Curbside Consult with Dr. Jayne 11/25/19

Clinician burnout continues to be a hot topic, so this American Academy of Family Physicians article caught my eye. It looks at the possibility that being able to better address the social needs of patients might reduce the possibility of burnout. I’m not surprised by this – physicians and other clinicians are trained to do their best to address all their patients’ issues, whether they are purely biological, psychosocial, or somewhere in between.

In many residency programs, we have all kinds of ancillary providers that help us do these things. My training program had PhD pharmacists, social workers, diabetic educators, dieticians, and psychologists to which we could refer our patients for a variety of services. Need a patient to receive education on anticoagulant drugs, their long-term monitoring, and the need for dietary changes? Check. Want to enroll a patient in smoking cessation clinic? Check. Newly diabetic patient who needs supplies and training? You got it. Patient who needs help navigating Medicaid enrollment or applying for supplemental nutrition assistance? Done.

When I headed out into practice, however, I was on my own to try to deliver many of these services. Even referring to subspecialists often became a battle that was made worse depending on the patient’s insurance coverage, ultimately resulting in the patient not receiving needed services.

At one point in time early in my career, only one of the city’s practices was taking new neurology patients who had Medicaid, which made the wait to see a consultant nearly a year long. This led to primary care physicians trying to do what they could to manage complex neurological issues that they weren’t trained to handle. You don’t have to ponder to hard to see where that could cause stress and burnout.

Not much has changed in the last couple of decades, although at times it’s a little easier to get patients in to see subspecialists, or maybe I’ve just built up enough friendships to be able to call in more favors. There are other more complex issues that we can’t solve through a phone call to a friend or classmate. Maybe it’s housing issues, transportation issues, or food insecurity. These are the types of issues that the study mentioned was looking at, along with whether inability to address patients’ social needs was a contributing factor to primary care clinician burnout. The authors went on to note that increasing services in the practice to address social needs tended to reduce burnout and improve clinician morale.

The study noted that participating physicians were concerned about how addressing social needs would impact their workflow. I’m curious about how those physicians went about adding services or training staff to address social needs and how that impacted not only the workflow, but the practice bottom line. Theoretically, some of the new care models, such as Comprehensive Primary Care Plus or Primary Care First, should provide additional funds to cover these additional services. However, it’s still not going to be enough.

A friend’s EHR has the ability to link out to transportation resources for patients, such as Uber. However, the practice has to pay for the transportation, leading to an ongoing internal conflict about which patients should receive those services. Independent physicians can make these decisions locally, but employed physicians are often subject to the whims of their owners, and productivity and case mix determines which physicians (and therefore patients) receive additional support and which don’t.

On the technology side of healthcare, we face similar difficult decisions. We have limited budgets and requests for more projects than we could possibly fund or staff. At one of my large health system clients, decisions often impact broad swaths of patients. Are we going to focus on systems to improve labor and delivery workflows this year, or fund the initiatives that the heart failure program has requested? How many patients would benefit from either approach? What about the community diabetes screening initiative, or the dental care mobile van? Should we look just at patient count, or go further to see how interventions would impact people over time?

At one point, money earmarked for optimization of frontline nursing workflows was diverted to cover consulting services needed to complete a required regulatory upgrade. This led to a relative revolt by some of the staff involved in advocating for projects that didn’t get the nod.

The emotions felt by some of the IT staff were no different than what was probably felt by the physicians in the study. In particular, those whose projects weren’t taken forward felt disenfranchised and often had a profound sense of loss. Some of those whose projects succeeded had something akin to survivor’s guilt as they watched other worthy initiatives wither. It also engendered a sense of fear and concern, with people wondering whether their project would be the next one to be defunded or otherwise not fully implemented. Sure, projects get canceled in every industry, but I think my colleagues in healthcare IT feel it more acutely because they know their work has the direct ability to impact patients’ lives.

The emotions become even more acute when you are working for organizations that are sitting on billions of dollars of resources, but may not be spending as much on patient care as they should. The marble lobby of the tertiary referral hospital is particularly luxurious (and the fountain is pretty darned impressive), but neither of those see patients. They don’t make up for the negative emotions felt by the clinical staff that empties the exam room trash cans every other day because the housekeeping budget was cut and services are only provided on even days. The luxury boxes at the ballpark and the over-the-top billboards are also a visible reminder of the money the health system is willing to spend on non-patient-care activities.

As the old adage goes, you have to spend money to make money, but somehow that spending is becoming less palatable when healthcare is on the line and patients are literally dying due to lack of basic interventions.

It’s easy to see why people in healthcare are burned out, no matter where you work or what your role is. Our inability to meet our patients’ needs is only a proximal cause, with many root causes beneath. I’m cautiously optimistic about new models of care that might help alleviate suffering or reduce gaps in care, but it may take years to determine how successful they really are. In the meantime, we need to support each other and continue to try to come up with innovative ideas to solve some of the most difficult problems humanity faces.

What would make you feel less burned out? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/21/19

I wrote a few weeks ago about my adventures with flu vaccines and how the charges are handled by my insurance. Kaiser Health News dug into the phenomenon this week, going farther in noting the differences in costs among one payer’s own employees. The payments ranged from $32 in Washington, DC to $85 in Sacramento.

This illustrates the results of negotiations between payers and providers, the madness of which leads to the need for entire segments of the healthcare IT industry to keep up with it. Anyone who has worked with practice management or revenue cycle systems has experienced the phenomenon and the layers of code needed to wrangle it, and I salute you. It remains to be seen whether the government will be successful in forcing providers and payers to disclose this information publicly. Efforts to do so will likely be in the courts for some time.

I’ve been doing some behind-the-scenes work on clinical guidelines, and recently tried to track down data on a drug that is supposed to be available as a generic that we couldn’t find. The Wall Street Journal made note of the problem this week as well, observing that multiple factors keep those drugs from making their way into patients’ hands. It’s a disappointing phenomenon, but an interesting read.

In other drug news, a serious outbreak in pigs is likely to cause a shortage of the critically necessary blood-thinning drug heparin. African swine fever is on the march, killing nearly 25% of the world’s pig population, particularly in China, where the majority of heparin is produced. The World Health Organization is recommending that governments stockpile heparin, so be on the lookout for extra alerts and clinical decision support needs in EHRs.

Mr. H already reported on the AMA’s call for inclusive EHRs for transgender patients, but I want to throw in my two cents. Several years ago, I worked on some focus groups with a vendor who was trying to get this done. It can be complex, because there are many variables to document, including legal status, legal name, preferred name, surgical status, hormonal status, anatomical status, genetic status, etc. The vendor was focused and had several physician advocates who would continually explain to business analysts and developers why this was important. They ultimately they got the job done.

I’ve heard rumblings from other sources that this is a big lift for a small number of patients. But without the ability to document key clinical data and use it at the point of care, it results in a subpopulation being treated differently and in ways that might actually be counter to good clinical care.

The AMA also adopted a policy to promote education on health issues related to sexual orientation and gender identity for medical students and residents. I didn’t know much about the transgender population until medical school, where I had a professor who was public about their transition. It was a tremendous opportunity for learning and understanding and made a great impact on me, ultimately leading to me having a good number of transgender patients in my practice. I’m fully supportive of efforts to make EHRs inclusive for everyone, whether it’s based on differences in gender, age, race, ethnicity, or any other characteristic that may influence health. To be the most effective, we need to be able to meet our patients “where they are” and this is one way to work towards that goal.

Measure-palooza: The American Heart Association (AHA) and the American College of Cardiology (ACC) have released updated Clinical Performance and Quality Measures for adult patients with hypertension. The new report includes 22 new measures and expands focus from blood pressure measurement to care delivery systems and approaches. Their goal is to look beyond individual provider performance.

That’s great in theory, but it’s not how most other clinical quality measures programs work. It may also add workflows to EHRs, resulting in poor usability that will be blamed on the EHR rather than an explosion of guidelines and measures. There are also mismatches in the quality numbers used by AHA/ACC, CMS, and the National Committee for Quality Assurance. I’m sure EHR requirements writers are wringing their hands at this point. The report also includes a focus on digital health, including remote monitoring for hypertensive patients.

Maybe the EHR isn’t so bad: A recent study conducted at the University of Pennsylvania Health System showed an increase in orders for certain cancer screening tests when a “nudge” alerted users from the EHR. The alerts were targeted to medical assistants who created the orders for licensed clinicians to review and hopefully discuss with their patients. Despite the increased orders, there were not significant changes in the number of patients who completed the recommended screenings within a year-long time frame.

I recently worked with a practice that raffled off a big-screen television to patients who completed home colorectal cancer screening kits within a specified time frame. I’m not sure how legal it was, but it was certainly effective at motivating patients to submit a sample.

Kudos to the clinical informatics team at Oregon Health & Sciences University, who recently implemented a drug pricing comparison tool within Epic. It factors in data points such as co-pays, deductibles, and the need for prior authorization. The information has been available to dispensing pharmacists for a long time, but moving it to the point of care is key. It doesn’t matter how effective a drug is when it’s never going to be taken because the patient can’t afford it.

My clinical practice offers cash-only prescriptions at the point of care, which simplifies things for patients who know what their co-pays are (most of our drugs are either $15 or $30). However, many of our patients have no idea what their co-pay might be and are unable to make an informed decision. Having a tool like this at the bedside would be a benefit for the rare cases when we have to prescribe more costly drugs.

Flu season is getting well underway, particularly in the South. My practice is running low on vaccine and expects to be out by the end of the month. If you’re thinking about getting vaccinated but haven’t done it yet, time is of the essence. Three children have already died this season. If you still have plenty of vaccine, maybe an outreach campaign using those expensive population health tools is a good idea.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/18/19

A former colleague of mine reached out recently, frustrated by a physician in his organization who is demanding that clinical decision support features in some applications be turned off. He was asking for tips to help counter the argument.

It turns out that the physician in question believes that if the application presents you with guidelines that you ignore, you are liable. Fortunately, it’s a pretty easy counterargument. If a guideline exists and you ignore it, regardless of whether it’s in your application, you are liable. In many cases, if a guideline exists and you don’t know about it but a physician would be reasonably expected to know about it, you are liable.

The whole point of clinical decision support is to bring those guidelines  — which you may or may not be familiar with or incorporating into your practice — to the point of care so you can react to them. Of course, this assumes that the clinical decision support in question is accurate and appropriate.

Since crossing into the realm of clinical informatics more than a decade ago, my clinical activities have been limited. This is partly by choice (realizing that I can’t do justice to the traditional primary care paradigm when practicing on a very limited schedule) and partly due to workforce economics. Unless you’re a physician administrator at an academic institution or your CMIO situation includes a specific carve-out for clinical care, it’s unlikely that someone wants to hire you to see patients one day a week.

Since the scope of my practice is relatively limited, one might think it would be easier to keep up with the knowledge base, but it’s still very challenging. I remember a couple of years ago when one widely-used antibiotic fell out of favor for a particular condition. It was a good six months before one of my go-to journals reviewed the primary article and another three months before I actually read it, meaning that I was prescribing a less-than effective medication for a good nine months before I knew any better. What if there could have been clinical decision support at the point of care, which would have alerted me to the fact that the antibiotic selected was no longer recommended for the diagnosis I had entered?

Conventional wisdom is that medical knowledge doubles approximately every eight years. Physicians graduate from medical school and are then trained in residency by physicians who might have been in practice anywhere between one and 60 years. One would expect great variability in those teaching physicians’ knowledge bases as well, which is another plus for clinical decision support.

There are a number of pros and cons around whether clinical decision support should be regulated and how that might impact shifting liability. Others voice concerns about whether this will lead to so-called cookbook medicine or encourage mental laziness among physicians. Regardless of the strength of decision support or whether it’s regulated, physicians still have a duty to determine whether the recommended course of care makes sense or if there are any concerns about the recommendations.

Physicians need to understand where the recommendations found in clinical decision support systems originate. Are they from well-known guideline producers, such as the US Preventive Services Task Force, the Centers for Disease Control and Prevention, the American Cancer Society, or the American College of Obstetricians and Gynecologists? Are they just automated and exposed guidelines that are doing simple checks against diagnosis codes, SNOMED codes, LOINC codes, and medication codes, or are they using artificial intelligence or machine learning?

Rand Corporation blogged about this issue way back in 2012, and the thoughts around it haven’t changed significantly. Straightforward clinical decision support, such as drug-drug interaction checking is great, but alerts have to be at the right level for a physician to highlight the most critical cases while preventing alert fatigue. Users who click through alerts without reading or digesting them will continue to be at risk for increased liability in the case of a poor outcome.

Oregon Health & Sciences University’s Clinical Informatics Wiki covers this issue as well. It notes that, “As long as 25 years ago it was realized that availability of computerized medical databases would likely erode the local or community standard of care.”

Changes to the community standard of care might not be a bad thing. Many of us believe patients should be treated the same whether they live in the city versus rural areas and regardless of differences in income or demographics. However, there have been pockets of the country where physicians were held to a different standard for a variety of reasons.

Take the PSA test for prostate cancer risk. At a time when the US Preventive Services Task Force was specifically recommending against testing (in part because of the number of false positive tests leading to unnecessary biopsies and other downstream consequences) my community performed them across the board because a leading urology researcher at a local academic institution drove expert opinion that they should be done. If you didn’t do a PSA and a patient turned out to have cancer, you were in for a bumpy ride.

OHSU notes correctly that state laws have lagged behind current technology and that the scope of the legal medical record varies from state to state. I’ve worked in organizations that swear that the final signed chart note in the EHR is the legal record, and others who said, “everything in the database is the legal record.” I’ve worked with attorneys going down SQL rabbit holes trying to figure out what a physician knew and when based on various timestamps, user IDs, and other metadata.

The wiki authors also note the need to better understand how clinical decision support systems influence clinician judgment and how their use might impact those who are “not adept at system-user interfaces.” They also note the relative lack of case law in the area, but go on to say that, “Physicians are likely to be held responsible for the appropriate use and application of clinical decision support systems and should have a working knowledge of the purpose, design, and decision rules of the specific decision support systems they use.”

For some EHRs and related systems, this is easier than others. I’ve seen systems where you can quickly drill down to the specific recommendations and understand why a flag was thrown. I’ve also seen systems where alerts don’t seem to make sense and searches of well-known physician resources fail to shed light on the subject (nor do simple Google searches, so a double dead end). The bottom line remains, however, that regardless of the volume of information out there, physicians are expected to know the answers and do the right thing for their patients.

How does your organization address liability for clinical decisions, whether human-created or prompted by technology? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/14/19

Many EHR aficionados view discrete data as the holy grail of information, but a recent article in the Journal of the American Medical Informatics Association looked specifically at data from unstructured clinical notes. The authors found that such “real world data” was more accurate for use with algorithms to predict coronary artery disease when compared to structured data.

The study looked at data from a six-year time span, gathering a specified set of clinical concepts through structured data gathered from standard query techniques as well as AI-driven analysis of unstructured data. The authors used data from over 10,000 clinical notes and looked at language around existing coronary artery disease, diabetes, and other clinical predictors of coronary artery disease. Food for thought for all those folks who are uncertain about the role that narrative documentation may continue to play as we move forward.

I was glad to see a recent ONC blog that noted that nearly one-third of hospitals can access prescription drug monitoring program (PDMP) data from within the EHR. However, it seems like that number should be much higher if we really want to move the needle on inappropriate prescribing of opioids. If providers aren’t viewing data from within the EHR, that means they have to access a separate system, which in itself adds a barrier to use. The piece didn’t mention rates of integration for ambulatory EHRs, which is where a lot of opioid prescribing happens.

Nearly all states have PDMP registries, with only Missouri lagging behind. (Interestingly, that state was one of the last to have a statewide immunization registry, which makes it look a bit like public health isn’t a priority for the legislators.)  I rarely prescribe opioids, and when I do, it’s usually for 10 or fewer pills, but I still access the PDMP whenever my suspicions are raised about a particular patient. Usually the PDMP confirms my impression, leading to a very direct conversation with the patient.

This hit my radar at the same time as a communication from the American Academy of Family Physicians about its recent vaccine-themed letter to the US Department of Health and Human Services. The letter urges that EHR vendors not create financial burdens for physicians trying to connect to state immunization registries and called on HHS to “hold information technology vendors accountable for creating a national standardized, easily accessible, accurate, robust immunization information system.” It also called for universal payments for vaccinations, which makes sense after my recent experience which I’ll call “A Tale of Two Vaccines.”

One member of my family received their vaccination at their primary physician office. The explanation of benefits statement lists a charge, an adjustment, a payment to the physician, and a patient responsibility of zero since the entire amount was applied to “well care.” I received my vaccination at my clinical employer. Although it’s required as a condition of employment, they bill it to insurance and then absorb any non-covered portion. My explanation of benefits lists a charge, an adjustment, and no payment to the physician since the place of service was “urgent care” and the entire amount was applied to my deductible. If I hadn’t been an employee, I would have paid the entire cost.

Insurance companies should either pay for a vaccine or not, regardless of the place of service, as long as the same CPT codes are being used for billing. Hundreds of patients receive their vaccines from my clinic because we’re fast, friendly, and accessible. I hope they’re not receiving the same rude billing surprises that I did.

I’m skeptical about a new Facebook Preventive Health tool that is supposed to help empower people to seek out vaccines and other preventive services. They plan to use age and gender to identify target populations. My first concern at reading that is that perhaps they don’t understand the difference between sex and gender and how those contribute to the equation. Hopefully that was a lapse on the reporter’s part, since the official Facebook web page notes age and sex as the demographics it’s monitoring.

The official page also notes that it is referring patients to Federally Qualified Health Centers with its “find locations near me” for patients to get checkups and to the HealthMap Vaccine Finder for vaccines. It goes on to say that it “doesn’t verify locations on these lists and the lists may have inaccuracies.”

The feature is available only on the mobile Facebook app and doesn’t give specific sources for all of its recommendations. It did say that a mammogram was recommended for my age and sex and it should be yearly, citing the American Cancer Society as the source. There was no readily visible source for flu vaccination, blood pressure testing, diabetes screening, cholesterol screening, or cervical cancer screening, although they could be found by selecting a details arrow.

It also recommended I have an annual stool blood test for colorectal cancer screening, which is not in harmony with the US Preventive Services Task Force recommendations for my sub-50 age group. It went on to say that “test kits are free with most insurance plans” and I can guarantee that it is not free with my insurance, which covers only what is recommended by the USPSFT. The American Cancer Society (which Facebook cites as its colorectal cancer screening reference) even says clearly that insurers are not required to cover screening for individuals under 50 years of age. Those kinds of discussions will not be enjoyed by physicians when patients roll in with “authoritative” information from Facebook.

The Federal Communications Commission’s Intergovernmental Advisory Committee issued a recommendation last week regarding “State, Local, Tribal, and Territorial Regulatory and Other Barriers and Incentives to Telemedicine.” Not surprisingly, the major issues they cite include broadband access and a patchwork of laws and regulations that impede adoption. Looking at the broadband issue, redundancy is an issue for facility-based telehealth programs.

The report recommends that live video with appropriate image and audio quality be available so providers can accurately assess patients, adding that access to the full patient chart is desirable. They didn’t give much attention to consumer-facing telehealth. They note six policy areas where work needs to happen from a regulatory perspective: reimbursement, licensing, health information exchanges, insurance parity and malpractice overage, privacy-information sharing and HIPAA, and also being able to establish a doctor-patient relationship based on telehealth.

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Curbside Consult with Dr. Jayne 11/11/19

My recent conversation with a local university student about how the US looks at public health efforts got me interested into digging in a little more into a local health system’s work to address social determinants of health. I reached out to a former colleague who is now in a leadership role. He asked to remain off the record, since not all of his views fully align with what he is working on as part of the health system’s efforts. I totally understand having to stay off the radar to keep your job, so I was happy to oblige.

One of the major pushes of the health system has been expanding access to care, whether it’s with a mobile unit to visit areas that don’t have providers or whether it’s creation of school-based clinics. They are finding that even those approaches sometimes aren’t enough.

One of the areas where they set up a school-based clinic has a high absenteeism rate, with girls posting higher numbers than boys. Digging deeper, they found that teen girls sometimes aren’t in school due to lack of access to menstrual products. As someone who has worked with a church group to sew reusable menstrual pad kits for girls in developing nations, this doesn’t seem like something we should be seeing in the US. The clinic set out to solicit donations for menstrual products, and guess what? The absentee numbers went down. It’s a great example of how we need to really understand all the factors that are driving health, education, and wellness.

This approach may resonate with practices who help care for high-risk patients by providing transportation or assist with obtaining housing or groceries. If patients aren’t able to meet their most basic needs, they’re not going to be focused on things higher up the hierarchy, like healthcare and medication.

My colleague said this approach is something he actually struggles with philosophically. Some programs focus on those individual social needs, but don’t look at how you need to go about improving the underlying social and economic situation in communities as a whole. The individually-focused interventions are cheaper than delivering more intense medical interventions for sure, but they don’t assist people who haven’t become patients yet or who aren’t in the healthcare system.

He recounted a recent meeting among community health stakeholders, where they spent nearly two hours debating and defining what they mean when they say “social determinants of health.” The phrase was being thrown around and meant different things to different people, and they felt it was important to get everyone on the same page.

Although I don’t doubt that it was probably a painful meeting, it sounds like it was necessary. As he was telling me the story, it reminded me about how people throw around “pop health” and “population health management” and various permutations that may not mean the same thing depending on who is using the phrases and where they’re coming from.

During one of their community-focused initiatives, they actually had quite a bit of resistance from a small segment of community members. Some felt that the hospital’s participation was a way of trying to “medicalize” issues that community activists want to have a much more social and/or services focus. Instead of heaving the health system lead the charge, they want to see it led by community centers, faith-based organizations, and other community-led groups.

In addition to concerns about medicalization, there were also concerns about the hospital staffers not reflecting the community demographic and the optics of having a primarily Caucasian outreach team working with a community whose makeup is predominantly African-American. That’s something that isn’t always thought about, but may certainly be part of how interventions are received.

Patients and community leaders are also skeptical about value-based care. Some see it as rationing by another name, especially when it’s being primarily led by the medical establishment. Others see it as a way for conglomerate health systems to increase their dominance, which can lead to the erosion of community-focused health services.

My colleague mentioned that he struggles a bit going back and forth between the community outreach projects and the health system’s flagship hospital, where he has an office. The hospital’s lobby looks more like a high-end hotel than a healthcare establishment, and executives regularly divvy up the organization’s luxury box tickets for events at the local stadium. When he sees what might be considered excesses, he immediately thinks of how many social services could be delivered using the money spent.

He also has a hard time wrapping his head around the half billion dollars that has been spent on a recent EHR implementation and associated consulting services when his repeated requests to add a social worker to his team have been rejected. He notes that the EHR project hasn’t been all bad since it has made it easier to obtain and use data about different outreach projects they’ve been doing. It’s been useful for clinical reminders and identifying gaps in care to try to optimize health for individual patients. They’ve also been able to use address data to refine locations for community-based health screenings and vaccination clinics. He notes that has been easier since his request for a 0.5 FTE data analyst position was approved.

Apparently there are some ongoing tensions with the local public health organizations, who feel that competing health systems are more about bringing attention to their facilities than about advocating for essential public health needs such as sanitation, preventive services, and immunizations. The health system is having a retreat in a couple of months to talk about its community health efforts and it will be interesting to check in with him and see if there are any major changes to strategic direction or if the plans remain status quo.

I wonder what that retreat would look like if they invited public health leaders, or better yet, also included representatives from the other major healthcare players in town? Maybe that could lead to a more coordinated effort, but I’m just hypothesizing. I wish there were words to describe the eye-roll that resulted when I made that suggestion.

On a side note, I wanted to say thank you to all our readers who are veterans and also to their families and loved ones. We appreciate your service and your sacrifice.

How does your organization integrate with the local public health infrastructure? Is it working, or are there suggestions you would offer? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/7/19

It’s been a crazy week, with a couple of days of travel being paid back with hundreds of emails in my inbox. Even as I unsubscribe and use filters, it seems like there is always something going on that generates more correspondence than it should (think reply-all apocalypse).

I’d love to sell services around creating an effective email policy to some of the organizations I work with. It seems to be a skill that is sorely needed both in the commercial space and in the volunteer space. I’m getting ready to head out for a week-long trip and am trying to pre-tie loose ends, and predicting what might need to be taken care of in my absence is always a challenging exercise.

The Drug Enforcement Agency is one of the major causes of increased email traffic in my inbox. It seems like my recent renewal has triggered enrollment in a number of mailing lists that have to be individually stamped out like a game of Whack-a-Mole. Some of them have forced me to go through the unsubscribe process twice to get them to stop. The mailing list preferences have names like “Prescribers” and “Prescribers-All” so you don’t know what you’re really unsubscribing. I like to have as little contact with the US Department of Justice as possible, so I hope I have finally gotten things back to where they were prior to my renewal.

Registration is open for the 2020 ONC Annual Meeting, with the theme of “Connecting Policy and Technology: Bringing the EHR to the Patient.” The event will be held in January 2020 in Washington, DC. The published agenda only shows the various time blocks for sessions, with a note that the full agenda is coming soon. Personally, I like to see the agenda before I plunk down money on a conference, but I’m guessing that most of the people who attend the ONC meeting are going to go regardless.

I enjoy attending conferences as a way of learning new things and engaging with people in person, but the cost of many of them poses a barrier. Maybe we should start a “Send Jayne On the Road” conference fund so I could report from around the country and across the globe. Warm locations preferred between November and February, of course.

CMS is plugging information sessions for its new Kidney Care First (KCF) and Comprehensive Kidney Care Contracting (CKCC) Model Options, which are part of the Kidney Care Choices (KCC) model. They are targeted towards nephrologists and dialysis facilities along with accountable care organizations that focus on kidney disease, and build on the Comprehensive End-Stage Renal Disease Care Model structure.

It’s good to see a model with a goal to delay the need for dialysis and encourage transplantation, but the reality is there is still a shortage of kidneys out there. We also need to be spending money to reduce the causes of chronic kidney disease, including diabetes and hypertension.

I recently attended a local health IT event and sat with some students. One of them was from a different country and is in the US pursuing a master’s in public health. His big observation is that public health in the US is far less prominent (and less well-funded) than in his home country, which was a surprise because he had assumed that because the US has “rich resources” that we would have it together.

Public health often gets the short end of the stick. I learned a great deal about public health informatics while working towards my clinical informatics board certification. It’s a fascinating field that has great potential to positively help people.

If you haven’t received your influenza vaccine, there’s still time, but the season is ramping up. Flu season officially began October 1 in the US and roughly two percent of all visits to healthcare providers in the past week were for influenza-like illnesses.

We’re seeing quite a bit of it at our facility, and even though the flu tests may be negative for influenza A or B, if it walks like a duck, quacks like a duck, and has a bill and webbed feet, we’re treating it as such. Louisiana leads the nation at reporting “widespread” flu activity, so make sure you’re prepared if you’re headed to the Big Easy.

Patients are always surprised when I quote flu statistics to them. I receive a weekly virology digest from our medical center’s infectious disease division that shows how many patients were tested and which viruses are prevalent in the community. I want my patients to know that we’re using evidence and data in their care and not just our best guess.

With Google recently announcing the decision to buy Fitbit, I’ve been asked a couple of times what I think about the company’s role in healthcare. A recent CNBC piece quoted Google Health head David Feinberg outlining plans to bring Google search technology to bear against EHRs as well as generally improving health-related searches on Google. Feinberg spoke at the recent HLTH conference and outlined some pretty far out sounding uses for auto-complete in the EHR as well as better enabling surgeons who visit YouTube before operating on patients.

I like my physicians to already have necessary skills before working on me and am not sure I want them watching a video to know what to do before they walk in the room. I just referred a patient to the emergency department this week because she needed a procedure that I haven’t done in 20 years and my physician assistant hadn’t done in 15. Although it was tempting to watch a refresher video and give it a go, that’s not the best care for the patient.

My clinical care recently has been challenging enough, and the root of much of what I have been seeing is our broken and chaotic healthcare system. One morning I saw a patient who had been briefly paralyzed after a fall, but who came to urgent care because he didn’t have insurance and didn’t want to go to the emergency department. The diagnosis was an unstable neck fracture that could have led to more permanent paralysis at any time, and yet he still refused our calling an ambulance to take him to the ED.

The following day, I saw a patient who qualified for Level 1 trauma status after a vehicular-pedestrian hit and run who also came to the urgent care because he didn’t have insurance. He at least consented to the ambulance transfer. The ED physician called me to give follow up and was shocked that patients like that come into the urgent care. We see them all the time, and unfortunately their visit to us just adds another layer of cost to the system. It’s a sad commentary for healthcare in general.

What’s the saddest commentary on healthcare you’ve seen recently? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/4/19

I had the privilege of attending a prestigious medical school, so I’m always on the lookout for articles about our “rivals” doing something that my alma mater’s institutions aren’t. Johns Hopkins recently launched what may be a first: the Center for Psychedelic and Consciousness Research. They received a $17 million donation from a private foundation and four philanthropists, one of whom is Tim Ferriss, author of “The 4-Hour Workweek.”

The center’s director is interested in studying drugs such as LSD and their potential to treat depression, anorexia, substance abuse, and possibly early Alzheimer’s disease. Apparently Hopkins isn’t the only place who wants to be on this cutting edge. Research is also being done at institutions including New York University, Yale University, University of Wisconsin-Madison, University of California, and the University of Alabama at Birmingham. The center’s director expects that federal funding for psychedelics will increase.

In the article, he speaks at length about a typical psilocybin treatment session. It’s about as far from eating magic mushrooms at a party as one can get. Prior to the session, patients spend up to eight hours with the clinical team reviewing their personal and family histories as well as “life circumstances” to build rapport since the drug can make patients feel vulnerable. On the treatment day, patients receive the medication, lie on a couch, wear eye shades, and use headphones to listen to music. They are encouraged to focus their attention inward while two clinical guides monitor them for six to eight hours. Drug effects typically begin after about 30 minutes and peak a few hours later, then gradually resolve. Patients report sensations that range from love and joy to anxiety or panic. Test subjects often feel that they have a redefined sense of self, which can lead to ongoing positive changes in mood and behavior.

The team has studied the compound in patients with cancer who report decreased depression and anxiety. Patients have reported a positive impact on tobacco cessation efforts. I was surprised to hear that a couple of pharmaceutical companies have shown interest in the drug. I suppose it’s not much different from other drug agents where we don’t entirely understand the mechanism of action or how effective it might be, but companies smell profit potential and so they dive in. Psilocybin has been decriminalized in Denver and Oakland, but those cities aren’t entirely representative of the rest of the US as far as potential for future use.

Of course, this topic has little bearing on the world of healthcare IT, other than use of platforms for research and data aggregation, but it was a good diversion from reading about CMS releasing the Final Rule for the 2020 Quality Payment Program.

CMS continues to tweak the recipes for the Merit-based Incentive Payment System (MIPS) along with the Advanced Alternative Payment Models (APMs) under the guise of reducing burden, responding to stakeholder feedback, and better aligning with various legal requirements. I’ve honestly given on up trying to follow all the MIPS details since my practice remains opted out, and most of my clients have hired full-time people to keep up on everything rather than relying on consultants.

Long story short, various performance categories have been re-weighted, thresholds have been increased, and the finish line keeps being moved. CMS is also finalizing its proposal for MIPS Value Pathways, which of course carry the MVP moniker. I’m sure anyone who participates in the program, which starts in 2021, won’t consider themselves most valuable players in the eyes of CMS.

In other random web surfing this weekend, I saw that Amazon and JPMorgan plan to roll out new health insurance plans for their employees for the 2020 year. The new Haven Healthcare plan will include wellness incentives and will be deductible free. Berkshire Hathaway apparently has a similar pilot. The plans will be offered through traditional insurance providers, including Cigna and Aetna, and may vary slightly depending on the state. The plans are supposed to be more clear than other plans as far as what patients have to pay and how co-pays are applied. Patients will receive rewards for meeting health-related goals.

I had the unique opportunity this weekend to deliver an impromptu education session (which I fear may have turned into a little bit of a sermon) about the state of healthcare delivery in the US. We had some unexpected downtime at my clinical gig, so I was doing some reading on value-based care and my staff asked me what it was all about. Since most of them were in high school when Meaningful Use came about, we did a brief tour through the history of US healthcare, the rise of electronic health records, and what life was like back in the dinosaur days before the internet came into being.

Even though several of them are applying to medical school and have been working in various clinical settings for some time, they had shockingly little understanding of how healthcare is financed here, other than knowing that when patients don’t have insurance, things often get dicey. At least one had experience working in a free clinic and had that frame of reference, but for others, it was eye-opening. Many of the jobs done by aspiring medical students are focused tours through the healthcare system. They might be in the emergency department, at a clinic, or volunteering in a medical office. I can’t imagine that many of them are spending time in the local billing office or following around certified professional coders, although maybe they should be.

They left with some homework assignments. Not only books to read, but also to consider watching “Halt and Catch Fire” on Netflix so they can better appreciate the overwhelming assortment of technology that they can choose from every day. If you haven’t seen it, it’s a fictional tour through the early days of the PC industry and the creation of the internet and search engines. I enjoyed it tremendously during my treadmill sessions earlier in the year. I’m currently watching Charité on Netflix, which depicts the prominent Berlin hospital during the 1800s. The series is in German with English subtitles, and I’m enjoying the depictions of famous physicians of the time.

What random tidbits are you thinking about? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/31/19

From Policy Wonk: “Re: Primary Care First. Great job on your review of this disaster of a program. Thanks for going deep on the 100-plus pages!” I attended the PCF application webinar on Wednesday. Although I shouldn’t be surprised, I’m continually baffled by some of the things that happen with these programs. The most recent highlight is that the application requires the applying practice to list the NPI for every provider who has worked in the practice since 2013, even if they are no longer there, are no longer practicing, or are deceased. No concrete reason was given for this despite several people asking about it. I was also surprised by the continued inability of CMS to release slides for its webinars on a real-time basis. The slides had to be done to deliver the webinar, so why not make them available for immediate audience download? Telling interested parties that they’ll just have to keep checking back on the Primary Care First website is a tremendous waste of people’s time. I’d be interested to hear from anyone who actually plans to apply for this program.

Mr. H covered this earlier in the week, but I wanted to put in my two cents about the Walgreens plan to close 40% of its in-store clinics while adding Jenny Craig weight loss services at more than 100 locations in an attempt to boost sales. The Jenny Craig services will include individual consultations along with customized menu planning and meal delivery. As a clinician, I’m not a fan of Jenny Craig. My patients who have tried it have found the weight loss to be unsustainable when they stop purchasing food from the program. The company also hit a nerve with me last year when it announced its intent to add DNA testing to its weight loss plans because “customizing nutrition plans to an individual’s genetic makeup can offer members even greater personalization for weight loss and overall wellness.” 

The reality is that most people who need to manage their weight don’t need super-sexy-sounding gene-driven remedies. They need basic nutrition advice, including how to prepare their own food rather than using higher-cost commercially packaged options. I love the way that the C-suite folks describe these moves, with the Walgreens CEO saying they are focused on creating healthcare destinations around a modern pharmacy. The reality of most Walgreens stores is that the actual pharmacy space is a tiny fraction of the store, with the rest of it being little more than a glorified convenience store.

I’m always on the lookout for cool healthcare tech, so was intrigued to hear about the Hyperfine portable MRI. The device, which is in the prototype state, is small compared to a traditional MRI, about the size of a large wheeled curbside trash can. Although the images aren’t quite the same quality of a standard MRI, there’s no need to magnetically isolate the patient. Hyperfine’s founder Jonathan Rothberg cites the ability to image patients without moving them as another benefit. The unit is slated to be significantly cheaper than existing machines, with a cost of close to $50,000 rather than the millions needed to buy a standard machine and set up a dedicated imaging suite. Rothberg’s previous entrepreneurial experience includes Butterfly Network, a handheld ultrasound that connects to the iPhone. The MRI device is under study in the neurological intensive care unit at Yale University. The company has applied for FDA clearance for brain imaging in adults and children.

St. Louis-based clinical genomics company PierianDx closed a $27M series B funding round this week. The round included ATW Partners and SJF Ventures, with participation from existing investors including Health Catalyst Capital, Inova Health Systems, RTI International, and ARUP Laboratories. The company was founded in 2014 from Washington University in St. Louis and focuses on advancing cancer diagnostics and enabling clinical genomics as the standard of care. The company plans to use the funds to expand current operations and further develop its solutions. For those of you whose memory of Greek mythology is fuzzy, the Pierian Spring was sacred to the muses, and was regarded as a fountain of knowledge that would inspire anyone who drank from it.

From Gong Show Afficionado: “Re: earnings calls. The 10/21 article is phenomenal and I wanted to thank you for taking the time to share it! I used to think a lot about earnings transcripts and coming up with % allocations of speaker (i.e. if CFO is speaking less % of the time or answering less % of the questions quarter over quarter, I would assume a bad thing?) but not tone or word choice, so you got me thinking about it. I’ve bee on the sales side and now that I’m on the other side of sales pitches I have that inescapable feeling of you are lying to me and I know it because I’ve been on your side of the table. It makes decision-making difficult. It would be incredibly powerful to have a sales pitch BS evaluator hooked up to an LED scoreboard that you could have hanging above the conference table during the pitch so the buyer could provide real-time feedback to the seller on how they’re doing. Every time someone mentions their use of a data lake, the scoreboard goes straight to zero.” I’d go further to suggest a trap door that dumps onto a funhouse slide that takes the rep directly to the door and could be triggered by either an overall buzzword count or by a “whammy” button that we could hit when we the sales effort goes off the rails.

Hopefully your Halloween night will be ghoulish but not dangerous. The Journal of the American Medical Association came through this week with a host of Halloween-themed articles sent via email:

• “Spook House Sporotrichosis.” This piece from 1997 highlights the risks of hay bales used as props in haunted houses. Outbreaks of the condition are rare, and the article highlights an outbreak noted in a dermatology practice. Four of the patients had handled hay bales in a haunted house and one visited the house. The causative organism, Sporothrix schenckii, is one of my favorite things to say, so the article caught my eye.
• A more recent piece  focuses on “Pedestrian Fatalities Associated with Halloween in the United States.” It highlights that the relative risk of a fatal pedestrian accident was 43% higher on Halloween compared to control evenings, with the average Halloween leading to four more pedestrian fatalities. That’s a good reminder to wear reflective clothing, use flashlights, and make sure your vision isn’t obscured.

Personally, I plan to spend the evening pairing the occasional Reese’s Peanut Butter Cup with a nice glass of cab.

What’s your favorite Halloween candy? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/28/19

CMS has finally delivered its Request for Application for the Primary Care First program, which had long been promised to arrive in summer of 2019.

Everyone loves an endless summer, except for the people who have been waiting a really long time for the application for a program that was to start in January 2020. Now, applications are due by January 22, 2020 for a program that won’t begin until January 2021. CMS also promises that “in the coming week” it will release a “Statement of Interest” form for prospective payer partners who want to declare their interest in a non-binding fashion. A formal solicitation process for payer partners will then run from December 9 through March 13, 2020. CMS notes that “this timeline will allow payers to clearly assess where there is likely to be high practice participation in Primary Care First, and make an informed decision about regions in which to develop their own aligned approaches as payer partners.”

Continuing with some vague deadlines, CMS notes that the selection process for practices and payers will take place in “Winter-Spring 2020,” which gives them a fairly long runway since summer apparently stretches to October 24 in their universe.

The CMS FAQ document had some interesting tidbits, for those of you who haven’t had a chance to dive into the documentation yet:

• If more than 3,000 practices apply and meet the eligibility criteria, CMS will use a lottery system to select final participants.
• A second round of applications will occur for practices that are participating in the Comprehensive Primary Care Plus (CPC+) program, to begin participation in Primary Care First starting in January 2022.
• Neither Federally Qualified Health Centers or Rural Health Centers are eligible to participate. CMS states this is because the program is designed to test payment reform for traditional fee-for-service payments, where the excluded centers bill under different but distinct rules.
• Participants will have to comply with interoperability requirements that will be spelled out in the Participation Agreement, which is not yet available for review.
• CMS “anticipates that Primary Care First will qualify as an Advanced APM for all give years of the model test.” I’m not sure why they can’t put their nickel down at this point and declare it. I find the “anticipates” language bothersome.
• CMS will be using a modified CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey “to allow for increased response rate and ease of use among beneficiaries.”
• CMS will allow practices to reduce or waive the applicable co-insurance for the flat primary care visit fee, but practices are responsible for assuming these costs. Practices can determine which patients might benefit most from this, such as patients with frequent emergency department visits or hospital admissions. Practices will have to submit an implementation plan for this at a later date.
• Practices can offer other “beneficiary enhancements,” such as transportation to the primary care provider or other follow-up services. Patients can also receive access to remote monitoring technology or nutrition programs such as Weight Watchers. These will be detailed in the Participation Agreement, which again we haven’t seen.
• Additional guidance regarding telehealth will be provided at a later date.

I began to dig into the 102-page Request for Applications document and immediately began to regret it. There are seven possible levels of performance for regional performance bonuses dependent on the practices’ performance relative to a regional reference group. There are also tiers for the Continuous Improvement bonus.

When I reached the part about “Quality Gateways,” which practices have to meet in Year 1 to receive a bonus in Year 2, my eyes began to cross. My vision cleared up, though, when I saw that participants must agree to participate in CMS efforts to evaluate the model, which may include everything from surveys and interviews to site visits and other unspecified activities. Everyone loves agreeing to more site visits, and the part about “unspecified activities” certainly leaves room for uncertainty.

I was glad to see that the appendix does have all of the application questions listed out, since the application itself requires a login. That at least allows practices to make sure they have all their information gathered before they try to key it all in.

At this point in the game, I doubt any of my current practice clients will want to participate, but if any do, I’ll be referring them out to some consulting colleagues who are more specialized in this area than I will ever be. The devil is definitely going to be in the details for practices that go this route, and only they will be able to truly determine whether the proverbial juice is worth the squeeze. My state isn’t one of the ones that has been selected for the program, so I won’t be hearing about it in the physician lounge, that’s for sure. I do have enough colleagues around the country, though, and I hope at least one of them bites so I can share their experience with our HIStalk readers.

Having to wade through all the Primary Care First documents was enough to make me grateful to have back-to-back clinical shifts scheduled. Unfortunately, I saw my first vaping casualty,  a teenage patient whose lung collapsed after he decided to celebrate a recent academic event with some vaping in the high school parking lot. Luckily, he was in the car with a friend who saw him begin to go into distress and brought him for attention right away. The patient went from being reasonably conversant to beginning to turn blue over the course of a few minutes while we were waiting for EMS to arrive.

It was just another day at the office for our team of in-house paramedics, but based on the level of terror his friend experienced ,I doubt either of them will be vaping much in the near future. Due to the acute timeline of the incident, the patient’s parents didn’t arrive at our office until we had already bundled him into the ambulance and sent him on his way. That’s got to be just about one of the worst feelings a parent can have.

The rest of the weekend was largely uneventful, for which I’m grateful.

How did you spend your weekend? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/24/19

I enjoy mentoring students and I am always excited when one of them is admitted to medical school. There is a lot of buzz around the schools that are offering free tuition or that are subsidizing a large amount of tuition, but most people in medicine don’t realize the financial barriers that occur upstream.

My student has to pay a $1,500 deposit in the next two weeks. Although he’s working full time in our office as a clinical tech, that’s a hefty amount of money after he’s already paid for the application process, travel and lodging for interviews, the MCAT exam, test preparation, and of course an undergraduate degree.

This is a timely topic that was recently covered in the New England Journal of Medicine. The article looked beyond the shocking costs to explore how they impact the types of people that apply. Not surprisingly, few applicants come from lower-income households and minorities continue to be underrepresented in the applicant pool.

Some schools are trying to reduce application costs by having students host applicants. Other programs may reduce the cost of the MCAT and applications or offer guaranteed admissions for students at a certain level of performance at affiliated undergraduate institutions. Schools are starting to look at virtual interviews as a way of lowering costs. It’s been suggested that schools should revisit their supplemental “secondary application” processes as a way of increasing the diversity of the applicant pool while reducing the cost burden.

All of us would benefit from a more diverse physician workforce, rather than having a full quarter of applicants coming from households with greater than $250,000 in annual income as the current statistics demonstrate. Still, it illustrates the pressures that clinicians have already been under before they ever enter practice. For those of us that look closely at clinician burnout, these are contributing factors that have already raised the stress game for those who haven’t even begun to stress around government regulations or burdensome technology.

Score one for AI. A recent study by researchers in NYU School of Medicine shows that an AI tool that uses machine learning can identify breast cancer with 90% accuracy. The tool was trained on over a million images and 14 radiologists reviewing 720 images were included in the study. The tool was able to identify “pixel-level changes” in breast tissue, but radiologists were able to use logical reasoning that the AI could not. The authors conclude that AI can augment radiologists.

It remains to be seen whether this can be extrapolated to other data sets and whether it can be brought into clinical practice, but for those of us in high-risk situations, such AI augmentation is welcome. I don’t personally read mammograms, but for those of us in age brackets where eyeglasses start appearing in our pockets, it’s a nice idea to have a set of extra “digital eyes” on radiology images.

I missed this a couple of weeks ago, but apparently Senator Rand Paul has introduced a bill to overturn what he considers the “dangerous provision” of legislation allowing the US to institute a unique patient identifier. He claims his physician creds make him an expert. Clearly he’s not an informaticist and has never had to disentangle the merged records of premature twin siblings Andrea and Andre, that were combined due to a faulty matching algorithm. He cites breaches as another reason. I’m pretty sure most data breaches that would reveal a universal patient ID would also reveal name, address, DOB, phone number, and often SSN, which are the current keys to your data.

Jenn clued me in on this article answering the question of, “What’s the best shoe for the busy physician?” Physicians were surveyed with 255 responses received, including 172 men and 81 women. The idea that shoe choice is important was nearly unanimous, with 40% expressing a fondness for casual shoes or loafers, 29% choosing dress shoes or heels, 20% wearing sneakers, and 11% wearing clogs or similar.

I was initially surprised to see that more younger physicians are choosing dress shoes since that demographic is often accused of being overly casual. However, it would make sense as they have less overall mileage on their feet compared to the rest of us.

According to the article, physicians suffer from flat feet, plantar fasciitis, pain, and bunions. Physicians are sometimes self-conscious about their shoes. One of my mentees started wearing what she considers “ugly” shoes because she had too many patient comments about her “cute” shoes and felt patients weren’t taking her seriously because of her choice of footwear. My personal favorite shoe, pictured above, is the Medimex Plogs line. They’re vented for breathability, have massaging nubs on the footbed, and are also autoclavable, perfect for whatever might be on the floor of a medical environment.

Speaking of people having opinions on how people dress, I was unsurprised to see this report about women at Ernst & Young being coached on how to dress. Even if a fraction of the allegations in the piece are true, it’s a fairly horrifying read. Unfortunately, I continue to see companies who have different expectations for employees based on sex and/or gender, and also those that have no idea what to do with non-binary employees.

I have been in a position where two executives debated another’s competence while making comments about her lack of artificial hair coloring, including comments on how “all that gray makes her look old.” From that conversation, I learned that apparently men with gray hair are distinguished, but women who go natural look old.

I worked for another client that required female employees to wear at least a two-inch heel and skirts, with no slacks allowed. They didn’t last long on my roster. I’ve seen assertive women labeled as “shrill” when their male counterparts are revered as “go-getters” in the last several months, regardless of publicity around discrimination and lack of equity or parity.

I recently attended a retreat hosted at a facility owned by a traditionally male-dominated company that had a large number of female participants. The company has made many public statements about its deliberate actions to increase female participation and empowerment. Interestingly, a visit to the newly created female showers at the athletic facility revealed a urinal in one of the two stalls. At least they created some individual showers rather than the group / open showers I had heard were in the male locker room area, but it’s hard to believe that organizations still think that group showers are OK for anyone in this day and age, regardless of whether they’re separated by sex or gender.

All the restrooms were clearly marked male or female, with no availability of non-gendered, family-friendly, or separate accommodations for those who might need additional assistance even though the facility is open to families. Nothing rolls out the not-so-welcome mat like inadequate restroom facilities, so I wouldn’t be surprised if they continue to encounter challenges in recruiting women or people outside their historical demographic.

Does your company have a corporate dress policy? Is it equitable regardless of sex or gender? What do you think about the current climate? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/21/19

The past week has been entirely too crazy, working on projects for a couple of vendor clients whose offerings are starting to overlap with each other. Everyone is chasing after certain industry buzzwords, and if you can add a feature or two that gets you into a different space where people might be more willing to spend money than your current prospective clients, apparently you go for it.

It’s been challenging for me as it’s hard to keep track of what’s a real feature that is able to be delivered vs. something that is in the works, but only parts of it are actually in the code, especially in an agile development organization. It’s particularly challenging when company leaders talk about features under development as if they are actually part of a general release.

In a startup organization, words are thrown around much more freely than they typically are in publicly traded companies, who sometimes mind their language a bit to stay on the right side of the shareholders. With that in mind, I was excited when a reader clued me in to a recent analysis looking at corporations’ earnings call transcripts in an attempt to determine whether the words used in the calls are harbingers of credit risk. Researchers at Washington University in St. Louis looked at over 132,000 earnings call transcripts and used machine learning methods to create a measure of credit risk. The resulting information informs an algorithm that assesses elements from changes in credit ratings to risk of bankruptcy.

What if you could extrapolate those findings to examine the earnings call transcripts of EHR vendors to create a model that would let you know how much of what they were saying was possibly accurate vs. what might be considered creative accounting? What if you could use proxy words to identify impending layoffs or bad decisions that were about to make your stock drop? Mr. H follows some of the earnings calls much more closely than I do, but I have definitely heard some interesting comments on calls in the past that could be interpreted in a variety of ways:

“Our cash generation capabilities continue to expand our storehouse of dry powder.” I’m not sure using gunpowder as a comparative term is a great idea in this day and age. Does the company want to seem like it’s war-like and on the offense? Or perhaps it’s a commentary on the executive team’s ability to blow up the company by continued poor decision-making?

“Scary.” I recently read an earnings call transcript that used the word three times in a variety of contexts. Could there be something predictive about the state of mind of the people on the call?

“Our team is always impatient to go faster.” That’s the kind of reassuring language end users love hearing from vendors with a track record of under-delivering or overpromising on features. Not to mention that when you’re caring for people’s loved ones, you typically don’t want your primary tools to be fueled by a spirit of impatience.

Those are immediately attention-getting, but I’d be more interested in the subtle comments that show that something is slightly off or that there might be some level of obfuscation going on. One recent call characterized what clearly looked like a cost-cutting layoff as an effort to speed compliance with new regulatory requirements. With a training database of thousands of vendor earnings call transcripts, I bet you could come up with some very interesting themes and potentially useful indicators.

In the next year or so, I have to start thinking seriously about a performance improvement project so that I can complete it and check the box for renewal of my clinical informatics board certification. Maybe I could build a tool that would better enable the HIStalk team to detect language that would be most predictive of a company that might have juicy things for us to write about, or what their odds might be of winding up on the HISsies ballot. I doubt those applications would be approved by the folks at the American Medical Informatics Association, but they would be entertaining.

If I don’t come up with a project soon, I’m going to have to seriously think about letting my certification lapse. The required projects are actually referred to as “Improvement in Medical Practice” projects, and since I don’t actually practice clinical informatics where I practice clinically, that gets a little dicey. My primary clinical employer doesn’t want the physicians to have anything to do with the EHR – there isn’t even an informatics committee. The COO (who is a practicing physician) calls all the shots on whether we’ll implement new features and how they will be shared with the masses. The likelihood of my being granted any ability to query the data or perform any kind of project is exactly zero.

They do allow a diplomate to substitute a 360-degree evaluation project instead, where they survey a half dozen of their colleagues to find an area that needs improvement, then work on it and survey again. That doesn’t exactly work in the consulting model, where I think my clients might be generally appalled if I asked them to spend resources essentially providing job coaching to someone they’re paying as their expert advisor.

Doing these projects as a way to maintain certification is frustrating regardless of your specialty. During a time when I wasn’t practicing clinically, I had to do a mock “hand hygiene” project where I had to manually enter a downloaded data set and then analyze it. The goal was to simulate the paper surveys that my peers were getting from live patients, but I learned exactly zero sitting there and keying in the data. It’s just another hoop that physicians have to jump through to try to stay certified.

That takes me back to the earnings call transcript project. Maybe if I write it as an abstract with enough sexy buzzwords I can sneak it past the evaluators. Sprinkle in some artificial intelligence, machine learning, and blockchain to get the job done.

If any of you other clinical informaticists out there have creative ideas for what a consulting clinical informaticist can do as a project, I owe you a drink at HIMSS.

For the rest of you: what’s the wackiest thing you’ve ever heard in an earnings call transcript? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/17/19

I had occasion recently to talk with a personal liability attorney, fortunately just socially and not professionally. He had some questions for me about the role of artificial intelligence in healthcare. Fortunately, I was able to point him towards a recent editorial in the Journal of the American Medical Association.

The article has a nice summary of the concerns that many in practice have about AI: communicating recommendations without the underlying rationale; poor training data sets used in the development process; and failure to reach an accurate result or recommendation. The JAMA article notes that case law on AI-related liability is lacking, but existing law can be extrapolated to cover these situations.

The authors’ examples support the use of AI as an adjunct to the existing decision-making process in order to prevent additional liability. However, as AI becomes engrained as part of the standard of care, this approach may necessitate more trust in AI systems at the point of care, in order to prevent the physician from making the error of underutilizing technology that could be of benefit. It’s a complicated equation, for sure.

The VA recently announced planned steps to increase data sharing with non-VA providers using the Veterans Health Information Exchange. They’re going to shift the current opt-in protocol to one where opt-out is the norm, so patients no longer have to provide a written release for the VA to share their data electronically. A quote from the VA in one of the articles I read about it states that community providers and organizations must have partnership agreements and be part of the VA’s trusted network to receive VA health information. I hope they meant to say that you have to be part of the network to receive information electronically, unless the VA isn’t covered by HIPAA, which allows providers to share information for Treatment, Payment, and Operations without a specific release.

The HIE plans to share information including: problem list, allergies, medications, vital signs, immunizations, laboratory reports, discharge summaries, medical history, records of physicals, procedure results such as radiology reports, and progress notes. Veterans who don’t want their data shared can still opt out, but they will have to be either all in or all out – previous mechanisms which allowed some data to be shared but not others will no longer be permitted.

Speaking of veterans, telehealth middleware provider Medici has launched “Operation 11/11” to provide no-cost virtual consults to all US veterans on Veterans Day, November 11. Proof of military service is required and participants can pre-register for services from 8 a.m. to 8 p.m. in their time zone on November 11.

Medici is welcoming four military advisors for the initiative and has also partnered with 2nd.MD to provide virtual second opinions for veterans with complex patients. Medici has an interesting model where providers pay to be on the platform and set their own rates for virtual visits. I can imagine it might be compelling for independent physicians, but struggle to see how it plays for the majority of physicians who are in employed situations.

I was intrigued to hear about Black + Decker’s new automated medication management and home health care assistant device, Pria (first covered on HIStalk nearly a year ago). It’s the first foray into healthcare from the people who brought us the Dustbuster. The voice-activated device tracks and schedules up to 28 medication doses along with reminders and timely dispensing. It also allows patients to have access to family members or caregivers using a built-in camera for video calls. It can also enable reminders for drinking water or other key health-related activities. The product is pricey at $600 plus a $10 monthly subscription.

I recently became aware of a club I have no desire to be a member of: telehealth providers who have licenses in all 50 states. Becoming licensed in a handful of states is enough work, so I can’t imagine wanting to have dozens of applications in process. The CNBC piece profiles a couple of telehealth providers who advocate for the approach as a way to treat patients more effectively particularly patients in underserved areas.

Data from the Federation of State Medical Boards indicates the club is pretty small, with only 14 physicians licensed everywhere as of 2018 data, up from six in 2016. The number will likely be higher for 2020 given the overall growth in telehealth. One interviewee notes the cost of procuring 50 licenses is around $90,000. In addition, there are annual fees to maintain them. If providers ever surrender a license, there’s also a process to explain that in future license renewals in other states, so if you’re going to do it, you had better be ready to maintain it. I’ve found telehealth compensation for physicians to be lower than pay rates in brick-and mortar situations. Unless you have the temperament to conduct, complete, and document visits every couple of minutes, I don’t see a lot of physicians opting for this type of practice.

An interesting potential use of artificial intelligence was detailed this week in The Wall Street Journal: prediction of marital arguments. Engineers and psychologists are using speech patterns, physiological data, and acoustic / linguistic information to detect potential conflict. One described use case is sending a text message to a highly stressed individual, warning them of an imminent conflict so they can take action.

The original 2017 study followed 19 Los Angeles couples and tracked data such as heart rate, perspiration, and activity levels. A phone app prompted them to document hourly reports on their feelings and also recorded speech content, pitch, and frequency in taking a three-minute recording every 12 minutes. Researchers were able to detect conflict with nearly 80% accuracy. The original data was gathered during a one-day period, which is a significant limitation along with the size of the sample.

A more recent investigation by the same researchers looked at 87 couples, using speed of speech and intonation to detect conflict. The research sounds promising. I hope they consider the next logical investigation, which would be parent-teenager interactions. I’m sure that would be a target-rich environment for conflict identification. Or, we could install such systems in healthcare IT conference rooms across the country – certainly there’s some conflict there!

What do you think about AI identification of conflict? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/14/19

Most of the scribes I work with are either applying to or have been admitted to medical school and are trying to save up money as well as learn about clinical practice. It’s fun to work with them because they’re eager to learn. I enjoy teaching but haven’t been on faculty anywhere in years. Most of them know I have another job besides seeing patients, and are often interested in what I’m working on from a CMIO standpoint. We talk a lot about EHRs and what’s different about using our niche system versus what they will encounter when they go to medical school.

A recent article in the Journal of the American Medical Informatics Association looked at the existing literature to assess the current state of EHR training for medical students and residents. The authors looked specifically at “educational interventions designed to equip medical students or residents with knowledge or skills related to various uses of electronic health records” and to “compare the aims of these initiatives with the prescribed EHR-specific competencies for undergraduate and postgraduate medical education.” There wasn’t a tremendous amount of literature for them to sift through in their analysis – only 11 studies. Of those, seven covered medical students, three included residents, and one included both groups. All of the interventions they identified covered data entry, but none involved manipulating the resulting data at a panel or population level.

They concluded that the documented interventions don’t really prepare students to show mastery in the competencies required to be effective physicians. In thinking through this, I’m not sure how many current physicians have EHR skillsets beyond just data entry. Most of the organizations I work with expressly prohibit their physicians from doing anything remotely involving data analysis or population health work. All of those functions are managed at the group level or health system level rather than by physicians. Although physicians may receive various clinical scorecards, they’re not really accessing or addressing the data on their own. This certainly would be different for independent physicians, although many of my peers in those environments don’t have the knowledge or understanding of how to get at that data, either.

In digging deeper into the study and its methods, I was surprised by how much the different training interventions varied. Some were a brief (one hour) self-directed module that reviewed screenshots of different areas of the EHR; others could be as long as a multi-week simulated EHR curriculum. Most of the included workflows were based on data entry or information retrieval. Other activities included retrieving lab results, looking at medication lists, orders, and billing functions such as E&M coding. The interventions had different ways to assess competency. Some included a pre-test followed by a post-test after the intervention. Only three studies included a control group. Nine of the studies involved changing skills and only two looked at changing attitudes. Other assessment methods included quizzes, surveys, self-reported questionnaires, chart review, and structured practice with standardized patients.

The students and residents did well when they were evaluated using quizzes and surveys, and were satisfied with that approach as well as being able to demonstrate competency. Other studies didn’t show a difference between the intervention group and a control group. One study was able to show that learners receiving the intervention performed better on standardized patient examinations while they were being judged on their ability to complete a structured patient visit. Although standardized patients are an important part of learning (particularly as students and residents learn to perform sensitive examinations) they always made me nervous, since they were fully aware of what I was supposed to be doing and what kind of findings were supposed to be present, and I was being compared not only against my own classmates but the dozens of students who had examined them in previous years.

I was curious as to the specific competencies the authors were including when they identified gaps in training interventions. They expected students, prior to beginning their clinical clerkships (usually in the third year of medical school at the latest) to “be able to describe the components, benefits, and limitations of EHRs; the principles of managing and using aggregated electronic health information, including tenets of electronic documentation as well as differences between unstructured and structured data entry; and articulate standards for recording, communicating, sharing, and classifying electronic health information in the context of a medical team.” They also note students should “be able to identify how systems may generate inaccurate data, discuss how data entry affects direct patient care and healthcare policy, gather relevant data from EHRs, and assess the reliability and quality of these data.”

Again, I’m not sure many practicing physicians would be able to enumerate all of these elements. They may also not have a “working knowledge of health informatics through chart audits and research projects.” On the flip side, maybe if the physicians I work with had received better education around the role of EHRs, they’d be more interested in the idea of clinical informatics as well as what they can do with the vast amount of data they’ve been keying into the EHR over the years. The authors did note that “a significant number of trainees have had exposure to the EHR before their medical training as scribes and that inclusion of these individuals in the studies may have affected the results.”

I’d be curious to hear from those of you who are academic institutions on whether your training programs are incorporating these competencies into the curriculum. My medical school recently began undertaking a complete overhaul of the educational curriculum, so you can bet I’ll be asking about it the next time I run into the new associate dean who has been tasked with that effort. We heard a bit about it at my medical school reunion in the spring, but the main points of her address were around providing clinical exposure to students far earlier than we experienced during our training. The only EHRs available when I was a student involved one that used a green screen terminal to access lab results at the flagship hospital, and one that used a light pen to navigate at the community hospital. The academic center was just beginning to build its own clinical data viewer, whose contents were hit or miss, as I entered my fourth year. Now after a decade of best-of-breed construction, they’re all using Epic.

Do you think your current practicing physicians can demonstrate mastery of the skills the authors evaluated? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/10/19

The ONC blog this week featured a discussion on Electronic Prescribing of Controlled Substances (EPCS). Among physicians who prescribe controlled substances, those who use electronic systems to transmit those orders remains relatively low at 32%. Although some states have mandated the use of EPCS, others haven’t forced the issue with providers. EPCS requires multifactor authentication, and the reality for those of us who prescribe relatively few controlled substances is that the amount of work (and additional technology needed) doesn’t outweigh the potential for reducing drug diversion or other bad acts.

When I do recommend controlled substances, our practice has in-house dispensing capabilities that prevent the prescription from being diverted since we fill it right there. On the off chance that a patient wants a paper script, we print it on compliant paper. I’ve issued one paper script in the last two weeks, and it was a situation where the patient didn’t really want the medication but since they had a complicated fracture I was concerned about them going through the weekend without a backup plan for something stronger. I don’t think that script for five tablets of Tylenol with codeine has a high likelihood of contributing to the opioid epidemic. Still, mandates are coming including the SUPPORT Act, which requires that certain drugs covered under Medicare Part D must be prescribed electronically beginning in 2021. Depending on the frustrations generated by the clinician’s EHR, I wonder if some providers might just consider no longer prescribing agents that will require additional technology.

Lots of chatter in the physician lounge about the recent New York Times piece regarding wasteful spending in the US healthcare system. The comments are also a good read, especially those that note that although burdensome and wasteful, if we cleaned up these processes a lot of people would wind up unemployed. The piece actually draws on a special communication published in the Journal of the American Medical Association that estimates that 20 to 25% of US health spending is wasteful. In order to truly eliminate waste, a number of solutions would have to be employed, including following principles of evidence-based medicine, which would reduce unnecessary testing and treatments that unfortunately some patients demand. The estimated $760 billion exceeds our spending on education and the military, which is a shocking number. Evidence-based care would shave $200 billion off of that, and trimming administrative costs could reduce it another $226 billion. Better care coordination could reduce another $205 billion in wasteful spending. Another big chunk of spending is related to fraud and abuse, ringing in between $60 billion and $80 billion each year. Lots of food for thought, for sure.

I’m not sure what to think about Devoted Health and its decision to offer coverage for Apple Watches for members of its private Medicare plans. Many Apple Watch users drive me crazy, with the constant checking of their watches as messages and information flows through to their wrists. It’s every bit as annoying as having someone in front of you checking their phone instead of paying attention – having a smaller form factor doesn’t excuse the behavior. The Devoted Health program will pay up to $150 towards the cost of the device for its members in a move to stand above other Medicare Advantage plans. The jury is still out on whether wearables truly drive improved health outcomes, so this may end up being little more than a gimmick to try to entice members to join the plan. The $150 earmarked for Apple Watches can also be used for health-related classes and other programs, some of which are actually proven to drive outcomes. Devoted Health has roughly four thousand members but hopes to scale to 100,000 members over the next four years as it expands beyond its Florida footprint.

The workflow at my practices requires me to perform initial readings on plan radiographs while we wait for an overread. Although I’ve had a fair amount of training, some findings can be subtle and are easily missed unless you maximize the contrast and other enhancements available as you view the images on the screen. Despite my accuracy statistics, I’m always relieved when I see the overread and know that the radiologist agrees. I’m eager to see artificial intelligence applied to radiology at the point of care for rank and file physicians, not just in the intensive care units where a lot of the research is being done. Recently, several radiologist’s organizations released a joint statement warning that increased use of AI in radiology can raise the risk of system errors leading to adverse patient events. They call on regulatory boards to monitor AI systems to ensure patient safety, and also call for development of codes of conduct covering the ethics of AI use and warned against using radiology algorithms for financial gain. I can’t wait to see what diagnostic imaging looks like in a decade – it’s one of the areas with the most promise for delivering high-tech solutions to the bedside.

As the leaves are falling and summer is way behind us, I’m going to continue to call out CMS and its Primary Care First program. Their promised Request for Application was due “summer 2019” since the first performance year starts on January 1, 2020. It’s a little difficult to gear up for a program when you don’t know if you’ve been accepted or even if you want to apply since you don’t know what the details are. CMS hasn’t even done the courtesy of updating its website, which still says it anticipates a summer release. Come on, folks, either release the app or officially delay the program. Don’t leave people hanging – and acting like a practice could realistically target a January 1 start date just makes you look out of touch.

Since my favorite smart jewelry company Ringly went dark, I’ve been on the look out for other smart jewelry items. I’m still baffled by Amazon’s Echo Loop smart ring. It’s not fashion forward in the least but belongs to a group of devices that may or may not fill a consumer need along with Echo Frames glasses and Echo Buds earbuds. It’s a bit pricey at $130, but has potential for people who want another way to control their smart devices. Amazon refers to the group of devices as “Day 1 Editions,” which are past the beta stage but haven’t been fully proven for consumer purposes. The company describes them as “things that we’ve found delightful internally and we want to get customer feedback on it so we can continue to innovate.” It only comes in black and is only available in ring sizes nine and up, so not exactly dainty. Interested customers have to request an invitation to try the product.

What do you think of Amazon’s new wearables? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/7/19

Normally my issue of Health Data Management goes straight into the recycle bag, since it’s usually a regurgitation of material I’ve already seen or even written about. The fall issue’s headline caught my eye, since “Great Expectations” is one of the novels I had to suffer through several times during my high school and undergraduate years. I’m sure they didn’t intend to evoke Charles Dickens, but maybe they did considering the major characters include a naïve youngster, a convict, and an eccentric who wants everything to be just like it did at a singular time in their youth. That sounds a bit like healthcare IT, especially when you add in the themes of rich versus poor, love versus rejection, and the ongoing struggle of good versus evil.

All literary parallels aside, I’m not sure what kind of expectations I have for what is to come in healthcare IT in the next decade. I think we all have enormous wish lists, but whether those items are brought to fruition or continue to dwell in the world of pipe dreams will remain to be seen. I think about some of the things I dreamed of as a child that currently exist. What if you could have a soundtrack for your daily life, that could play whatever song you were in the mood for? If the iPod and numerous MP3 players were close but not quite, now we have Spotify to satisfy most of our music cravings. What if you could talk to your computer and get information without even typing? Siri, Alexa, and Cortana can continue to duke it out, but I’m happy to be able to see what the weather is like while I’m scrambling around in the morning doing three things at once.

On the other hand, we see an industry that continues to remain somewhat hobbled by regulatory requirements, where many vendors have had to cast aside true innovation in lieu of checking a host of boxes for functionality that their users not only don’t want but find tedious or annoying. It doesn’t matter how good they might be for patient care, if no one uses them it’s a fairly moot point. Unless there’s a carrot or stick involved, organizations and their users aren’t going to just adopt things for the sake of adopting new features. There’s too much else at stake and too many other things that demand (and deserve our attention).

With that in mind, I’m not sure what I think about the upcoming requirements to (finally) institute Medicare’s Appropriate Use Criteria Program, which has been in the wings for years. Health Data Management happened to cover it in the issue that caught my eye, and I have to admit I had kind of forgotten about it, since it’s been coming at us in fits and starts for so long.

Essentially, on January 2, physicians who order advanced imaging tests (such as MRI, CT, and PET scans) for Medicare patients have to consult qualified clinical decision support systems before ordering those tests. The software is supposed to incorporate evidence-based guidelines and Appropriate Use Criteria (AUC) to make sure people aren’t just ordering expensive tests for every little thing, or because patients demand them. Commercial payers have already tackled this issue by requiring prior authorization for these kinds of tests, which Medicare is trying to avoid by instituting the AUC requirement. There are eight conditions that are being targeted, including low back pain and headaches.

The problem with the proposal is that the penalty occurs in the wrong place. If ordering physicians don’t do the right thing, then radiology providers won’t be paid for the test. This puts them in the position of having to make sure their referral base is doing the right thing, with some even offering access to clinical decision support systems for their referring physicians, who might also have that support within their EHRs. The prior authorization requirements used by commercial insurers put the burden squarely where it belongs – on the ordering physician who needs to be ordering tests that are needed and that will provide useful diagnostic information.

The first year of the program is designed to be an educational and testing opportunity for all involved, with the nonpayment penalty being applied starting January 1, 2021. Ultimately, CMS plans to force providers who don’t follow requirements for clinical decision support to seek a prior authorization. With all the work that organizations have put in during the last several years for this requirement (during its on again, off again progression), one could wonder whether it just would have been easier to institute a prior authorization requirement in the first place. Ordering physicians already have those workflows in place in their practices and the lion’s share of work is done by non-provider staff members. Medicare could have been the leader here, standardizing the requirements and drawing commercial payers into line to create a single set of prior authorization rules across all payers. Instead, it has created an additional burden that no one in the process (other than CMS apparently) wants to deal with.

I’ve been in the clinical trenches for a long time, and frankly I can only remember one time a prior authorization was denied for one of my patients. It was a scenario I can only describe as a goat rodeo. The CT scan was ordered urgently, as the patient was in my urgent care with severe abdominal pain and a host of abnormal blood tests. Since no one is sitting at the insurance company at 7pm on a Friday night to handle a prior auth, we proceeded with the test and tried to get the auth retroactively on Monday morning. The reviewer was demanding more information, because in my note I described one of the areas of abdominal tenderness as “mild” rather than using a more serious-sounding word or even omitting a qualifier altogether. It didn’t matter that the patient had guarding and rebound tenderness in another area of the abdomen, which are ominous findings on their own; the reviewer had the word “mild” stuck in her craw.

I had to admit I became rather hot around the collar, and might have asked her if she gave a damn about the fact that the patient had a 6cm tumor in their pancreas that was causing obstruction and mayhem. She certainly hadn’t bothered to look at the test result itself, which more than showed the study was warranted. By the time we were trying to get the prior auth, the patient had already been admitted to the hospital, undergone a number of invasive tests, and was coping with a cancer diagnosis and the high likelihood that he’d never see his children graduate high school. Eventually the reviewer relented and approved the test, but it was silly that we even had to go through the exercise.

Maybe that should be my “great expectation” for the 2020s, that some day physicians who are spot-on with their test ordering won’t have to jump through hoops on behalf of their patients. I don’t have a lot of hope for it, though. What’s your great expectation for healthcare IT in the next decade? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/3/19

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/30/19

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.