition software after the fact. The turnover in good scribes is an issue that was also validated in the research, and I experience that every year when medical school and physician assistant school acceptances are issued.

Fortunately, our scribe program staffs ahead of those transitions but it’s always a challenge to have the new scribes ramped up prior to flu season. You can bet that with COVID they’ve definitely earned every bit of experience they claim. I’m still waiting to hear from any readers (or friends of readers – come on, help a girl out here) who might be using one of the Ambient Clinical Intelligence solutions offered by Nuance or one of the other voice recognition vendors. There was a great deal of interest in the system at HIMSS a couple of years ago, but I have yet to encounter anyone actually using it in the wild.

The Journal of the American Medical Association tackled a weighty topic recently with its piece on “Science Denial and COVID Conspiracy Theories: Potential Neurological Mechanisms and Possible Responses.” Although this was a “Viewpoint” article rather than a research article, it has some interesting points. The first is the relationship between neurodegenerative disorders such as dementia with the adherence of an individual to false beliefs. Other psychiatric disorders include similar manifestations, such as delusions of grandeur and paranoia. The author proposes that false beliefs form due to faulty sensory information and impairment of brain systems designed to evaluate thoughts and beliefs.

Until reading the article, I had forgotten about Capgras syndrome, where certain dementia patients believe that a loved one has been replaced by an impostor. He explains the mechanisms by which that occurs as well as other delusions associated with dementia. He goes further to discuss the role of social media in amplifying conspiracy theories and other misinformation.

Based on what we know about dopamine and the addictive nature of social media, I can concur with his assertions. Mix in some low science literacy and we wind up where we are, with patients who legitimately believe that COVID is being spread by 5G cellular towers. He calls on the medical community to “mount systematic efforts around science education beginning in childhood and across the lifetime.” It’s a nice idea, but right now many of us are simply too exhausted from treating COVID patients.

From the Hall of Shame: Several towns along the east coast trusted a private physician to set up COVID testing clinics, but he proceeded to over test while billing exorbitant rates. Some patients were charged upwards of $1,900 and he was also recommending daily telehealth visits for a separate fee. Of course, his game wasn’t discovered until the bills started hitting, which typically takes at least 30 days for most patients with health insurance. Towns were effectively duped, with promises of a speedier economic recovery through greater testing. They in turn promoted the services, and then the physician took advantage.

Seems like a pretty clear ethics violation and I hope the relevant licensing boards take note. The physician is clearly delusional, stating that he tested for all kinds of other respiratory viruses because “just testing for coronavirus is one of the most dangerous things you could do… it is crystal clear that mentality is bad for public health.” I’d argue that unnecessary testing is also bad for public health, as is medical bankruptcy. People like him are the reason patients don’t trust the medical establishment. It takes far too many good experiences to undo the damage caused by a bad apple like this one.

Have you received a balance billing statement for COVID testing or related services? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/9/20

It’s been a busy week in the clinical trenches. If you had ever told me that I would see nearly 150 patients over two urgent care shifts, I would have told you that you were crazy. Nevertheless, it’s the world we’re living in.

I’m continually impressed by the ability of my team to dig down deep, but we’re starting to push hard against leadership for some kind of daily cap on the number of patients we can see. As an urgent care, we’re not subject to the same rules as hospital emergency departments, which means we can turn people away. It’s not ideal, but neither is the reality of 12-hour shifts turning into 14, 15, or 16-hour ones, especially when staff is scheduled to see patients again the next day with less than eight hours turnaround time.

I’ve asked to cut my schedule down for our next scheduling block, but it doesn’t start until January. I have a sneaking feeling they’ll give me the same number of shifts regardless, because I don’t see us becoming less swamped when the projections show that COVID cases will likely be at their peak during the third week of January.

I’m keeping myself grounded with informatics projects as way to try to preserve my sanity. A couple of articles caught my eye, because even with a pandemic upon us, clinicians are still dealing with heavy burdens of non-clinical work and technical systems that don’t always deliver the support promised.

This piece in the journal Pediatrics highlights the fact that pediatricians are averaging nearly seven hours of EHR use each day. Researchers found that EHR documentation and review of patient records totaled 6 hours, 40 minutes of the time that the EHR was in use. That’s an average of 16 minutes per visit, with approximately 12% occurring after hours. Researchers looked at EHR log data from January to December 2018 for all pediatricians and adolescent medicine physicians who practice in the 2,191 health care organizations represented in the Cerner Millennium EHR Lights On Network database. This encompasses over 20 million outpatient encounters by 30,000 physicians.

The study is interesting because researchers could look at the variability in time as it compared to optimization efforts across similar EHR platforms, as well as roles and responsibilities for data entry and the differences in implementation and training across organizations. I’ve seen wide variability across organizations’ use of the same platform that can lead to “make or break” type workflows. The quality of training physicians receive also seems to be directly proportional to their success with the EHR and whether they succeed in the system or struggle. Other interesting facts from the study:

• More than 94% of pediatricians in the US use an electronic health record.
• Active users were defined as those who logged into the system with activities recorded <45 seconds apart; clicked  the mouse at least three times per minute; completed at least 15 keystrokes per minute; and who had mouse movement of greater than 1,700 pixels per minute.
• After-hours use was defined as that between 6 p.m. and 6 a.m. local time on weekdays and anytime on weekends (which may not accurately reflect “non-office” times for those working half days or coming in early to work on the EHR).
• Physicians practiced at various locations: integrated delivery networks (34%), regional hospitals (30%), independent physician groups (22%), and academic medical centers (11%).
• The physicians monitored on the Network represent a 44% sample of US pediatricians based on comparison with the 2018 American Board of Pediatrics database.
• Pediatric rheumatologists spent much longer in the EHR at 30 minutes per encounter.

The study was limited by the fact that it only looked at physicians on Cerner Millennium. It also excluded other provider classes, such as physician assistants or nurse practitioners. The authors conclude that a need exists to “continue to identify and eliminate unnecessary and low-value activities across the entire physician workflow.” I don’t think anyone would disagree with that.

The second article, from JAMA Network Open, looked at the impacts of e-consultations on the workload of primary care providers. The authors looked at Veterans Health Administration primary care providers who were using e-consultations to interact with subspecialists. Researchers interviewed 34 clinicians who had experience with e-consultations in 2017. Although primary care clinicians felt that the process improved clinician communication, they also felt that the burden for additional diagnostic testing and follow-up was shifted from the subspecialists to themselves. They also thought that they were being asked to diagnose and manage conditions that were not only outside their comfort zone, but possibly outside their scope of practice.

The study was limited by its small sample size as well as its qualitative approach, and researchers were not confident that participants were objective. Participants also noted the need to track and follow up on e-consultation requests as a barrier, which seems tangential to the actual consultations themselves, although still important. Participants also felt that the templates that were  used to document were not user-friendly and/or included required fields that were not relevant to care. I love qualitative research and appreciate the fact that the authors included actual respondent quotes in the article. The authors conclude that various workflow improvements could be made in tracking and documentation systems that would help the primary care clinicians.

However, they didn’t seem to mention the need for further analysis on the other end of the e-consultation request. What do subspecialists think about it? What kind of burden does it add to their day? Are there other modalities, such as virtual visits, that deliver the same outcome for the patients (including decreased time to subspecialist consult) that would be more acceptable all the way around? As in many studies, more research is needed, but I hope next time they look at both sides of the workflow.

These articles underscore the need for those of us on the healthcare IT front to continue to do what we can for better outcomes for patients and clinicians alike. We also need to feel empowered to challenge operational and clinical teams to address dysfunctional workflows that might not be helped by technology and to help those teams think through the idea that tech might not be needed to save the day.

Have you been involved in the e-consultation process at the VA? What’s your take on it? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/5/20

Our friends at the Massachusetts Institute of Technology have created a cough detector that claims to identify COVID-positive patients even if they do not have symptoms. The system uses artificial intelligence models to identify characteristics of cough sounds that can’t be detected with the human ear. Researchers propose embedding the technology in cell phones as an early detection device. The work leverages technology that is already in process for early identification of Alzheimer’s disease. Researchers note that AI algorithms can identify various factors from a cough, including a person’s gender, language fluency, and emotions.

Researchers used thousands of recorded coughs as well as voice recordings to train the model. In the COVID analysis sample of 1,000 patients, the model was accurate for 98.5% of COVID-positive patients, including 100% of asymptomatic patients. They acknowledge that the algorithm is no substitute for proper testing, but see it as a tool that could differentiate between healthy and unhealthy coughs, alerting people to the need for testing.

I started a new project this week with a client whose attempts at value-based care delivery were in shambles. They had someone on staff who was designated as the manager of quality initiatives. Apparently she would come to meetings and “talk big” about the work she was doing, but actually had a complete lack of understanding of the work that needed to be done in order to drive the quality needle. When the physicians’ contracted health plans would send membership rosters to the practice, she simply stuck them in a binder rather than actually doing anything with them, such as confirming whether the patients on the roster were active patients in the practice or seeing whether they were current on preventive screenings or recommended health services.

In meeting with the practice’s leadership in scoping the engagement, it was clear they didn’t understand some of the basic concepts of value-based care, including the need to understand patient attribution and to reach out to those patients for whom they had been deemed responsible. I felt like we needed to take it back to a 100-level course, so this week began with some educational sessions to explain the basics of attribution and empanelment.

They seemed so surprised to hear that a payer would use claims to attribute responsibility for care that it made me wonder whether they had been completely absent from all discussion of value-based care over the last decade. Certainly they hadn’t been reading the literature that was regularly put out by their specialty society. I’ve found that the American Academy of Family Physicians has done a great job creating materials for physicians, but unfortunately, they can’t force their members to read them.

The empanelment discussion was a good one as well, since it immediately devolved into an argument about how large their panels should be or whether it was acceptable for some providers to have larger panels than others. Fortunately, our engagement includes a subproject to look specifically at physician panel size since their wait times for appointments seem to indicate that their panels are too large. They have physicians who have cut back their hours due to health reasons, but who continue to accept new patients, and the process is creating a mismatch in supply and demand. I’m surprised no one ever recommended that they close panels, but then again by the time I wind up consulting with a practice, usually there has been a series of “things no one ever told us.”

Even though these engagements can be challenging because the client has a lot to learn and I have to figure out how to get them where they need to be without them feeling like I’m completely upending their world, they can be really enjoyable. I’m usually able to make a difference for staff as well as physicians, because staff has often been compensating for overloaded schedules and isn’t experiencing the fulfillment they could be if the practice truly embraces team-based care. The project will be a little slower going than I’d like because we’re doing everything remotely, so there’s not that burning platform of having a consultant on site. It should be a good counterbalance to the grueling months ahead in the land of urgent care.

I had the opportunity this week to spend some quality time around a backyard fire pit with one of my favorite clinical informaticists. Even though we live in the same metropolitan area, we used to just run into each other at the annual AMIA meeting. Since there aren’t any in-person meetings this year, we made it a point to get together since the scheduling stars aligned to provide us an evening where we were both free.

He has always worked in the academic space, where I’ve been more in the health system and vendor arenas. We still face many of the same challenges, though, including clashes with upper management who don’t always see the value in physicians who work on the technology side. We’re also tasked with helping bridge the gap between organizational leadership and end users who might not understand why applications are implemented in a particular way that best supports organizational goals but might not meet specific users’ expectations.

Both of us have had a lot of job changes in the last several years, and it was good to get his perspective on how the pandemic has (or in many ways, hasn’t) transformed care delivery at his organization. Some things never change, and his practices are still doing manual appointment reminder phone calls and manual COVID screening, which seems to me a shocking waste of human capital. As a clinician, I’d much rather see those staffers redeployed as care navigators, health coaches, or in working with patients who aren’t candidates for digital reminders or screenings, or who have complex situations to navigate such as arranging rides, coordinating with family caretakers, etc.

I enjoyed filling him in on some of the interactions I have with startup companies and how they’re trying to solve various healthcare workflow issues as efficiently and economically as possible. There’s definitely some inertia at his institution, but it would be fun to do a project together some day. Until then, we’ll have to settle for commiserating by the fire, six feet apart.

What new solutions is your organization deploying to handle the next wave of COVID or to prepare for vaccination? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/2/20

I have to admit that being a blogger is a challenge sometimes. Although often the ideas for my columns come to mind easily after working in the clinical or IT trenches, some days are a struggle.

Today was one of the latter. I sat for a good hour without a solid idea in my head. I think a big piece of today’s writer’s block was the sheer stress I’m facing in the upcoming week. The clinical world has been completely out of control, with a good number of our providers down for the count with COVID or caring for close family members who have COVID.

Leadership is begging us to come in on our days off, which is a hard sell when you’ve barely been away from the clinic after your last shift. You also know that if you go in, you’’ll be crushed. So many patients who need to be seen that they are lined up before staff even arrives at the office. One of my receptionists had to park more than half a mile away, which led to a late clock-in and a fair amount of drama getting the situation remedied. Staff has to park in the lots of neighboring businesses and now has the worry of being towed to add to the stress of the day and concern about potentially becoming infected with COVID.

When you’re running with absurd patient volumes, any glitch in the technology becomes nearly catastrophic. At one of our sites, the Citrix client disappeared from multiple PCs. This led to a storm of calls to the help desk and frantic attempts to gain access to the system, all while the front desk was bringing patients in and filling the exam rooms. Trying to execute downtime procedures when you’re also trying to work with the help desk and get yourself up and running is nearly impossible. Trying to perform data entry from paper at the end of the day after you’ve seen 80 patients is just too much to ask.

Patient expectations are high and patience is low, for certain. We’re seeing over 2,000 patients a day and it’s taxing our radiology systems, with images slow to load. When you’re trying to diagnose COVID from chest x-rays because you don’t have enough rapid test kits, that’s a recipe for frustration.

The increasing hacking events directed at healthcare institutions aren’t reassuring. We’re getting daily reminders to avoid using email on work computers to reduce the risk of phishing. Employees who have been caught charging their phones via USB cables to the PCs have been disciplined. Websites have been locked down to the point where you can’t even access major pharmaceutical company information, which is always fun when you’re trying to find a package insert because you’re looking for the details needed to answer a patient’s questions.

Then there’s the thread of physical altercations. Although I haven’t had any at my worksites when I’ve been present, we did have an incident with an anti-masker patient who was ridiculing staff and other patients. He became physically agitated and had to be escorted out of the office. Businesses in our city are starting to board up in preparation for anticipated civil unrest, which is something we never planned for. Although we haven’t received a clinical bulletin on treating patients who have been exposed to pepper spray or other chemical irritants, you can bet that many of us have read up on it.

At least with my experiences in my own clinical office, I’m well prepared to meet the needs of my healthcare IT clients. Most of them are worried about the same issues, but with the hacking concerns magnified as the clients become larger in size. There are so many staff out of the office (both clinical and from a technology standpoint) that no one wants to implement any new solutions or features because they don’t want to stress already burdened caregivers or run implementation teams ragged. It sounds good to hit the pause button, until you realize that some organizations have received grant money or other awards that have strings attached, such as deadlines.

I spent a good chunk of the weekend re-engineering an implementation plan to make all the training virtual and asynchronous, including recording some of the training videos myself. Fortunately, the client has someone who can do some edits and cleanup. Although I can train with the best of them, my moviemaking skills are nearly nonexistent.

With the numbers coming off the Johns Hopkins COVID website this week, everyone is understandably worried about where the next few weeks will take us. Patients are continuing to travel and resume normal activities, and some are going overboard trying to stock up on experiences in advance of potential lockdowns. Mental health services are at a premium and those patients frequently find themselves in the urgent care setting because their primary physicians aren’t able to see them on a timeline that the patient finds acceptable.

I treat panic attacks and anxiety all the time, but there’s a special kind of anxiety that shifts to the clinician when you’re trying to help a patient cope with the fact that she has to have an outpatient hysterectomy because the hospital has put a freeze on “elective” cases that require an overnight stay. We certainly didn’t train for a world where any of what we’ve been experiencing over the last few months would be OK.

Third parties are feeding off the desperation of providers to do something other than practice medicine face to face. I was approached by a telehealth company that wanted to offer me $10 per visit and touted the ability of their platform to let me see 10-12 patients an hour. That, dear readers, is absurd. And the frightening thing is the number of physicians they’ve already signed up. I’m sure the patients don’t know that physicians are going to try to run on those volumes, or that they’re not going to get the level of care they deserve since they’re paying many multiples of that amount for the service. One colleague was offered $10 an hour to supervise a nurse practitioner. Certainly our licenses are worth more than that, but the employer thought it was more than fair. My colleague took a page from Nancy Reagan and just said no.

Then there’s the elephant in the room, which is, what will happen after Tuesday? Patients are girding for everything from “life as usual, since COVID will be gone” to full-scale civil unrest. I saw a patient last week who had been having chest heaviness that got worse as the day progressed but was better first thing in the morning. The culprit – he was wearing body armor around the house, “preparing.” You should have seen the look on my scribe’s face when I pulled that little detail out of the patient. Toilet tissue is once again flying off the shelves, although I was excited to finally score some bleach at the grocery store.

Whatever happens as a result of the elections in the US on Tuesday, my fondest hope is that people will remain calm, work through their emotions, and not lose their cool. I hope we rise to the occasion, regardless of the outcomes and the personalities involved. We all need a break.

How is your organization preparing for election day chaos? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/29/20

Hospitals and health systems are going on the offensive against COVID. One example is this two-page ad in the Tulsa World that illustrates hospitalizations within Saint Francis Health System.

Hospitals in my metropolitan area are approaching maximum capacity, having taken numerous transfers from rural hospitals that quickly became overwhelmed as cases surged. Our flagship tertiary care hospital has put limits on elective operative cases, not only to preserve bed capacity, but also to try to mitigate the load on care delivery staff who are anticipating a rocky winter.

One of my ICU nurse colleagues has been working with COVID patients since the beginning, spending several months in a vacant college dorm to reduce the risk that she would take the virus home to her high-risk household. In the ultimate show of compassion, another nurse from a “regular” unit offered to trade places for a few weeks so that my friend could have a break. It’s people like these that drew many of us to healthcare, those who truly set the example of service. But it’s a sad commentary on where we are right now and the concerns around what is to come. We had two more resignations at my practice this week and I fear more are to come.

ONC released a data brief this week looking at the state of interoperability among major US cities. The report looked at variation in interoperability within 15 cities, which are represented by combined statistical areas. They looked specifically at four key areas of interoperability – to find, send, receive, and integrate electronic health information with sources outside their health system. Data on HIE participation was also included.

Not surprisingly, small / independent hospitals performed the worst, with system-owned hospitals reporting higher rates of engagement across all domains. I practice in one of the areas that was surveyed and can attest to our paltry performance. The hospitals refuse to share information with independent facilities, and most of the time, my best source of information at the point of care involves the patient handing their phone to me so I can flip through their MyChart account.

The state HIE isn’t much help either since they won’t let individual physicians participate. Physicians only get access if they’re part of an organization that is sharing data. There are plenty of us that are independent, locum tenens, or contract physicians who care for patients outside the walls of a hospital or across multiple rural facilities, and it would be useful to have access to the data when those patients cross our threshold. That’s how the state’s prescription drug monitoring program works – it’s funded by tax dollars and each provider has their own login. Not sure why the HIE needs to be different.

My office recently suffered the devastating loss of a staff member, who passed away at the practice during the work day. It’s been an incredibly difficult time for everyone. The office has been closed and we just re-opened Wednesday. Based on the experience, I have a new item to add to our contingency plans for such a situation. If you have shared PC workstations, I highly recommend having someone log in to the PC that was last in use by the staffer in question and make sure that their login screen isn’t going to pop up for the next person to see. It never occurred to me that it might be an issue until I walked past a staff member who was staring catatonically at a login screen with her departed co-worker’s name, waiting for her password. The whole situation has been traumatic. This was another hurt that the team didn’t need on our first day without her.

Especially in a pandemic, there’s a lot of focus on the clinical workers at hospitals, along with those who perform essential functions such as food service, housekeeping, and facilities engineering. You don’t hear much about the unsung IT heroes, although they’re just as critical where taking care of patients is concerned.

One of my physician friends reached out to me recently about what she perceived as an IT disaster and I had to agree with her assessment. The hospital has had some significant delays in the return of pathology results over the last few months, due to layoffs and backlogged specimens. She’s been waiting for several sets of patient results to return and checking the system daily because she knows it’s a big deal for her patients. The lab director had told her to be patient, but I understand her reluctance to do so when she was waiting for information that could change her patients’ lives.

Late Sunday evening, she received a large volume of pathology results to review, some of which had been finalized and released by the lab more than five days previously. Apparently one of the interfaces had gone down and the results had been available but just sat there queueing until someone finally noticed an issue and pushed them through after restarting the interface. Her hospital recently outsourced quite a few of its IT functions and she couldn’t help but wonder if the changeover had anything to do with the failure, so called for my thoughts. My impression is that of a multi-level failure, first with the interface itself, then with the monitoring systems, then with a lack of notification to the responsible providers explaining the situation.

She had several dozen sets of results to address, but in a system her size, there may have been hundreds if not thousands of patients who were impacted. I know she felt terrible about the delays and was trying to figure out how to find time in a busy Monday office schedule to call notify all the patients. The reality is that on the other side of each one of those pathology results sits a woman who has likely been worrying about the outcome of her biopsy and that failure of the system added additional burden that she probably didn’t need right now.

It’s important for those of us in the healthcare informatics world to realize how critical our work truly is, and for the leadership that manages our departments to make sure we have the resources to do the work properly. My heart goes out to all the patients who had their results delayed and especially to those who received news that likely changed their lives.

Has your hospital cut resources for infrastructure reporting and monitoring? How does it notify patients and clinicians of similar situations? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/26/20

Mr. H posted a poll yesterday looking to better understand when patients / readers have most recently encountered a scribe and in what context. Having spent the better part of more than a decade working with scribes in various different capacities, I thought I would chime in with my experiences.

I had my first encounter with the idea of scribes in 2006 when I was working on my first large-scale EHR go-live. We had a couple of physicians in our medical group who were not technology savvy by any stretch of the imagination. One of them had never used a home computer, even for email, Internet surfing, or the occasional game of solitaire. We began her implementation with some basic computer usage, working on tasks such as turning on a laptop and getting the hang of using a mouse by playing solitaire. Over the course of multiple weekly visits, we tried to work with her on being able to do basic EHR tasks, such as prescribing medications and reviewing patient history elements.

Even though she was willing to try, given the volumes in her clinic and the complexity of her patients, it became clear that she wasn’t going to be able to continue to practice the way she wanted to while trying to use the EHR. We were able to convince our administration to consider allowing us to train one of her medical assistants as a scribe.

The next step was to try to find a scribe training curriculum. I found one online that had been created by a medical student and included plenty of content on medical terminology and how to act in the exam room. Since this was a seasoned medical assistant, she already knew the latter, but she wasn’t that keen on sitting through a bunch of PowerPoint slides about terminology.

We ended up doing some modified on-the-job training, where we pulled several dozen notes from the physician’s files and used them to role-play mock encounters, with one trainee acting as the patient and the other supporting the medical assistant as the scribe. We also had to do simulated patient care scenarios with the physician to teach her how to communicate with the scribe, such as how to describe her examination findings and how to ask the scribe to find EHR information and show her any lab results that she could act on during the visit.

Even though we thought it would be a short-term arrangement since the physician’s retirement was always a topic of conversation, it continued for nearly a decade. Patients were happy since they already knew her long-time medical assistant, although we had to make sure that we backfilled her role as a medical assistant so she wasn’t trying to do two jobs at the same time. It’s clear that having a scribe extended the physician’s ability to stay in practice while still meeting all of the medical group’s benchmarks.

Fast-forward to today, where I’m in an organization with its own in-house scribe training program that is extremely rigorous. Our scribes are first hired as medical techs, where they are put through an extensive classroom program followed by a rigid schedule of on-the-job training where they are required to demonstrate mastery of a subset of procedures and skills before moving to the next level. After more than a dozen supervised 12-hour shifts, they are required to work independently for six months before they can apply to be scribes.

Once they make the cut, it’s back to the classroom for more medical terminology training and additional work with the EHR, followed by a written test. If they pass, they begin to practice in-person scribing, followed by several shifts with the company’s founder and other senior physicians. Some don’t make it through, but those who do know that they are gaining invaluable experience since nearly all of them are pre-med students. The company makes them commit to at least a year of work before they’re hired, which most of them are happy to do as they use the time to work on med school applications and attend interviews.

I love having a scribe and it’s rough when I work a shift without one. You get so used to having everything you say automatically added to the orders or the note that sometimes when you are flying solo, you forget to order things. It takes time for the brain to adapt back to doing things yourself. Fortunately my staff is patient as they ask me whether I was planning to include discharge instructions for a patient or ask whether I’ve reviewed labs that have been added to one patient’s chart while I was seeing another.

Quite a few of our scribes began medical school this fall, so we are knee-deep in training the next class. Given the volumes we’re seeing with our recent COVID surge, they’re certainly getting an education.

I’m not sure what I think about virtual scribes, even though the idea is clearly a hot topic. I definitely think that patients need to be informed of the presence of a virtual scribe and to be given the chance to opt out, much as they might when a human scribe is present in person. In reality, I’ve only had a couple of patients opt out of having someone else in the room. Most of the time they are thrilled that I can focus on them rather than the EHR, and the encounters go much quicker because the documentation is done in real time. However, the virtual model has limitations in being unable to truly interact with the scribe or to use the scribe’s laptop in real time to show patients their lab trends or copies of their imaging studies.

I would be  interested to hear from anyone who is using a virtual scribe model. In what clinical situation have you implemented virtual scribes? How accepting have your patients been? What are the challenges? Any unexpected successes? If you had it to do over again, would you do anything differently?

Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/22/20

Continuing its ongoing slide towards irrelevance, HIMSS issues its call for proposals for the 2021 conference, which is slated to take place in Las Vegas in August.

There are quite a few places I’d rather be during the summer than there, so I’m rethinking my plan to attend. Part of me wants to see what the stripped-down version of HIMSS looks like, but I’d rather save my desert trips for the winter months. For those of you interested in presenting, proposals are due by November 2, meaning the material will be nine months old by the time you take the podium. Speakers receive complimentary registration, but then again, most of the rest of us are also receiving “free” registration since they refused to refund our fees for the canceled 2020 conference.

The Journal of the American Medical Informatics Association publishes a review on “Physicians’ electronic inbox work patterns and factors associated with high inbox work duration.” Looking at primary care physicians, they quantified the time spent on inbox management while looking at use patterns to identify which types of messages took the most clinician time. They found that PCPs spent an average of 52 minutes managing the inbox on workdays, with 19 of those minutes occurring outside work hours. Most time was spent on patient-initiated messages and results management. The authors conclude that interventions targeting these two areas would help reduce inbox workload.

I’ve long been a promoter of having support staff assist physicians in managing the inbox, but there continue to be barriers in this regard. Some organizations think there is too much medico-legal risk to have staff screen or triage messages, but others are supportive of the approach. Most employed physicians I’ve worked with seem reluctant to push back, since their employers don’t want to spend money on qualified support staff and they feel like it’s a losing battle. Many physicians feel like they’re in captive employment situations, and you can bet employers take advantage of this, knowing they’re not likely to vote with their feet.

Despite promises of coverage for the expenses of COVID patients, patients are starting to see surprise medical bills arrive in their mailboxes. Patients who don’t have a documented positive test due to testing shortages or those who end up seeking care out of their insurance network seem to be the most at risk. These examples further demonstrate the brokenness of our US healthcare system, where people routinely delay in seeking care because they’re worried that they won’t be able to pay for it.

I treated an elderly patient recently who needed a cardiac workup to confirm whether her symptoms were being caused by a heart attack. There’s not a lot we can do in the urgent care to definitively make the call. Because her home country has a nationalized health service, she was resisting a transfer to the hospital because she had heard of the exorbitant cost of hospital visits in the US. Ultimately she agreed to go, but declined an ambulance transfer. Since our local hospitals routinely block independent physicians from receiving follow-up information, I’ll never know if she made it there or not or what her outcome was.

The ongoing pandemic is a huge stressor to patients and healthcare workers alike. Some companies are offering virtual therapy and meditation apps to try to help their workers cope. Kaiser Permanente is offering the Calm meditation app to millions of its members, and other payers have been bolstering their mental health service offerings as well. My primary clinical practice recently suffered a devastating loss as a staffer died at the site. Given the age distribution of our employees and their engagement with technology, I suspect they’d be more apt to engage mental health services through an app rather than having to pick up a phone and call the employee assistance program.

The Joint Commission issues a “Quick Safety” bulletin covering “the optimal use of telehealth to deliver safe patient care.” They seem a little late to the dance since it’s October and most organizations have been using telehealth services since the spring, often with great success. They include some good pieces of advice, including the need to develop protocols for virtual care to reduce variation between providers. They also note that staff roles and responsibilities need to be defined.

The latter is something I still see organizations struggle with, as they make the assumption that virtual visits need to be 100% the responsibility of the provider. The most efficient telehealth platforms allow for a similar flow to the in-person visit, with staff performing pre-visit and post-visit tasks so that the physician can focus on the parts of the visit that require their specific attention.

The American Medical Association, which controls the CPT codes used in medical billing, has released two new codes for COVID testing this week. Both of them address use of combination tests that look for Influenza A and B along with COVID-19.

Academic medical centers and other large institutions have been developing their own tests for this, but what we really need is mass quantities of a rapid test that covers these pathogens and can be administered and resulted at the point of care. My state continues to be in a surge, and it’s become painfully obvious that the only thing that is going to keep some people home is having an actual positive test result. Many are clear about their intentions to continue “living their lives” in the absence of a positive result, regardless of their symptoms or exposures.

It’s certainly a disheartening time to be a physician. My community just lost another physician to suicide this week. We’re also seeing COVID take a toll on our providers who have other health issues but who have been trying to “power through” due to the extreme need in the community. Two of my colleagues are on bedrest for pre-term labor and two more have taken unspecified medical leaves.

There’s also an emotional toll. We are expected to just keep going regardless of what we’re seeing around us. While hospitals typically have post-event shakedowns after tragic Code Blue or major trauma events, there’s not a parallel for most of us in the ambulatory realm other than just trying to look after one another. No one’s clapping and cheering for the healthcare providers any more, but some of us are working harder than we have since the initial spring peaks. I’m definitely seeing some unhealthy coping behaviors, so keep an eye on your friends and family if they’re in the clinical trenches.

What is your organization trying to do to bolster morale ahead of flu season? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/19/20

There has been a tremendous amount of anxiety in the virtual physician lounge this week. One of the local hospital systems announced that they are going to start releasing all physician notes to patients via their MyChart implementation. Apparently, there was very little information provided about how confidential information will be addressed, particularly among teenagers, and physicians are concerned about the repercussions.

I’ve been watching the conversations, trying to get a feel for how the situation looks to physicians who aren’t informaticists and don’t have a full understanding of why this is happening. Some of the comments underscore the need for education and highlight the opportunity that hospitals have to make sure their medical staff members are all on the same page and understand the background:

• Why are all the hospitals jumping on this bandwagon? Seems like just another patient engagement trend.
• It’s an absolute mandate from CMS.
• It’s a Medicare thing. I’m just going to do my Medicare patient notes on paper and scan them in.
• I’m going to make a smart phrase now to explain that I’m no longer using MyChart.
• Patient notes are for me and my colleagues, not for the patient.
• This contradicts state law, I’m not doing it.
• I’m just going to make my notes very sterile, generic, and useless in order to avoid patients freaking out about things they don’t have the training to understand.
• There’s a $1 million fine if you don’t do it.
• X health system has an option to “not share the note.” I assume this is going away.
• Y health system just implemented an option to “not share,” I guess this is due to the new requirement.
• No patient ever needs to see the back and forth messages between my staff and me, whether it’s in their chart or not.
• I’m just going to make shadow charts on all my patients.
• I hope they take this into account with the patient satisfaction surveys. Patients are going to hate seeing the real truth about themselves.

To be honest, I was surprised by how bitter and angry some of the comments were. It made me a bit embarrassed to be part of the physician community in my area.

At least there were a couple of physicians who chimed in who had previous experience with OpenNotes, trying to reassure people that it won’t be as bad as they are anticipating. Another pointed out a positive experience with patients who claim they were never advised of various parts of the treatment plan, but it was clearly documented in the notes they received after the visit, which led to some good discussions with patients who could benefit from taking charge of their health.

It was a very different conversation than the one going on among my clinical informaticist peers, who have been detailing their plans in various informatics forums. It sounds like there is a strong consensus on only releasing ambulatory notes and test results after they have been signed by the responsible physician, and only releasing inpatient documents after discharge, but that’s where the consensus ends. However, there has been some good discussion around the fact that the regulations are somewhat vague and it’s not clear whether “progress notes” includes all progress notes (such as nursing, physical / occupational / speech therapy, social work, etc.) or just physician notes.

Some health systems are running full speed ahead for a November 1 go live, but others seem to be biding their time hoping that there will be a delay in enforcement. Although I see the value of patients having access to their notes, most health organizations are pretty strapped right now, what with the pandemic and all. Many of my independent physician friends are barely keeping their heads above water, with another one deciding to retire at the end of the calendar year. I think there are quite a few of them who wish that a health system would acquire them, but it doesn’t seem like there’s a lot of available cash for practice purchases these days.

How is your organization preparing for the upcoming mandate? Do you think your physicians understand what it’s all about? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/15/20

CMS has announced amended repayment terms for providers who received Medicare loans due to COVID-19. Repayment will begin one year from the issuance date of each provider’s (or supplier’s) advance payment. There is $106 billion in outstanding payments, which were intended to help bolster healthcare providers who had cash flow issues during the early stages of the pandemic. This is a positive development since they were originally scheduled to begin payback in August. Speaking with my friends who are independent physicians, they’re still struggling to get back to regular volumes and are worried about what things will be like once flu season hits.

Physicians across the country are still faced with shortages of personal protective equipment and aren’t equipped to manage COVID-positive patients in the office, so they often send them to the emergency department or local urgent care providers. If infections start to pick up, they’re going to be in the same place as they were last spring, if not worse. Providers who are still experiencing hardships can request an Extended Repayment Schedule that allows repayment over a three- to five-year period. In an interesting twist, CMS is also allowing recipients of the $175 billion in Provider Relief Funds to use those monies towards repaying the Medicare loans

St. Louis-based health system Ascension announced Monday that its 1,200 local employees will be able to work remotely permanently. The organization will be reviewing its local office footprint while supporting employees who have told leadership that they’re happy working remotely. Other local health systems are likely operating by the same playbook. Friends at BJC Healthcare mentioned that many remote IT and process improvement employees aren’t expected back in the office until June 2021. That gives the system plenty of time to evaluate their lease commitments and figure out where and how to shuffle the employees that eventually return in person.

From Non-Essential Travel: “Re: travel. Given the story of being in close confines with someone who flouted the rules, I’m curious whether you would recommend non-essential air travel to others at this time? Also curious whether your role, which brings you into more frequent contact with people who are COVID-19 positive, influences your decisions (i.e. you’re around it all day and have become accustomed to some level of risk). I know you discussed using air travel for important business reasons previously, but with so much conflicting information on what’s safe and what’s not, curious your take on the merits and risks of non-essential air travel at this time.” Good questions. I think that like everything else to do with this pandemic, the issue is one of weighing the pros and cons and finding the right comfort level with the decision. To be honest, for me this trip had significant elements related to mental health beyond just getting away.

I’ve been in a situation for six months now where I’ve been seeing twice (or sometimes more than twice) my usual patient volume within a 12-hour shift, which sometimes stretches to 13 or 14 hours to make sure all the patients are accommodated. My employer is extremely customer-focused, which creates a grueling environment for the staff. We don’t turn anyone away and we see all levels of acuity (at least until we can stabilize the patient while we call 911 and wait the heart-stopping 4 to 7 minutes for the fancy truck with the flashing lights to arrive). I’ve seen wounds and injuries that I haven’t seen since I worked in the big-city emergency department and have been expected to manage them until backup arrives. It’s gotten to the point where I know the ambulance-based paramedics by name.

When I finally make it home, I head straight to the shower, throw my work clothes in the washer, and then finally find dinner at 9:30 or 10 at night. The level of stress is pretty crazy, and some of us are left with few people with whom to commiserate. Non-medical friends and family members just cannot fathom what it’s like, although I’m not even in the worst of it by any stretch of the imagination.

Add that to the fact that we’re staring down the barrel of rising COVID numbers in my area, an extreme level of pushback against any kind of public health measures, and an impending flu season (which has already started for us) and I felt like if I didn’t get out of Dodge now I wouldn’t be able to do it for at least six or seven months.

The physician I met up with is much in the same position as I am. The reality of our dark thoughts led us to at least contemplate the fact that this is such a craptacular year that one never knows when one’s number might be up. I think a lot of people have forgotten (or didn’t realize) that back in March and April, physicians were updating their wills. That fear is still in the back of our heads, especially because we’re still seeing people who are deadly sick even though many in the US have returned to their normally scheduled programming, including leisure travel.

Bottom line: if not for this trip being an antidote to those dark thoughts, I would not have gone.

As someone who routinely encounters in the vicinity of 20 COVID-positive patients a day plus the other 40 to 60 who ultimately test negative, it’s nothing to throw on an N95 mask and some eyewear and hop on a plane with open middle seats (although I admit I fluid-restricted myself so I would have zero chance of needing to use the airplane lavatory, and did not eat or drink on the plane). Would I take my kids to Disney World just for fun? No way. Would I support someone making a trip to see a relative who might not be with them for much longer? Yes, with the right precautions.

I know the travel industry is hurting, along with many other sectors of the economy, but for the average person, I don’t know that the risk/benefit equation works out in favor of non-essential air travel. I’ve been wanting to make a non-essential trip to Boston to test-drive a custom musical instrument for nearly 10 months, and even though I could swab myself to meet the Massachusetts protocol and hop on a plane tomorrow (heaven knows I have enough unused airline tickets), I still haven’t done it.

The issue of the safety of air travel is certainly top of mind for many, and a recent article in the Journal of the American Medical Association looked at the topic. The comments on the article are interesting, and point out some level of conflict of interest among the authors that creates a shadow on their conclusion that the risk of contracting COVID during air travel is lower than that of being in an office, classroom, grocery story, or on a commuter train.

What do the rest of the road warriors out there think about air travel at this time? Leave a comment or email me.

Email Dr. Jayne.