EPtalk by Dr. Jayne 8/22/19

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

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 8/19/19

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

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

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

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

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

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

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

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

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

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

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

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

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

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EPtalk by Dr. Jayne 8/15/19

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 8/12/19

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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EPtalk by Dr. Jayne 8/8/19

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

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

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

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

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

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

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

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

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

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

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

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

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

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

May each of us find the art within.

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Curbside Consult with Dr. Jayne 8/5/19

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/1/19

The Federal Trade Commission has agreed to a $5 billion settlement with Facebook following allegations that the social media giant misled users about their ability to protect personal data. Privacy advocates argued that Facebook deceived patients about the “Groups” function, encouraging them to share personal health information which was then exposed to the public. Although the settlement also requires Facebook to create an internal privacy oversight board, some say the penalty doesn’t do enough to protect user privacy. The settlement order will be in place for 20 years and sets up multiple compliance channels. The settlement, nearly 20 times larger than any previous settlement, must still be approved by a federal judge.

CMS announces additional Primary Care First Model Payment Office Hours sessions aimed at reviewing the proposed model payment structure and various model components and measures. CMS still hasn’t released the Request for Application for the program, so many of us are waiting for the details before we make decisions on participation. They did update the anticipated timeline for the RFA from “spring” to “summer” on their website, however.

CMS did, however, release the proposed rule for the 2020 Medicare Physician Fee Schedule this week. The Relative Value Unit (RVU) conversion factor went up a whopping $.05. Bundled episode of care codes were added for telehealth treatment of opioid use disorders. There is additional refinement of Evaluation and Management (E&M) codes for outpatient visits, including retention of five levels of coding for established patients and the reduction to four levels for new patients. There are also changes to the time requirements and medical decision making requirements for all of the codes. History and Physical are now required only “as medically appropriate,” which should be interesting when audits start occurring.

Medicare supervision of physician assistants will have increased flexibility for PAs to practice more broadly; requirements for physicians who precept students will be relaxed so that re-documentation is no longer necessary. Payments for Transitional Care Management will be increased along with the development of new HCPCS codes for certain Chronic Care Management services. I’m not sure that this addition of Medicare-specific codes will make things more simple, although it should allow physicians who spend additional time and resources to be able to differentiate that in their billings. A new code for Principal Care Management will also be created to compensate clinicians for providing care management services to patients with a single serious or high-risk condition.

Since they can’t release just one proposed rule, they also released the 2020 proposed rule for the Quality Payment Program. Highlights include:

• Increasing the performance threshold from 30 to 45 points.
• Decreasing the category weight for Quality and increasing the weight for Cost.
• Increasing the data completeness threshold for quality data submission.
• Increasing the threshold for Improvement Activities for group reporting.
• Updating requirements for Qualified Clinical Data Registry measures.

I’ve long been a follower of CIO Sue Schade and really enjoyed her recent blog post on meeting norms. Sue is currently doing interim IT work at the University of Vermont Health Network and is getting used to their rules regarding meetings. It sounds like they’re walking the walk and talking the talk on the fabled “50-minute meetings” that I always try to get my clients to adopt. People need time to refresh and readjust between meetings and the back-to-back culture I see with most of my clients doesn’t add to a positive working environment. Their “meeting norms” include providing agendas and meeting materials in advance with the invitation, and allowing people to bypass meetings that don’t have an agenda. They’ve also adopted meeting-free Fridays to allow people to focus on work and individual interactions.

It takes time for organizations to move to this kind of structure, but when they do, productivity typically increases and frustration decreases. You no longer see harried people scurrying from meeting to meeting or zoning out because they’re overextended.

I missed this newsy tidbit last week, but AHIMA and CHIME went to Capitol Hill to lobby to eliminate the 20-year prohibition of federal funding for a unique patient identifier. Representatives urged the Senate to support the Foster-Kelly House amendment to the Departments of Labor, Health and Human Services, and Education, and Related Appropriations Act of 2020. Removal of the ban would allow HHS to fund efforts towards a unique identifier. After working with patients from around the world who are used to having to provide a national health card prior to receiving services, it certainly seems like it might be an improvement over the matching algorithms we have that use name, DOB, address, and phone numbers.

JAMA Network Open confirms what we all already know: US adults are becoming more sedentary. In a cross sectional study looking at more than 27,000 adults, the time spent on sedentary behaviors increased from 5.7 to 6.4 hours per day in 2015 and 2016.

I wish they were here to collect data at the World Scout Jamboree, where I’ve walked 71 miles since I arrived. There’s still a few days to go, so that total will continue to increase. We’re seeing lots of tired feet, a bit of athlete’s foot, and plenty of orthopedic injuries as tens of thousands of scouts try to maximize the time they have left at the Jamboree.

Neckerchief trading is in full swing and I was excited to score one from the UK, but I had to trade away my medical neckerchief to get it. The nations of the world are relatively uninterested in sporting “neckers” from the US. Especially prized are neckerchiefs from Brazil and Belgium. Lots of people are interested in the ones from the Swedish contingent, but from what I’ve been told, they only receive one and don’t typically trade them.

We’ve survived our heat wave here in West Virginia and are having some rain showers that have already brought cooler temperatures. The next milestone is the closing show on Thursday night. I get to attend this one since I was working during the first one, and hope they bring back the fleet of 250 drones that swarmed across a 900 x 400 foot of aerial canvas during the first show. Everyone said the effect was outstanding, with attendees’ wristbands lighting up as the drones formed the shape of their home continents.

It’s only a few days until hundreds of buses roll back in to take the scouts to their next adventures. Some toured the US prior to the Jamboree and others plan to tour after. Either way, they (and the nearly 10,000 staff that have supported them) have had the adventure of a lifetime.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/29/19

It’s another beautiful morning in West Virginia and I was able to see the calm before the storm at the aquatics area.

A fresh team from Cerner has arrived to support us through the end of the Jamboree. Working with physicians and nurses from across the country and around the world has been a great experience. The Cerner team has really gotten into the scouting spirit, with custom Cerner badges and pins to trade with the medical teams.

Since we’re partway through the Jamboree, some of the other EHR realities have come into play, including reports that show that some providers aren’t completing their notes as timely as everyone would like. In that regard, it’s not a lot different from a traditional practice. We also had some new providers arrive to help us finish out the week, and I got to spend some time as a super-user helping a subspecialist through his first shift.

It’s been great interacting with providers from around the world. During a cold snap, we learned about manual massage techniques used in Europe to warm hypothermic patients. We also learned about their method for performing CPR vs. how it’s done in the US. We’ve had some good discussions about single payer and government-based healthcare and how rationing does or does not occur in other countries.

The international providers were fascinated by some of our discussions around Meaningful Use and MIPS, when we were talking about the government requirements for providing printed visit summaries. Fortunately, here the only reason we need to provide written summaries is so that the patients know what to do in follow up. I’m glad the EHR offers instructions in multiple languages as well as easy-to-read versions given the fact that we are dealing with teenagers. It’s good since we are treating patients whose parents aren’t here and who are from other countries. I also learned a little more about how our system interoperates with the local hospital when we have to do transfers for patients who need a higher level of care.

Friends at home have asked me what the biggest challenges are with treating an international population. There are some obvious things like spoken language and medications having slightly different names on the world market. One less-obvious thing is how the EHR handles special characters used in many patients’ names. Attendees completed health history forms when they registered for the Jamboree and much of that information has been imported into our EHR. However, many of those characters have been replaced by placeholder characters, which can make it tricky to search for patients if they’re not wearing their ID badge with their registration number.

For the most part, the data that has been flowing into the EHR has been accurate. I understand from talking to one of the back-end IT personnel that it was a big challenge to merge it in from its native data source, but that they were committed to getting it done right.

AT&T has done a phenomenal job with the WiFi capabilities at The Summit, and we’ve had good coverage not only in the medical areas, but also while we roam thousands of acres of program areas. The Scouts are using a variety of social medial platforms, including a game called Novus that allows them to connect with other attendees using a wristband and then see contact information in their Jamboree app. Participants can get prizes for connecting with attendees from different countries and also for visiting various program areas and clicking their Novus devices.

The highlight of the week was Thursday, when all of the program activities — including the zip lines, scuba pools, paddle boarding, and swimming areas — were closed. Participants were encouraged to cook their traditional foods and wear traditional dress, and walking through the camp was like taking a trip around the world. I sampled spicy chicken from Trinidad and Tobago, fizzies from South Africa, Inca Cola from Peru, a German sausage stew, and some delightful sugared pancakes from The Netherlands (they reminded me a lot of beignets in New Orleans, proving again that that world is perhaps a bit smaller than we think).

We were able to partake of traditional Peruvian dance, a sauna from Finland, salted licorice from Sweden, tea and steamed pudding UK-style, and both Marmite and Vegemite. Then it was back to work to see patients who had a bit too much sun and perhaps more variety of foods than they were used to.

I only have a handful of shifts left before I head home. I have to say it’s been quite an experience. There have been challenges in delivering care in a rugged environment and also in standing up multiple health centers that are only going to run for a couple of weeks. The EHR has performed like a champ, but I suspect I might be a little more tolerant than some of the other users I hear grumbling from time to time. You’d hear that at any healthcare facility, however.

Tomorrow I have a rare day off and am going to spend it whitewater rafting in the New River Gorge. Rumor has it that the trip we’re going on has a couple of Class 4 and Class 5 rapids. I’m a little nervous about that since I’m used to water that’s a little more flat and navigated in a canoe, but I’m open to the adventure.

If you could visit any country in the world, where would you go and why? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/25/19

The Federal Communications Commission (FCC) approved a proposal creating a $100 million fund for telehealth, targeted to reach low-income and rural Americans. The so-called Connected Care Pilot Program would help providers offset the costs of broadband service to help low-income patients and veterans access telehealth services. The fund is designed to cover a percentage of internet connectivity costs for organizations agreeing to participate in the pilot. The FCC is receiving public comments on the proposal, which is specifically designed to increase use of remote patient monitoring services and virtual care.

Earlier this month, National Public Radio did a story on the role of telehealth in rural communities. Profiled services include California Medicaid’s video counseling sessions, which can dramatically reduce the backlog for behavioral health services. A recent NPR poll showed that 25% of rural Americans have used some kind of telehealth services in the last few years. Although some rural telehealth models include patients visiting a local clinic to confer with a subspecialist hundreds of miles away, others rely on the patient having broadband connectivity at home, which is a limiting factor for up to 20% of rural residents. The piece also illustrates the often undocumented costs of rural patients having to drive hours for care – missed work, hotel stays, and childcare. Payment for certain telehealth services continues to be an issue, so we’ll have to see if the funding can keep up with the demand.

I was disappointed to see that a US judge struck down a recent rule requiring pharmaceutical manufacturers to disclose drug pricing in their TV advertisements. The rule would have required wholesale pricing data to be included for consumers to better understand the relative costs of therapies being promoted. Not surprisingly, drugmakers Merck, Eli Lilly, and Amgen were behind the challenge. Although I agree with the ruling that the Department of Health and Human Services doesn’t have the authority to force manufacturers to disclose pricing, I’d love to see Congress make this a reality. Some of the most commonly advertised medications have prices from $500 to $17,000 per month, which shocks patients when they come in and we have to explain why we’re not going to prescribe them.

After spending time in the hospital with a relative, I was glad to see this article on alarm fatigue in hospitals. Clinicians, psychologists, musicians, and designers are working to make alarms that are less jarring and more helpful. Alarms have been linked to patient confusion and staff anxiety as it is difficult to know whether alarms are legitimate or false alarms. I was surprised by the statistic that from 2005 to 2008, more than 500 US patients had adverse outcomes (including death) from alarms that were ignored, silenced, or otherwise mismanaged. A working group aims to develop an alarm standard with more pleasant alerts than those currently in place from the International Electrotechnical Commission.

Random statistics of the week:

• The global EHR market hit $31 billion in 2018.
• Growth was up 6% from a market of $29.7 billion the previous year.
• First-year medical residents spend 43% of their time interacting with EHRs
• There are over 700 companies in the EHR market
• EHR mergers and acquisitions have increased 15% over the past year

Allscripts and Microsoft have agreed to team up to promote EHR data sharing. Users of Microsoft HealthVault will be able to use the Allscripts FollowMyHealth patient portal to move EHR data to family and home care teams. HealthVault will be retired on November 20, 2019 and users can move their data any time before then. The FollowMyHealth app is available for both IOS and Android.

If you haven’t completed the transition to the new Medicare Beneficiary Identifier, you’re running out of time. After January 1, 2020, claims with old patient identifiers will be rejected. As of the week ending July 5, providers submitted 76% of all fee-for-service claims with the new MBI.

Since I’m spending the rest of this month with the young people of the world, I was interested to see these statistics on worldwide vaccination rates. The World Health Organization notes that more than one in 10 children – or 20 million worldwide – missed out last year on vaccines against life-threatening but preventable diseases such as measles, tetanus, and diphtheria. Vaccination rates are slowing in poor countries or those with ongoing conflict, resulting in a loss of the herd immunity effect where high vaccination rates provide protection for those who might not be vaccinated. Measles is booming in the US due to under-vaccination and worldwide cases topped 350,000 last year.

For those of you interested about my medical volunteer adventures, there have been some ups and downs with the deployment of the EHR. They broke out a ton of laptops, a forest of extension cords (fire marshal beware), and some clinical scenarios, but 20+ care teams were using the same scenarios and  test patients, so we were documenting all over each other. Kudos for drawing those scenarios from real patients at the last National Scout Jamboree in 2017, but they weren’t delivered to us in a facility-specific, way but rather to all the medical people together. My team spent a long time figuring out how to order x-rays only, to be told later in the day by our chief medical officer that we would not be ordering x-rays since only the downstream facilities did that — we just needed to put it in our discharge instructions. In defense of the Cerner team, they were also working with a multicultural, multinational team that hadn’t yet been assigned to care teams, so in some ways we were a little off kilter ourselves.

Still, we made it through, and Cerner was kind enough to come to our facility and offer some refresher training to make sure we are ready for when the world arrived. I am having a great time getting to know my team – nurses from Sweden, Austria, and the Netherlands along with nursing students from West Virginia University. They’ve been teaching me about healthcare in their countries and we’ve all been teaching the student nurses (and the Cerner trainers) about the scouting movement. The latter were especially impressed at our ability to quiet a room full of contentious physicians simply by raising three fingers into the air. I doubt they’ll be able to use that on their next training audience.

Some of the Cerner team members are serious scouters and I had the chance to talk in depth with one of them today. She’s staffed several prior Jamborees and knows how they work and how to talk physicians off the edge, which apparently has happened a couple of times this week. As much as the Scout motto is “Be Prepared,” some of the physicians didn’t do their advance training and are a little behind the eight ball. The trainers are staying in tents and hoofing it to work every day just like we are, so we’re starting to build a bit more camaraderie.

It was impressive to see what had to be more than 1,000 charter busses pour into the Jamboree over a 36-hour period and watching open fields turn into seas of tents. Our patient panel includes more than 7,700 youth from 75 countries. I worked my first night shift last night after the opening ceremony, which brought a sea of 50,000 people scattering back into six basecamps. I rendered some postoperative care to a patient whose visit to the US involved the removal of his appendix on the way to the Jamboree, which although within my scope of practice, was not something I expected to see. We also had a brush with hypothermia this morning as overnight temps dipped into the 40s F. I learned that the M997A3 Tactical Humvee Ambulance is not only rugged but warm and the National Guard was a godsend for my patient at 5:30 a.m.

After my post-call nap, I hit a couple of continuing education sessions on orthopedic trauma and wilderness first aid / evacuation.

Today marks my 900th post for HIStalk and I appreciate all of your support over the years. Thank you for sharing my adventures both inside and outside of the hospital.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/22/19

Around the World with Dr. Jayne

This week, I embarked upon the adventure of a lifetime, as I had the opportunity to serve on the medical staff at the 24th World Scout Jamboree.

With somewhere upwards of 43,000 Scouts and leaders from around the world converging on West Virginia, there is a definite need for medical staff. I applied to serve way back in November 2017 and was selected in January 2018, so the anticipation has been building. Although the event is being held on a Boy Scouts of America property, the US is co-hosting with scout organizations from Canada and Mexico. The last time a World Scout Jamboree was held in the US was in 1967, so it’s truly a once-in a lifetime opportunity.

There are scouts from over 150 countries attending, so it will be a patient base like I’ve never cared for. Talk about not knowing what might walk through the door! In addition to caring for illness and injury that occurs as a result of the Jamboree itself (heat exhaustion, sunburn, blisters, insect bites, sprains, strains, cuts, dehydration, and more) there’s the need to provide care for all manner of chronic conditions in both young people and their adult leaders as well as the thousands of staffers that are there to support them.

I’ve never practiced in a tent before. And speaking of tents, I’ll be spending the next two and a half weeks living in one. Everything I need had to be packed in a single duffel, which was an adventure in itself.

There are 500 volunteers assigned to the Jamboree Medical Services team, including physicians, nurses, paramedics, EMTs, behavioral health personnel, dentists, optometrists, and more. A full-service Jamboree Health Center has diagnostics including x-ray, but I will be embedded with the participants in one of the “base camp” medical centers that runs 24 hours a day.

Because the World Jamboree is being held at the site of the two most recent US National Scout Jamborees, the State of West Virginia had the licensure and credentialing process down to a fine science. It was just like completing a hospital credentialing process (minus the letters of recommendation) and each of us receives a temporary “Summit Health Services Permit” allowing us to practice only at the Summit Bechtel Family National Scout Reserve and only during the specified Jamboree Dates.

The health services team isn’t just made of US volunteers. On my bus from the Charlotte airport, I met up with several international medical volunteers as well as those from other disciplines that are more “scouty” than healthcare – shooting sports, aquatics, aerial sports, climbing, and mountain biking. There is also an entire logistics team, including food service (thank goodness they’re already on site, ready to feed a horde of hungry scouters) including registration, transportation (routine and emergency), security, communications, and pretty much any other services you can think of for a small city. In fact, for 12 days, we’ll be the second largest city in West Virginia.

In addition to preparing for somewhere in the vicinity of 10 miles of walking each day, not to mention heat and humidity, the health services team has also been preparing for the challenges of delivering thousands of “new patient” visits each day. Other than a brief health history that may or not be available electronically, we’ll be starting most of our visits from scratch.

The EHR is from Cerner, and many of us have been through training (including super user training in Kansas City) as well as running drills in a sandbox environment prior to arrival. We are on site for several days prior to the arrival of the participants, completing training, setting up the medical facilities, and conducting drills. West Virginia is very concerned about the potential for a measles outbreak in this environment, with volunteers assigned to measles response plans based on their personal immunity status.

As clinicians, our EHR training focused entirely around the actual patient care piece. However, my clinical informatics brain had numerous questions about the potential for interoperability, sending records back to participants’ home care teams, caring for an international population, and more. I reached out to Cerner for an interview a couple of months ago, but they declined to make anyone available. There will be Cerner employees on site, so if you’re one of them and want to talk anonymously off the record, drop me an email. They say The Summit is going to be the most wired camp in the world for the next couple of weeks, so I won’t have to be off the grid. And to Cerner proper – if you change your mind, I’m still interested in chatting.

I’m actually looking forward to the EHR experience. Not only does the Cerner version we are using have content embedded from Intelligent Medical Objects (IMO),  we’re not worried about coding or billing, so we can actually focus on taking care of patients. Although patient privacy will be upheld consistent with the dictates of professionalism, there are no covered entities involved, so no HIPAA.

I’m also looking forward to the clinical experience. Since most of the patients are Scouts or their leaders, we might be able to assume that some level of personal first aid or home care has been applied prior to their arrival on our tent’s doorstep. I’m sure the folks staffing the “Thrasher Mountain” program area might see a little different case mix than I’ll see at the base camp, but you never know.

I’m excited to work with health professionals from different countries and different models of care, and of course to meet young movers and shakers from around the world. This is a time for people to learn that they are more alike than they are different, and to come together as citizens of the world rather than of their own nations. We’ll be living under the principles of Scouting as established more than 100 years ago and hopefully returning home with a renewed desire to make the world a better place.

I’ll be filling our readers in on the challenges of practicing in this unique environment as well as my experiences with healthcare IT in the field. And if you happen to be here, I’ll be the blonde in the khaki shirt.

Have you been on a medical volunteer trip? Was it high or low tech? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/18/19

I took a little break from work and writing this week due to an unexpected illness in the family. As much as hospitals focus on their subspecialty capabilities, imaging, and technology, the one thing that stood out during our stay was the importance of compassion and high-quality nursing care. The care provided by both regular floor nurses and the hospice team contributed more to our patient and family experience than anything else the facility had to offer.

I’m glad we were at a community hospital with a patient-centric focus. The staff was kind enough to allow us to spill over into a conference room for take-out meals after the cafeteria closed and kept us fortified with drinks and snacks. I think we were the only hospice family on the nursing unit and it’s a fairly low-census time of the year for many facilities, but it was good to know they were looking out for ways to make us comfortable.

Being “the doctor in the family” puts you in a unique position. I was grateful that the nurses were willing to let me eyeball the orders so I could help put the rest of the family at ease about the plan of care. It was also an opportunity to think back on the patients in similar situations that I’ve cared for over the years and whether my efforts matched up to their families’ needs. Hospice care delivered in-hospital has come a long way from having the on-call intern make it up as they go along.

I appreciate the work done in the field to ensure patients have maximum comfort and that families have the support they need, especially when things don’t quite go as anticipated. I also appreciate the role of social media in the modern grief process. Although it’s easy to make fun of memes and the silliness we see out there, nothing beats being able to contact dozens of people quickly without having to call each one. Memories can be shared collectively rather than individually and overall it impacted positively on the experience.

Now I’m back home and back to the healthcare IT grindstone. A reader sent me this article about a skill for Amazon Alexa that allows patients in the UK to receive answers based on information vetted by the National Health Service. The NHS hopes this will reduce backlogs for patients who need advice on uncomplicated conditions. I spent some time learning about care in the NHS firsthand and enjoy the British commentary on issues. The author notes that “maybe, just maybe, this could also save some from going down an online rabbit hole into rubbish health forums.” I had forgotten how much I love the word “rubbish,” especially in that context, and will look for ways to use it going forward.

As expected, privacy and civil liberties groups are against it despite Amazon’s assurances that confidentiality will be maintained. The Health Service has set up a special division, NHSX, tasked with increasing the use of technologies, including electronic prescribing, artificial intelligence applications for radiology, and more. Clinicians want to make sure that research occurs to ensure the quality of the advice, and also that accessibility factors like cost are factored in for new approaches. My experience with Brits and healthcare is that they tend to be quite matter-of-fact and that is borne out in the comments on the piece: “Take paracetamol (basically Tylenol), and if you’re not better or dead in 48 hours, contact your doctor.”

New data has been added to the Physician Compare website reflecting data for the 2017 Quality Payment Program. We didn’t participate, so I don’t have any data, but a quick glance at several colleagues who did participate shows no data for them either. I’m not sure why they’re not displaying, but it adds to concerns about data validity and whether patients are really going to use the metrics to select their physicians. Most of the Medicare patients in my area select their primary care physicians based on who is accepting new patients and whether they can even get an appointment rather than being concerned about quality data that may or may not be accurate.

Speaking of data, here’s some that might be useful. Research presented at the American Diabetes Association annual meeting looked at whether individualized text messages sent to diabetic patients with recent emergency visits can improve glucose control, medication adherence, and ED utilization. The authors identified the ED as a place where high-risk patients can be engaged when they are in crisis and might be willing to make changes to improve their health. The goal is to use texting to bridge between the urgent issue and stable long-term care. The original intervention was one way and patients received two messages daily for six months. The control group received the same information in a pamphlet. The program has now been commercialized and a second module targeting family and caregiver supports is available. Although small at 166 patients, a study on that approach will be completed later this year.

The beginning of July marks the time when newly-minted physicians begin their careers as hospital interns. Internship and residency has changed quite a bit since I was in those trenches, mostly through the implementation of work hour reforms and the addition of dedicated days off, caps on admissions, and extra layers of supervision. A new study published in BMJ shows that “exposure of physicians to work hour reforms during their residency was not associated with statistically significant differences in 30-day mortality, 30-day readmissions, or inpatient spending.” The authors compared rates during 2000-2006 and 2007-2012 to reach their conclusions. The study looked at 485,000 admissions and compared outcomes for patients cared for by physicians in their first year of independent practice vs. patients cared for by physicians in their tenth year of independent practice during the same-year cohorts. The study is somewhat limited by its observational construction and limitation to internal medicine physicians, but it’s a good start.

For those of you in the EHR implementation trenches, how is your July going? Are the new house officers “getting it” or are you ready to pull your hair out? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/11/19

I’ve been snarky about some of the things coming out of the White House in the last few years, but I can get behind the newly-announced effort to reduce the impact of end-stage kidney disease over the next two decades.

For a long time, there has been a push towards center-based dialysis and all the challenges that come with the procedure – patients making multiple trips to a facility each week, ongoing disability, and generally feeling crummy in between treatments. The goal is to move patients towards in-home dialysis, which can be liberating for patients who are good candidates for home-based treatment. I’ve been on cruises where patients do their own dialysis at night and participate in activities during the day without missing a beat. Not to mention that home dialysis is cheaper. Having worked with some of the dialysis giants in the past, I’m not sad to see them lose a little market share.

Medicare spends more than $110 billion on kidney care, which represents one-fifth of all fee-for-service payments under the program. The new directive includes payment models to encourage early treatment of kidney disease and advocation for home dialysis. It also includes mechanisms to refine organ procurement and a public awareness campaign to help patients realize the benefits of early diagnosis of kidney disease.

With a well-configured EHR system, it’s fairly easy to identify patients with or at risk for chronic kidney disease and start doing outreach. However, operational and clinical structures are needed to make the disease a priority among everything else practices are doing. It will be some time before all the rules and policies are in place to support this initiative, but it’s nice to see something positive coming to the healthcare community.

Last week the US government issued a new Request for Information as part of the Patients Over Paperwork initiative. The RFI seeks additional public input on regulatory, policy, practice, and procedural changes that would reduce administrative burdens for providers, patients, and families. The comment period will be open through August 12.

It looks like the feds are dragging their feet however on the Primary Care First initiative, where an application was promised in spring 2019 for a January 2020 start. I haven’t seen the Request for Application document yet and the website still shows it as pending, which is frustrating for practices and providers who were actually interested in the program. I’m guessing CMS had a bit of a premature launch on this one, based on the lack of deliverables and their ongoing rearrangement of webinars on various topics (the one scheduled for Wednesday, July 10 has been moved to July 24). Many of us are waiting for the application, which was promised to clarify various details. If you know anything about when it’s coming, leave a comment so the rest of us can play along.

My adventures in telehealth continue, so I was excited to see this article about mothers being power users of virtual medical consultation apps. I see a ton of ads on Facebook and other media targeting my demographic, and the vendors agree that women are a major audience. My brick-and-mortar practice has considered telemedicine, but hasn’t moved forward.

It would have been a great option to have the other day, when one of my provider colleagues called me to see if she could put herself on my schedule for a rash. Even though we had a phone conversation, she sent me a picture of the rash, and we discussed a plan of care, we couldn’t bill for the visit due to limitations in the EHR. Ultimately one of our medical directors took charge of the situation and got my colleague the care she needed, but in reality we were just a few clicks away from a virtual visit.

The telehealth segment is targeted to exceed $64 billion in the next six years, so it’s not surprising they are targeting family health decision-makers. Mothers make nearly 80% of the decisions around their family’s healthcare, according to a 2017 Kaiser Family Foundation study. It seems that most of the services being offered at present time are acute / urgent in nature but the smart money is on providers that are building out the true capability for virtual primary care.

I know I don’t want to go to a physician office as a patient unless I have to. Many are still highly inefficient and can suck the wind out of your sails for an entire day. I had an exception with a recent visit to the optometrist, where my physician was running late and they proactively offered a visit with another provider to keep me on schedule. I declined because I like my optometrist and he is worth the wait, but it was a nice gesture, and if I hadn’t had the day off, I might have taken the offer.

I still run into a fair number of providers who don’t understand the Security Risk Assessment that is required under HIPAA. There are some great (and reasonably priced) vendors out there who deliver white glove service, but practices still opt to go it alone or try to skip it entirely. ONC and the HHS Office for Civil Rights are holding a training session for their homegrown Security Risk Assessment (SRA) Tool. It is designed for small to medium-sized providers to help them conduct their internal security risk assessment. A webinar will be held July 17 for providers and staff to better understand the tool. They will also have the opportunity to ask questions and provide feedback. I haven’t seen the tool lately – a previous version hadn’t been updated in some time – so I hope it’s beneficial.

Speaking of ONC, the public comments on the Trusted Exchange Framework and Common Agreement (TEFCA) are now available. ONC received more than 100 comments from a variety of stakeholders, including professional societies, providers, health information technology vendors, hospitals, public health organizations, payers, patient advocates, and health information exchanges. Most of the comments are what you would expect, although there are some curveballs among the submissions. I’m still struggling to understand what one individual from Tashkent was trying to say and how it related to TEFCA. Patient Stuart Morgan is “very much against these efforts to make my medical records more readily accessible by other parties that I have no control over.” He goes on to mention the difficulties in trying to correct inaccurate records, including “information that is totally false, entered by a doctor or other medical worker who appears to have a grudge against me.”

What was surprising about the list is the number of vendors who didn’t submit comments. Perhaps in their opinion TEFCA is perfect the way it is? Or maybe they were unaware it was going on? As a provider, I would be concerned if my vendor didn’t send a comment.

What do you think about TEFCA? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/8/19

I was off the grid this week doing some volunteer work. Since I sent Mr. H my posts in advance, I failed to notice that Independence Day in the US fell on Thursday, so Happy Belated Birthday, USA.

One of my volunteer partners is a US history teacher, who asked some very pointed questions that provoked discussion on how treasonous the revolutionaries were, Not just the so-called Founding Fathers, but the Founding Mothers who stood behind them. Cokie Roberts wrote a book using their correspondence as source material. I read it a few years ago and was glad to learn of women like Deborah Read Franklin, who held things together on the home front so their husbands, sons, and brothers could help shape a nation.

After being away, the first place I stopped on the internet was of course HIStalk, where I was ecstatic to learn that Samuel Shem is at it again with “Man’s 4th Best Hospital.” I still recommend “The House of God” to all of my clinical scribes who aspire to attend medical school or physician assistant school. Although many things have changed since 1978, there are still a number that are the same.

Clinicians are still faced with rampant absurdity on a daily basis and often develop some off-the-wall coping skills in an effort to not descend into madness themselves. I thought about it yesterday when multiple patients had issues where I was forced to offer less-effective care just because of their insurance coverage. Of course, it’s always the patient’s decision to pay out of pocket for the more effective option, but seeing that choice made is a rarity. I can’t wait to see his treatment of the topic of electronic health records and the crazy world in which we are forced to operate.

I’m glad Mr. H mentioned it. Even as a HIStalk insider, I still marvel at his ability to distill the news of the day and help us keep up even after we’ve deliberately avoided the internet.

As is usual after I’ve been away, my inbox was full of messages clamoring for my attention. It’s increasingly difficult to sort the wheat from the chaff. Although I have all kinds of rules in operation, I still struggle to find the important items at times.

An educational activity on “Managing Common Summer Health Conditions” from the American Medical Association caught my attention, although I was somewhat surprised that they grouped tick-borne illnesses and sexually transmitted syphilis in the same educational session. I was shaking my head, but then I came up with a couple of snarky “Summer of Love” jokes, so maybe they do indeed belong together.

I’m working with a client right now who is trying to optimize their EHR to help them improve a variety of clinical quality metrics. Despite efforts for federal organizations to corral these measures into a meaningful cohort that is supported across multiple groups of payers, they are tracking subtly different metrics for different audiences. They’ve worked with various payer medical directors and others trying to find a resolution, but everyone seems entrenched in their own specific benchmarks. They use the excuse that they need to keep the metrics the same across all their providers, but since most of the providers in this particular metropolitan statistical area are contracted with the same payers, it just means that everyone has to suffer with a hodgepodge of requirements.

I understand where the subtle differences come from. Perhaps they see particular trends in their patient populations, or perhaps they’re chasing outcomes noted in recent literature. If it’s the latter, I was excited to see a recent article in the Journal of Internal Medicine that looks at one of the healthcare cost kings – diabetes – and how it develops in older adults, which are going to be a large segment of our patients moving forward. The Swedish National Study on Aging and Care looked at nearly 5,000 patients, following them for 12 years. Most of the older adults with pre-diabetes either remained stable or returned to a normal blood sugar range, with blood pressure and weight management contributing to the latter.

It’s unclear whether these results from Swedish patients can be translated to other populations and racial / ethnic groups. If they can, it may support a change in how we think about these patients. If the results aren’t generalizable to different populations, it may argue for a more precision approach to disease management that current EHRs haven’t even thought of. I’m pretty sure that the addition of clinical guidelines that are based on sub-populations would make many physicians’ heads explode. On the other hand, that’s right where we’re headed with precision medicine, although we don’t yet have all the systems and financial support in place to support that type of approach.

As a physician, I’d like nothing more than to be able to input factors about my patient, their family history, their genetic makeup, etc. into my EHR and have it tell me exactly what screenings they need and when they need them. As issues arise, it could also advise on whether they need aggressive treatment or conservative treatment. Right now we spend money treating some diseases that from a statistical standpoint aren’t necessarily fatal and/or don’t cause a lot of disability; but since they’re there, we feel obligated to beat them into submission. What if we could pick and choose the patients who would most benefit from treatment?

Delivering those kinds of recommendations requires a tremendous amount of data. I’m not apologizing for the patient safety issues or workflow horrors found in many EHRs. However, it does improve one’s mood to remember the reasons (other than facilitating billing and keeping up with government regulations) why EHRs might be a good thing. I’m looking forward to the day I can have a system capture my spoken office visit through a console on the wall (come on, Nuance, refine that technology for primary care already) and adaptively learn what I’m going to recommend for a patient based on my past practices. I’m eager for the arrival of seamless data interchange so that clinicians can have all of a patient’s data at their fingertips. Until then, I’ll keep plugging away with the EHR and working from the sidelines to make the technology better for providers.

What benefits of technology are most exciting to you? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/4/19

It’s that time of year when CMS releases updates to ICD-10 codes for the coming fiscal year. The files are now available and go into effect starting October 1. For those of you used to receiving a General Equivalence Mapping update along with your new codes, you’re out of luck. CMS previously announced that they would only update the GEMs files for three years after the implementation of ICD-10. It’s hard to believe it’s been that long since we kissed ICD-9 goodbye. I wonder how many clinicians are hoping they’ll be long-retired before ICD-11 comes around? Most World Health Organization member states are slated to start using it in 2022, but I’m betting it will be a long time before it makes it to the US.

Kaiser Health News reports some interesting data from the Food and Drug Administration database containing medical device malfunctions and injuries. Manufacturers sent data to this “hidden” database via Alternative Summary Reports rather than to the public FDA database used by researchers and patients. Top tidbits include: blood glucose meters had more incident reports (2.4 million) than any other device, with the majority of them being manufactured by a former subsidiary of Johnson & Johnson; dental implants comprised 2.1 million reports; 176 deaths were reported through the non-public workflow, including those related to insulin pumps, pacemakers, and ventilators; surgical stapler malfunctions numbered 66,000 in the hidden database vs. 84 in the public database; and breast implants accounted for nearly half a million reports. Despite the visibility of this issue, the FDA has replaced the alternative “hidden” reporting process with a new Voluntary Summary Reporting Program that may be just as hard to track as the previous Alternative Summary reports.

In the Virtual Assistant arms race, CNBC reports that Google Assistant does a better job than Alexa or Siri in helping patients with medications, although studies still indicate that voice assistants aren’t ready for prime time where health or medical data is at stake. The study looked at queries regarding the 50 most commonly prescribed medications and whether users received accurate information when asking a device to “Tell me about” a particular drug. Google Assistant identified 92% of brand name drugs and 84% of generics, with Siri scoring 58% and 51%, respectively. Alexa trailed at 55% and 46%.

It’s time to cut the cat videos. Nearly all of us have fallen down the rabbit hole that is YouTube and found ourselves minutes (or hours) later having watched video after video. (My personal favorite begins with the “Nope Ropes, Sneks, & Danger Noodles” offering  from Lucidchart and devolves from there.) New data shows that the number of people spending two hours a day or more watching TV or videos is high – 62% of children, 59% of teens, 59% of non-retired adults, and 84% of seniors. This inactivity places us at risk for obesity, chronic disease, and overall mortality. I made a pact with myself to only watch Netflix while I’m on the treadmill, so thanks to “Halt and Catch Fire” for helping me meet this month’s fitness goals.

I literally could not contain my excitement when I stumbled across this option in Office 365 that allows me to display a third time zone. I’ve been wishing for that enhancement for a long time and it will make my life so much easier. Not that I don’t know how to figure out time zones, but it’s a nice check and balance to be able to confirm it on the screen. We’ve all been the victim of wrong time zone meetings and I certainly don’t want to be a perpetrator. Now if they could just come up with a calendar widget for scheduling recurring meetings on different days of the week (a la GroupWise circa 2011) my scheduling desires would be complete.

A recent Journal of the American Medical Association article introduces the concept of a TACo, or Targeted Automatic e-Consultation. The TACo aims to bridge the gap between traditional sub-specialist consultations, which are time-consuming, and so-called “curbside” or informal consultations. Traditional consults are problematic because they require analysis of the chart, examination of the patient, and detailed documentation; subspecialists who are in short supply at some facilities can run themselves ragged trying to complete all their consultations. Curbsides are informal and might be limited by the information available along with lack of an examination; usually the recommendations aren’t documented in the chart because there isn’t a physician-patient relationship. Unlike other consultations which require a physician or care team member to initiate the consult, the TACo would be automatically triggered by certain laboratory or examination findings as they are documented in the chart. The receiving subspecialist would have access to a “customized view of the pertinent information” for virtual review and could then suggest focused advice, a formal consultation, or neither.

The approach is under evaluation by the diabetes service at the University of California San Francisco. The EHR identifies patients meeting certain criteria and presents key chart elements to the diabetes sub-specialist. Management suggestions are documented and most reviews take less than five minutes. The team published data showing improvement in diabetes management through reduction in both high and low glucose events. The outcomes have allowed the organization to provide continued funding to support the time spent in review by the subspecialists. They plan to expand the TACo concept to other services including hematology, metabolic diseases, and infectious diseases with an eye to common conditions that may be managed incorrectly and can be triggered by objective data mined from the EHR. The authors note that “if TACos prove to be beneficial, a convincing argument could be made for payers to reimburse them, just as care coordination and telemedicine ultimately became eligible for reimbursement.” Even if they were billable, organizations would still need to expend resources in managing the technology required to support the approach.

Is your organization considering something along the lines of a TACo, or is it just lunch food? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/1/19

One of the challenges we have in healthcare IT is figuring out whether different technologies bring an adequate return on investment. This can be particularly challenging when the expenditure falls to one team’s budget (such as information technology) but the cost savings occurs elsewhere (such as the central scheduling department).

Organizations use a variety of cost transfer mechanisms to try to sort this out, but often the calculations fail to fully represent the true work needed to deploy a new solution, especially on the part of the end users. This becomes even more complicated when the solution is a combination of technical tools and operational changes, such as might be required for a practice to advance through recognition as a Patient-Centered Medical Home.

As we move into value-based care, it will be more important for practices to understand the costs and benefits of new models of care. To be honest, many independent practices are not well equipped to try to figure this out. I was excited to see that NCQA has engaged with Milliman’s actuarial team to offer guidance on how practices can calculate return on investment for that type of clinical transformation project.

The NCQA white paper is publicly available, and even if you’re not knee-deep in one of these projects, it provides background for greater understanding of what it takes to re-engineer a practice. The hypothetic practice in the paper represents a 10-physician primary care practice with approximately 20,000 commercially-insured patients. The model concluded that there would be an increase in revenue, although it varied from 2% to 20% depending on payment models.

Although 2% still represents a positive return on investment, I’m not sure how many practices would be willing to embark on wholesale modification of how they do business for that small of a gain. Many practices pursuing Patient-Centered Medical Home recognition do so for other reasons, including the belief that it’s the right thing to do and/or that they will be able to provide better or higher quality care for their patients.

As with any calculation of this kind, NCQA points out that this is a hypothetical practice and our mileage may vary based on the actual characteristics of our practices. To further the effort, Milliman helped develop guidance for practices to develop a pro forma to calculate their own return on investment data. The guidance is clear on the fact that the numbers will vary based on:

• Practice size and location.
• Payer mix and payer models.
• Medical complexity of the patient population.
• Degree of change needed to practice processes, procedures, and reporting to align with PCMH.
• Ability of the practice to meet quality targets.
• PCMH program rules.

I frequently work with practices that are considering whether they will pursue recognition as a Patient-Centered Medical Home. Often, they jump straight to trying to figure out whether their EHR supports PCMH or whether their technology vendor has programs that will make it easier. Some vendors support a subset of PCMH standards but not others – a host of organizations have developed recognition programs, including HCQA, The Joint Commission, the Accreditation Association for Ambulatory Health Care, and the Utilization Review Accreditation Committee, not to mention other homegrown programs developed by practice networks, health systems, and payers. I find that educating practices on the differences between the different programs is a good first step beyond asking whether the EHR can support it. Often the burdens of a particular program will be a deal-breaker for a practice.

Practices must next consider whether they have the capacity to change, which often translates to whether the physicians have the capacity to change. If physicians are employed, this might be mandated by the organization, but in physician partnerships, it can be daunting if some partners want to move forward but others don’t. It doesn’t matter what the return on investment might be if you can’t get everyone on board. I’ve worked with physicians who aren’t able to delegate and don’t trust their support staff, so that makes the idea of team-based care a non-starter.

The white paper does a nice job listing out the costs during both the investment phase,  when it is figuring out how to manage the transformation, and during the maintenance phase, when they’re trying to sustain the change. They include the amount attributable to lost physician visits for the clinical champion along with time spent by a PCMH manager, other clinicians who lose time to huddles and quality improvement activities, care coordinators, etc.

In reality, many practices don’t allocate dedicated time for physicians to work on PCMH or other initiatives. Instead, they expect the team to perform these tasks on top of their usual workload, under the guise of “other duties as assigned.” I suppose under that model the return on investment becomes even greater from a purely monetary standpoint, although the job satisfaction element may be on the decline.

It goes on to note that contractual requirements for PCMH recognition are the strongest ways to drive provider behavior. The authors discuss the issue of multiple contracts with differing payers and the need to try to align those requirements in order to work efficiently and to not have to meet multiple PCMH standards. It provides a good list of questions for CEOs and CFOs to consider when contemplating a move to one of these care models.

Overall, I think the white paper provides an excellent tutorial for practices considering a change. There are definitions of key terms and explanations of the process along with the actual guidance for doing the calculations. Whether you’re on the tech side or the patient-facing side, it’s a nice primer to better understand what your organization might be getting into when they start talking about Patient-Centered Medical Home or other care models such as Comprehensive Primary Care Plus (CPC+) or Primary Care First, which are based on PCMH. Knowledge is power and I will definitely be using this tool as a conversation starter when working with practices who want to embark upon clinical transformation.

Has your organization found success under the Patient-Centered Medical Home Model? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/27/19

There’s been good uptake on the new Medicare cards since they began rolling out last year. Nearly 75% of claims are being submitted with the new Medicare Beneficiary Identifier as of last week. Both institutional and professional claims are at the top end of the range, with durable medical equipment vendors lagging around 64%. Our office staff has a number of word tracks they’re using to counsel patients on the need to get the new numbers on file and most of the patients seem to be aware of the transition.

I’ve got an Echo Dot on my desk. Although I use it mostly for alarms, reminders, and shopping lists, I haven’t really explored many of Alexa’s skills or other abilities. I was curious about an article that discussed a tool to detect cardiac arrest by monitoring so-called “agonal respirations.”

This gasping-type breathing pattern is fairly common after cardiac arrest. Half of cardiac arrests occur outside the hospital and more than 90% of them die unless someone calls 911 or starts CPR. Researchers at the University of Washington School of Medicine reviewed 911 recordings from confirmed cardiac arrests and trained a machine learning model to identify appropriate respiratory patterns using Alexa, the iPhone 5s, and the Samsung Galaxy S4. The tool identified 97% of agonal breathing events from six meters away. They also used audio recordings from sleep labs and private residences to train the model on the normal range of sleep noises, resulting in a false-positive rate of 0.2%. The authors hope to use other 911 databases to further hone the tool, which might be useful not only in homes, but in elder care facilities and on hospital units that might not have intensive monitoring capabilities.

Fortune recently reported on record venture capital funding for digital health companies. The all-time record of $14.6 billion in 2018 is up from a mere $1.1 billion in 2011. I think I’m most excited about devices that will help in the virtual visit space, including home-use cameras to look at ear drums or to capture good photos of the back of a patient’s throat. I’m less excited about home EKGs, knowing that even in the office it’s sometimes difficult to obtain a good tracing. Healthcare continues to appear to many investors as a bottomless pit of money and demand even as payers try to ratchet down the expenditures. One thing is for sure, the next couple of years will not be dull.

Speaking of telehealth, reader Randy Bak had some questions about my recent experiences: “On your telemedicine foray, please update when you accumulate a run of data. My big hesitation: how much expectation is there for unnecessary prescribing (particularly of antibiotics) from patients, and more importantly, from management? Also curious how the telemedicine doctor is equipped to follow a case for a couple of days when needed, for clinical, liability, and professional satisfaction purposes.”

Since I’m relatively new to telehealth and am only a sample of one, I reached out to several colleagues who provide telehealth services to get their opinions.

The first colleague I spoke with is part of a telehealth pilot program through her employer, which is the outpatient physician organization for a large integrated health system. Their telehealth offering really doesn’t have any clinical guidelines, and since the providers are delivering services to their own practice’s panel of patients, there aren’t any specific requirements for prescribing or not prescribing. It sounds like the physicians are basically doing the work that used to be done by their triage nurses, but are charging for it as a virtual visit rather than giving it away for free.  Antibiotic usage data becomes part of their overall practice data, although she reports that patient expectations for prescriptions are high. Follow up is easy since they’re document the visits in the EHR and can always task their clinical support staff to contact the patient, or reach out to the patient directly.

The second colleague I reached out to works as an independent contractor for a nationwide telehealth group, but in a specialist capacity as a dermatologist. He spends most of his telehealth time doing virtual visits, where the patient is in the office with their primary care provider, often at a rural health clinic. It’s more of a second opinion consultation service rather than a direct-to-consumer model. Being specialized, the expectations are different than what you bring up in your question. He doesn’t believe his group is doing very much with data and doesn’t receive any clinical scorecards. Even though that’s not the flavor of telehealth you were asking about, I figured it was worth finding out. He said there isn’t much follow up.

The third person I spoke with works for a large organization that primarily markets their services to employers as an employee benefit and to payers as a way to reduce emergency department expenditures. As expected when a payer is footing the bill, the focus is on delivering the right level of care and keeping a tight leash on scope of practice issues. He receives regular clinical scorecards that include metrics such as patient satisfaction and timeliness of visits, but also on antibiotic stewardship and appropriate referrals to a higher level of care.

In hearing about some of the specific grading, I was truly impressed. The providers are coached on how to have those difficult conversations about the fact that they’re not going to give everyone a Z-pack, and it frankly sounds like they are keeping a tighter leash on inappropriate prescribing than my brick-and-mortar practice is doing. Management sounds supportive and provides clinical guidelines summarizing the evidence. Providers who want to follow up with patients have some messaging capabilities through a patient portal, but it sounds like it might not be too widely used as most of their virtual visits are for self-limited illnesses.

My personal experience is more along the lines of the latter, with encouragement to practice good evidence-based care and not to wildly prescribe antibiotics just because patients ask for them. My favorite chief complaint from my brick-and-mortar urgent care is, “I’ve got 20 people coming for Thanksgiving, I can’t possibly be sick, and Dr. X always gives me a Z-pack.” Needless to say, Dr. X was no longer employed at my organization and I wasn’t going to give antibiotics to a patient whose only symptom was a feared complaint, so I wasn’t very popular that day.

Now that there is parity in reimbursement for telehealth and face-to-face services in many states, I suspect the payers will be active in forcing telehealth providers to gather data and demonstrate their quality, or at least prove that they’re not being capricious. With many players in the market, vendors are going to be looking for ways to differentiate themselves. Additionally, as my small sample showed, there are many different varieties of telemedicine out there and direct-to-consumer is just one piece of the pie.

Have you ever badgered a physician into giving antibiotics even though you knew they didn’t want to? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/24/19

I wrote last month about my experience with a dysfunctional registration process for imaging at Big Medical Center. I was sharing the story recently with a colleague who uses Epic at another institution and was gratified to learn that they have a much more seamless process. My Epic Jedi set up a demo for me, showing me all the bells and whistles on the system at his early adopter facility.

Like other vendors, Epic is working hard to get its clients up on the latest and greatest code. It’s certainly easier for support to have fewer versions live in the field. Several vendors are also starting to ship their upgrades with new functionality enabled, under the premise that clients won’t bother to turn the features off. Compared to what I saw with my Jedi, it sounds like Big Medical Center is either on an older version of Epic that doesn’t have some of the nice features for online check-in or has somehow failed to enable them.

My colleague and I discussed our shared belief that patients take more time when completing pre-visit activities at home. This might be because they can look up information they don’t know for sure, or call a family member, or because they’re not flustered because there is a clipboard standing in the way between them and their doctor.

We also talked about the release of results. My study results came by mail in 10 days, which was the same interval for their appearance on the patient portal. The results had been signed off by the physician within 24 hours of the study, so I’m not sure why the organization chooses to embargo them for another week when it’s a test that patients are allowed to have without a physician order. The old attitudes about protecting patients from their own results need to go by the wayside. He did show me some nice functionality for trending of patient-generated data that might be encouraging for physicians who are worried about incorporating that data into the chart.

The majority of my urgent care patients seem to be using MyChart, so we talked about some available features where patients can email their continuity of care documents to other providers via Direct. It seemed like it would be more nearly seamless than the “break the glass” functionality offered by Share Everywhere, with the added benefit of being able to actually consume and utilize the data not just view it.

We also talked about Epic’s Happy Together functionality that allows patients to see aggregated data across multiple instances of the system. For patients in my area where there are multiple competing health systems, it should be useful. It was a great conversation and gave me some ideas to help patients better manage their data when I see them in the urgent care.

Patients are embracing technology and are using apps during the office visit, whether it’s to look up a medication at the pharmacy or to show me lab results. According to recent data, more than half of all physicians are offering patients mobile apps for processes like appointment scheduling or retrieval of lab results. I know I would much rather interact with my providers’ offices through my phone or a laptop rather than have to call them and get stuck in the land of voicemail.

That assumes that the practice has an efficient online process as well, unlike the five days it took my ophthalmologist to respond to my appointment request through the patient portal. I can’t fault them too much, though. Just having an online appointment request is light years ahead of what some practices are offering or what they decide to “allow” patients to use. Plenty of clients decide not to embrace new features, which is why vendors are now in the position of having to “force” clients to use new features. I’m sure they’re tired of getting a black eye from patients and users when the real fault is in the client’s decision-making layer.

Vendors are getting better at serving up smaller, more frequent upgrades and updates that don’t overwhelm users or bring down the system for days at a time (with a few notable exceptions). This seems to make client leaders more comfortable with the process. In theory, as long as quality remains stable and the new features deliver what they promised, clients will be more willing to apply and use new code.

On the other hand, if an upgrade package is a dud (or worse, if it breaks any existing workflows) the vendor will have to work hard to regain its credibility. I’ve been on the losing end of a bad upgrade before and it wasn’t pretty, although it did lead to lifelong friendships made with the developers who spent weeks onsite keeping us in business. Without those relationships, it’s sometimes hard for customers to trust their vendors, which might be one reason that clients don’t like to enable new functionality that they don’t consider critical. Another issue is the fact that organizations are trying to deliver many initiatives at the same time, and when push comes to shove, something just has to be cut from the implementation and training schedule.

Hopefully over time vendors and their clients will be able to perfect that balance between delivering frequent releases of high quality while avoiding upgrade fatigue. We’re in a relative lull from a regulatory requirement standpoint, so it’s certainly a good time to catch up on new releases.

As a physician in a practice that seems a bit laggard, I have to confess I’m often jealous of early adopter sites that are embracing the bells and whistles. My organization is focused on expansion of new sites and growth of practice volumes, so it’s not surprising that they don’t want to spend a lot of time on technology projects. We’re also onboarding dozens of new staffers and a handful of new providers, so at the moment, stability seems to be the watchword.

How often does your organization take upgrades? Do you find them frictionless or irritating? Leave a comment or email me.

Email Dr. Jayne.