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.

Curbside Consult with Dr. Jayne 10/12/30

I’ve returned from my brief sojourn in the desert. Unfortunately, on my outbound flight, I had my first exposure to a passenger behaving badly.

The last couple of times I’ve been on a plane have been smooth, but this one was marred by a man who wouldn’t keep his mask on his nose. It wasn’t a case of the mask not fitting right with resulting slip. He would wait until the flight attendant walked by, then intentionally lower his mask. He had already been a problem at boarding, when he planted himself in the exit row and took his mask off entirely, claiming he was “hot,” but put it back on when confronted.

After being counseled by multiple flight attendants, he finally complied when they told him he’d have to give up his exit row seat and move to the front of the plane with them. If you’re hale and hearty enough to fly coast to coast, you should be able to wear a mask.

It was fantastic to be in a part of the country where they’re taking COVID seriously. Nearly everywhere we went, people were universally masked and businesses were deadly serious about customers keeping their masks covering their noses and mouths. My community at home is doing unfortunate things, such as having unsanctioned homecoming dances with numbers of attendees that not only exceed county guidelines, but are entirely unmasked. I wish the parents organizing these events could come spend a day in our clinic and see how many families we deal with whose lives are disrupted after the fact by these events, and see how hard the staff works trying to deal with it all. As a physician dealing with COVID all day, it’s grating to see people who don’t understand personal responsibility and how their actions can impact the lives of others.

The small town I was visiting has reimagined their downtown area to promote outdoor dining and distanced socializing, blocking off streets and expanding the footprint for restaurants to serve in-person customers. Given our relatively self-isolating outdoor activities, most of our meals were of the “pull it out of your backpack” variety, but it was nice to get out and do some people-watching on the day we ventured into town.

If you’re going to blow your day’s calories on a single item, I highly recommend a shake that comes accessorized with not only whipped cream, but a donut. I saw some sassy boots while window shopping, but refrained from looking further until I have somewhere interesting to wear them. Of course, I could always stroll around my house in them, but it’s just not the same.

My wingwoman on this trip is a surgeon, and given the types of cases she usually does, she hasn’t been doing much telehealth work. She works for a large integrated delivery network where after-hours care is handled by triage nurses, so she was fascinated by the fact that I could log onto my favorite telehealth vendor’s site and have a waiting room full of patients who wanted to speak with a random physician at all hours of the night. I only saw a handful of virtual patients, and only when I received escalation text messages that the patients had been waiting a long time due to a shortage of available providers licensed in one of my states. She comes from a totally different world where the patient population is somewhat captive, so she found the potential fragmentation in care a little unnerving.

There’s still a lot lacking as far as interoperability between telehealth vendors and the rest of the teams that care for the patients they serve. At best, the patient’s local physicians receive a PDF document or a copy of the patient’s care plan. At worst, they receive nothing. In order for third-party telehealth platforms to be a robust part of patients’ ongoing care, they’re going to have to reach a level of interoperability that’s on par with the capabilities of certified EHR systems used by those other providers. They’re also going to have to execute on those capabilities. I know those vendors (and their shareholders and investors) don’t want to hear about the amount of money it’s going to take for that to happen, but it’s the right thing to do for the patient.

For me to be an effective telehealth urgent care physician, I need an current copy of the patient’s medication list and problem list, not just what they recall or what they might have picked from the top of a dynamic picklist because they were in a hurry. I need to have a better picture of whether a patient is compliant or not, and what their local care team has been doing or what they might have already been thinking regarding next steps for a given condition that might impact my short-term care plan. Whether I get that data from a provider’s EHR or some kind of API integration direction with the patient doesn’t make that much of a difference to me, as long as the data is there and comes through in a usable form. For the platforms I practice on, I’m betting it will be months to years before we reach those capabilities unless something changes drastically in the interim.

It will probably be a while before I practice any telehealth since I have quite a few in-person clinical shifts coming up to make up for my time away. I’m pleased to say that my flight home was uneventful, with most passengers sleeping. I think my exit row companion and I were the only ones with our lights on, and he appeared to be working most of the flight just like I was. Seeing a fellow road warrior type back in his natural habitat made me smile.

I’m cautiously optimistic that we can continue to put systems in place that allow people to travel or otherwise move about more freely than they have been, assuming they (or their companies) can afford to do so. However, flu season is just over the horizon, so it will be interesting to see if things stabilize or if we have more challenging days ahead of us.

What’s your over/under prediction for the upcoming US flu season? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/8/20

I’ve helped numerous organizations with EHR system selection over the years, so I’m always skeptical when vendors or others report outcomes that can only be described as too good to be true. I always feel vindicated when I get to the bottom or an article and find some tidbit that I might have otherwise missed if I skimmed.

Such was the case with a recent write-up about FastMed Urgent Care implementing Epic. Although FastMed may technically be the first independent urgent care operator to take Epic live, they partnered with HonorHealth in Arizona. It’s unclear what level of partnership is present – is it a joint venture, a resource sharing agreement, or some kind of licensing deal?

The write-up morphs from a report about FastMed into a write-up about a July KLAS report where vendors were rated on their COVID responses. It goes on to quote an anonymous Epic client who says that the efficiency gained using Epic has allowed them to go from seeing 300-400 patients daily to about 1,000. If you weren’t reading carefully, you might think this was about FastMed.

It caught my eye because for an urgent care to make that dramatic leap in volumes, it would require changes in many more systems beyond the EHR, such as staffing, facilities, supply chain, and more. When actually considering information like that, it’s also important to understand the timeframe for that kind of ramp up. It’s unclear why they even included the KLAS report in the piece, but just another example of the sloppy writing that’s out there and why prospects and customers need to remain vigilant.

From Dancing Queen: “Re: resigned employees. I sat on a 1:1 call earlier this week, waiting for someone who ultimately no-showed. There was no response to outreach on Slack or email, and no out-of-office message. Turns out he gave notice around Labor Day and his last day was almost a week ago. This was a C-suite person with an administrative assistant. Why would anyone think it’s OK to leave meetings on the calendar and not notify anyone of his departure?” Unfortunately, not caring about the time of other people seems to be the new normal. I personally experience no-shows all the time, as well as people who arrive late with no notification and no apology. One company I work with has a serious issue with people just ignoring emails. Especially in the world of virtual officing, people need to revisit the ideas of common courtesy and respectful behaviors. I understand companies not doing blast notifications when people leave, but there’s no excuse for not putting on an out-of-office message that directs people to someone who is assuming responsibility for that person’s work. In one past life, we would see a little “x” in the Outlook directory in front of people who had left, but that doesn’t help if you’re an external stakeholder, vendor, or consultant.

Telehealth has become a key part of the care team for many patients and providers, but organizations are still struggling with patient acceptance and technology glitches. Some patients seem to be more receptive than others, for example, those who had difficulty traveling to see a distant specialist or those who have difficulty taking time away from work for appointments. Others may not have the technology needed to do a visit well or may be uncomfortable discussing certain issues at home versus in the privacy of the physician’s exam room.

Now that the initial pandemic-driven pressures for telehealth services have slowed, organizations are starting to rethink their strategies. Maybe they have outgrown the quick and dirty solutions they initially deployed, or maybe they’ve realized that the vendor they chose didn’t offer all the features they need to be successful.

Organizations that are trying to move beyond the urgent care and immediate care constructs are looking for more robust technology that includes elements like remote monitoring or enhanced triage abilities that help streamline the physician portion of the visit. One consistent request I’ve heard in talking with CMIO friends is the ability to have multi-party conversations, such as with the patient and children or caregivers who may be remote not only due to distance, but due to potential quarantine or isolation. Having everyone virtually on the same page can cut down on the post-visit interactions that providers sometimes have to conduct to make sure everyone has the same information.

Others are looking for solutions that will allow multiple providers, such as a multidisciplinary care team, to see the patient at once. These integrated teams are often used for pediatric patients with complex medical problems that require follow up from a variety of subspecialists, to avoid having families travel multiple times to tertiary care centers. This is also important for patients who need translation and interpretation services.

EHR integration is also an ask, especially for those that implemented lightweight, standalone systems. Providers don’t like having to use multiple systems and screens to access data and document while they’re seeing the patient. It will be interesting to see what the provider-based telehealth market does over the next year, as well as how things turn out for direct-to-consumer applications.

Since no one hangs out in the actual physician lounge anymore (thanks, COVID), we’ve moved to virtual forums to try to stay connected. I’m part of multiple physician and provider groups that are trying to keep each other updated on not only COVID-related happenings, but other healthcare issues, while trying to bolster our communal morale. One of the hottest topics recently has been the future availability of a vaccine for the novel coronavirus and speculation on how complicated the process will be for its distribution. We’ve been collectively pleased that vaccine manufacturers seem to be holding the line against political pressures for a premature release and that CEOs have frankly contradicted the White House’s claim that manufacturers were pushing back against FDA guidelines.

Manufacturers have plenty of skin in the game and can’t afford to rush a vaccine to market only to have it go wrong in the field. We’ve all seen those examples of drugs released without adequate testing (Vioxx, anyone?) that have come back to haunt patients, providers, and manufacturers alike. As a front-line provider, the decision to take an available vaccine is not insignificant. FiveThirtyEight put together some thoughts from vaccine professionals on how we might know when a vaccine can be trusted. Here are the best nuggets:

• Don’t get your vaccine advice from politicians or pharmaceutical companies.
• Trust independent scientists and medical professionals.
• Look at information from FDA reviews.
• Be skeptical of anything released before year-end.
• Trust experts who are straightforward about the limitations of potential vaccines.

No one wants to get back to normal more than the healthcare providers who are in the trenches dealing with COVID and its fallout. Everyone is tired in a thousand different ways. Our hope is that people will learn to wear masks properly and consistently, that people will be vaccinated when a safe and effective one is approved and available, and that everyone will show patience and grace while all this is going on.

What’s the best example of grace under pressure you’ve seen during the pandemic? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/5/20

Google is doing some interesting things with COVID data overlays for Google Maps. The company states that it introduced the COVID layer in Maps “so you can make more informed decisions about where to go and what to do.” The overlay shows the seven-day average of new COVID cases per 100,000 people, with labels that show whether cases are trending up or down.

The data was accurate for my area, which is a hotbed of COVID transmission. Based on the activity of people in general, I doubt many people are consulting Google Maps to decide where they should be going since local traffic patterns indicate that everyone is everywhere.

Part of the issue stems from our lack of a statewide policy, leaving it up to individual counties to decide whether they will have restrictions or not. I live in a more restrictive county and people are flocking to the neighboring jurisdictions for dining and social activities despite the fact that numbers are going up in those areas. We hear all about the fun they’ve been having at wineries, pumpkin patches, and haunted houses when they present to the urgent care for COVID testing.

Since we have six providers out with COVID, we’re not very amused. Even though I’m not in the office for a while, I still get the text messages begging for additional provider coverage. We’re already seeing patients who are positive for both influenza A and influenza B, and vaccination season has barely started. It’s going to be a long winter, I’m guessing.

Our practice’s leadership has been quiet at providing details on how many employees have been infected with COVID and whether the exposures have been work related. I see some fairly cavalier processes with masking at times and occasionally people are gathering in break rooms despite recommendations to the contrary. I’m trying not to judge – they might be part of our population that already has had COVID and maybe they’re sharing war stories over a sandwich, but it’s still eerie when you walk up on people unmasked and closer together than the recommended six feet.

As a former administrative type, I appreciate the organization’s reasoning for being mum, but as a patient care organization, I think it’s important to address the infection control issue head-on especially since we’re still having “extended use” of our N95 masks that borders on the absurd. Fortunately, I have some angels out there who have been sourcing masks for me, so between those and the work-issued ones, I am able to swap them out frequently. I still find it hard to believe that we’re in this position at this point in the evolution of the pandemic.

Further on the topic of “things that are surprising, but not really,” I continue to see a significant number of individuals out there in the working world who don’t seem to understand the concept of “the internet is forever and it’s certainly not private.” Employers, potential employers, customers, and prospects may be looking at our activity on social media. Personal accounts can be subject to scrutiny as well as professional ones, which is why it seems surprising when people post things that raise an eyebrow or even cause a full-scale cringe.

A friend was looking at the LinkedIn profile of someone who is actively seeking a new job and found a post that didn’t exactly scream “please hire me, I’m a serious professional.” I’m not even going to quote it because I can hear my dear sweet grandmother in my head saying, “Jayney-girl, that’s vulgar.”

It got me thinking about posts that I’ve seen lately on social media that have been more than a little out of line, considering that their authors are the leaders of companies or other public-facing figures. Granted, those of us that live in the US are in the middle of what might be the most polarized presidential election in modern history, but it seems that a good chunk of the population has completely lost its sense of decorum. Whether one agrees with the idea of a social media post or not, an inflammatory tone doesn’t reflect well on one’s company or one’s leadership ability.

It has gone beyond what we used to think as “questionable” posts involving scantily-clad selfies, strip clubs, large quantities of alcohol, or venturing into tasteless subject matter. I saw one executive who re-posted political material that openly mocked the LQBTQ+ community. I’m sure their community health center and reproductive health practice clients aren’t going to be amused by it. Part of me wanted to reach out and ask if he really did post it or if he had been hacked, but seeing some of the posts that followed provided an unfortunate answer to my question.

I’ve seen what I would consider to be bad behavior much more often from my friends at startups, which may not have the same corporate social media policies as established or publicly traded companies. I’ve seen some posts that are completely absent of common human decency , but if they don’t even meet that level, they’re definitely not going to meet standards of being respectful. I  was following a company to write a piece on a company, but but have canned it because I cannot in good conscience provide visibility for an organization whose leadership is openly hateful.

In the final days that we have leading up to our presidential election, I am encouraging people to remember how we used to interact with each other, with reasoned, thoughtful conversation rather than forwarded clips and disrespectful hashtags. Once upon a time we knew how to work together towards common goals rather than bashing each other. We still have tremendous problems to solve, particularly in the healthcare arena where all of us play a role. Chronic diseases haven’t gone away, nor have preventable harms in healthcare facilities. Maternal / infant mortality in the US is still shameful, and we’re nowhere near funding public health in the way we need to fund it even after COVID exposed our shortcomings. We’re still wasting healthcare dollars because of siloed data and lack of interoperability.

We still have a rough month ahead of us, but let’s all consider taking a vow of civility. Let’s think before we speak or write and read things twice before clicking “send” or “post.” I think we’ll all be the better for it.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/1/20

For those of you still playing along with the Medicare Promoting Interoperability Program, October 3 is the last day to begin the required 90-day EHR reporting period. This applies to eligible hospitals who want to try to avoid getting a negative payment adjustment (aka penalty) down the road.

It’s hard for some organizations to even care about the CMS programs any more. They are trying to keep their doors open on a month-to-month basis, and the idea of future penalties isn’t on the radar when they’re juggling staffing issues and figuring out how to protect their employees.

Another deadline approaching is that for submitting comments on the 2021 Proposed Rule for the Quality Payment Program. That comment period closes October 5 at 5 p.m. ET and comments may be submitted through regulations.gov.

COVID and the related lockdowns, shutdowns, and limitations to healthcare delivery are having negative impacts on patients in other ways. The Morbidity and Mortality Weekly Report from September 11 presents the results of a survey done in June looking at patients whose routine care was delayed. The survey estimates that 41% of US adults have delayed or avoided care, including 12% who reported having avoided urgent care.

A close friend of mine is going through some stress following a delay of care. When she was finally able to get in for her annual GYN exam, there were some abnormal findings, and now she’s beating herself up about whether they would have been found earlier had she gone in April as originally scheduled. I reminded her that in her age group she’s not even recommended to have an annual pap test, which means that her physician performed it “early” per the guidelines rather than “late” due to COVID. It’s hard for most laypeople to wrap their minds around how guidelines are constructed, especially when they’re worried whether they have cancer. At least her care team is running full tilt now, so hopefully she’ll have the answers she needs very soon.

ONC announces the awardees for the STAR HIE (Strengthening Technical Advancement and Readiness of Public Health Agencies via Health Information Exchange) program. The goal was to support state and local public health agencies, as they use health information exchange services to respond to public health emergencies such as natural disasters and pandemics. Five HIEs were each awarded two-year cooperative agreements: Georgia Health Information Network, Health Current (AZ), HealthShare Exchange of Southeastern Pennsylvania, Kansas Health Information Network, and Texas Health Services Authority.

I enjoyed this article in Nature looking at how researchers are using virtual assistants to diagnose coronavirus infections along with dementia, depression, and more. Vocalis Health, a start-up with offices in Israel and the US, modified an app that was being used to detect worsening chronic obstructive pulmonary disease in an effort to detect COVID-19. They asked patients who had tested positive to use a research app to record their voices, with the recordings processed through machine learning to try to identify a COVID voiceprint. The article goes on to cover the history of voice analysis with neurodegenerative conditions such as Parkinson’s disease as well as how it can be used for behavioral health conditions like mania, where voice features can be telling. I ran the article past my favorite voice expert who thought it was “very fascinating,” although I’m personally curious about how it handles patients speaking different languages with different dialects and regional accents.

Greenway Health is getting into the telehealth game with a solution slated to be available in October. It claims to “deliver quality care from remote locations without interrupting established workflows” and they’ve got a video on the website from their chief product and technology officer, but I’d find it a lot more credible if they had a physician announcing it. The rest of the information requires you to provide your information, so I took a pass.

My state chapter of the American Academy of Family Physicians reached out to me on behalf of the state department of health as they try to plan for administration of a COVID-19 vaccine. The documentation is extensive, including a participation agreement and a multi-page provider profile that requires details down to the brand, model, and type of storage unit that will be used for housing COVID-19 vaccine prior to administration. Based on our already unstaffable volumes, I can’t see my practice agreeing to be an administration site, but you never know.

I registered for the all-virtual Lenovo TechWorld conference today, to be held at the end of October. Based on my interests, it suggested a couple of sessions for me. I’m not sure where the “liquid cooling innovation” one might have come from, but it does sound pretty cool (pun intended). Unlike an in-person conference, it’s easy for the day-to-day to get in the way of virtual conferences, so we’ll see if I make it to any of the sessions.

I’m mostly interested in seeing how the virtual conferences run and what platforms they use, as well as how they engage (or don’t engage) attendees. The Optum Forum had some glitches this morning, with participants having to log out and back in as well as reload their browsers to continue. Sessions that may have been missed are posted for on demand viewing through October 30, however.

I’ve been dealing with some non-work issues lately, so I’ve been much more likely to answer phone calls from unknown numbers. I had the ultimate bad cold call the other day. I answered the phone as I always do, “Hi, it’s Dr. HIStalk” and the caller says, “Jayne, this is Dave.” “Sorry, Dave who?” “You know, Dave, from XX company. We met at the YY conference a couple of months ago (insert name of conference that I most certainly didn’t attend, because you know, COVID) and you said to call you in a couple of months.”

“I’m sorry, what is this about?” “I wanted to follow up on your cybersecurity needs.” When I began to explain that I don’t have any cybersecurity needs, he literally hung up on me. Definitely not a best practice for the sales playbook, and needless to say, his number is now blocked. I’ll also be making sure that all my hospital and healthcare friends who might actually have pressing cybersecurity needs know what bozos the company has hired so that they’re not inclined to give them their business.

What’s the worst cold call you’ve received? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/28/20

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/24/20

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/21/20

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/17/20

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/14/20

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/10/20

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/3/20

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/31/20

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.