EPtalk by Dr. Jayne 6/20/19

There is hope: The US House of Representatives voted last week to lift the ban that keeps the Department of Health and Human Services from funding efforts for a national patient identifier. The ban began in 1999 and blocks HHS from participating in private sector initiatives involving a unique identifier. HIMSS, CHIME, and other organizations have been lobbying for two decades to have the ban overturned in hopes of improved patient matching. The language was added as an amendment to the 2020 HHS appropriations bill and was introduced by both a Democrat and a Republican. Getting appropriations bills passed and signed into law can be tricky, so I won’t be holding my breath waiting for it to continue its journey on the hill.

Telehealth provider American Well has partnered with Cisco for a solution which enables virtual visits through television technology. Participating patients would use a set-top device that integrates with American Well. The solution is targeted to patients with chronic medical conditions as well as to older patients who might need regular visits. Many baby boomers are perfectly happy using smartphones and laptops and I’m not sure having one more device is necessary. People assume the older generations are “digitally dark,” but they are more savvy than you think. My own mother has a cooler, newer phone than I have. Years ago when I finally gave in to joining Facebook, the first friend suggestion I received was my then 87-year-old grandmother.

Lots of chatter in the physician lounge recently about media reports on the inclusion of “burnout” as a diagnosis in ICD-11. The World Health Organization says that media have it all wrong, that it hasn’t been recognized officially as a medical condition. ICD-11 includes burnout under “factors influencing health status or contact with health services” The chapter also includes indicators such as “contact with health services for reasons associated with reproduction” and “presence of device, implants, or grafts.” The American Psychiatric Association also states that burnout is not a medical diagnosis or a disease. Either way, being able to categorize burnout with a standardized code will allow for data gathering and better analytics. You can’t manage what you’re not measuring, but it will be a long time before we see ICD-11 in the US, so I’m not going to get too excited.

Speaking of mental health, clinicians in California are testing an app that tracks everything users do on their phones. The goal is to identify when a user is about to experience an emotional crisis. Various cities and counties are involved in the project, which is being tested on patients using the Los Angeles County public mental health network. It looks at historical use data to determine whether behaviors are changing and sends a message to the user. About half of initial pilot users dropped, citing technical issues or lack of interest. It’s an interesting concept, but one which would have to balance the loss of privacy with the potential benefit to users. For those with significant health conditions or risk for self-harm, it might be worth it, but for others it might be too invasive.

My practice has both x-ray and CT scan capabilities. Although the CTs are read immediately by a radiologist, we’re responsible for the primary reads on our plain films and often the radiology over-read doesn’t happen until our shift is over. Especially in that context, I’m excited about using AI to help interpret radiology studies, and frankly for some of our films, it can’t come fast enough. Although some films are grossly abnormal, other findings are subtle. Sometimes the quality of the studies is limited by the physical size and bulk of the patient. It would be great to have some support for those of us that are reading films in the field. Needless to say, I was excited to hear about the FDA approval of Zebra Medical Vision’s product that assists with CT studies that are looking for brain bleeds. The solution can reduce turnaround time, which is always good for the front lines. Zebra already has FDA approval for a chest x-ray product that specifically looks for pneumothorax. Maybe sometime before I retire I’ll have a virtual radiology assistant that pre-reads my films.

Like many of my peers, I enjoy learning about the history of medicine. I crossed an item off my bucket list a couple of years ago when I visited the Mutter Museum and admired Albert Einstein’s brain along with the Hyrtl Skull Collection. I’m also a fan of literature, so I couldn’t contain my excitement when I learned about a treasure trove of clinical notes from 400 years ago. The collection contains handwritten notes on more than 80,000 patients in early 17th-century England, kept by two healers who were known to cure their patients by using cues from astrology. The notes include treatments with tobacco and horse manure and cover conditions from depression to gonorrhea. Researchers at the University of Cambridge have put transcriptions of more than 500 cases online and its been great entertainment to learn about a patient whose “spleen was not sound,” as diagnosed by the presence of “black stuff that comes from by his excrements.” Another patient complained of “fretting & choleric & melancholy.” Other hot topics include childbirth, infertility, and witchcraft. My favorite treatment apparently involves avian slippers with “a pigon slitt & applied to the sole of each foote.”

Telehealth is officially the fastest growing place of service, growing 53% from 2016 to 2017 in comparison to 14% for urgent care centers and 7% for retail health clinics. Emergency departments experienced a 2% decline. This data comes from New York non-profit Fair Health, which hosts a claims database. Their annual white paper on place of service trends shows that organizations that are not thinking about how to incorporate telehealth might be missing out. Telehealth is still a small portion of all claims – 0.11% in 2017 data compared to 2.6% at emergency departments and 1.2% at urgent care clinics. This will only grow now that payment parity has arrived and telehealth or virtual visits are covered similarly to in-person visits.

I recently joined the ranks of telehealth providers and was surprised by how satisfying it can be. The patients are genuinely grateful that you’re there to take their call at 11 p.m. even if it just results in self-care recommendations. My previous proposal for being a dedicated after-hours telehealth provider for one of our local health systems was met with lack of interest and I still think they’re missing a major opportunity. I care for plenty of their patients in person at my urgent care, so we’ll have to see how long it takes for one of them to turn up in my online queue.

Have you ever used telehealth services for yourself or a loved one? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/17/19

I wrote recently about a less than optimal shift where we had multiple intermittent issues with our EHR that impacted electronic prescribing and several other key functionalities. Although the issue was fairly serious, it turns out that a good portion of the lack of communication our users experienced was the fault of our practice leadership rather than the vendor. In trying to “protect” the clinicians from what they felt would be distracting, they erred in providing too little information. It turns out the vendor was communicating pretty well, but they weren’t passing on the information to those of us on the front lines.

This is a challenge for any healthcare organization – figuring out the right way to communicate about serious issues and knowing how often to provide updates, even if the update is “no update.” In organizations where clinical leaders work closely with the IT team, there can be good conversations around a service disruption and how to handle it. There can be discussions about user culture – whether they would benefit from more information or less and whether the disruption is more of an annoyance or a disaster. When clinical and technology leaders don’t work together, there’s an increased risk of erring too far in one direction or another.

I still encounter organizations that don’t believe it’s important to have dedicated clinician support for health information technology systems. When I put on my consulting hat, one of my tasks is to try to convince these practices that they can’t afford not to have clinician leadership where EHRs and other systems are concerned.

I recently pitched to a convenient care practice that has almost 100 providers. They have one nurse who spends a couple of hours each week working with the EHR, mostly responding to specific end user questions rather than working on global strategy. I spent a few days in the practice to identify potential opportunities for workflow improvement as well as long-term strategies.

The first thing I identified while watching physicians document was that none of the physicians were using medication favorites. Apparently they aren’t allowed to build their own favorites because the organization is concerned about upkeep. Instead, there are some global favorites that everyone can use, but that might not be aligned with current treatment guidelines. Providers can delete the global favorites, but can’t put anything in their place, leading to the opportunity for errors when physicians try to use the global favorites and edit them as they go.

There were some order sets available, but they weren’t very complete, and many common diagnoses didn’t have associated order sets. As a result of providers not being able to build their own order sets, I observed several clinicians using Word documents that contained their most common patient instructions that they would copy and paste into the free-text plan field. Some of these makeshift order sets didn’t seem terribly evidence-based and they varied dramatically from person to person. The diagnosis screens were cluttered with diagnoses that didn’t seem to be commonly used, while providers were having to search for conditions that they treated several times each day.

When I perform a practice analysis, I also dig into how the practice handles upgrades and changes to payer requirements or federal programs. It turns out that that when it’s time for an upgrade, the physician CEO and the EHR nurse evaluate the release notes and decide which features they will implement and how the end users will be trained. They don’t seek input from any of the users or even the physician group’s medical directors. The two of them personally deliver most of the training in a one-on-one fashion, which means that some users might get trained as much as six weeks prior to the upgrade. Others might just receive a PDF that they are supposed to review before launching into the new workflows. There’s not a lot of satisfaction around that process.

Understanding that process explained some of the issues I saw in the system, including a workflow for in-office medications that borders on dangerous. There are fewer than two dozen medications available in the office, many of which are in specific unit doses. Rather than configuring an order screen with those medications and defaulting in their strength, form, and administration instructions, providers are required to individually select every parameter for every order. Some medications can be ordered multiple ways.

For example, one drug can be ordered either as 3 ml or 2.5 mg. Since the medication is 2.5 mg/3 ml, either order is appropriate, but I saw several physicians click for 3 mg or 2.5 ml, neither of which were correct. The system didn’t flag these, but instead the clinical support staff was responsible for changing the orders. Incorrectly ordering albuterol at that scale isn’t going to cause significant harm, but for other drugs, those types of mistakes are far more serious. Beyond the safety issue, there’s the matter of the numerous clicks required to even order a single drug.

I identified all kinds of operational issues in the practice as well. Although they have a time clock system for both clinical and business office staff, they don’t have hourly providers use it. Instead, providers have to email their “stop time” every night and it takes a manual process to document the time in both the payroll system and the scheduling system. For the latter, they use one system for providers to request their schedules and another system to actually publish the schedules. They’ve switched payroll systems three times in five years, which makes me wonder whether it was really a software issue or something much more challenging to fix.

There were plenty of other issues to tackle, enough to keep several consultants busy for many weeks. I knew there were some internal disagreements on whether to bring in outside help, so I prepared a conservative proposal in multiple phases to allow them to get used to the idea of letting someone help them. The return on investment was easy to demonstrate, but as I presented to their leadership I could tell they weren’t interested. It was clear that the CEO believes his way is not only the best way but the only way to do things.

Although many of their technology struggles could be made better through the application of skilled assistance, they’re not ready for change. Given the challenges that will be upon them as healthcare continues to evolve, it will be interesting to see where they are in three to five years.

What’s the scariest CPOE system you’ve seen? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/13/19

I’m an avid reader and was very excited to hear about “Code Blue” by Mike Magee. The author is a physician and chronicles decades of bad behavior by what he calls the “Medical Industrial Complex” of self-interested parties that drive our healthcare non-system.

Magee skewers physicians, hospitals, payers, pharmacies, drug makers, legislators, and other special interests. He notes that healthcare reform as been needed for decades, going back to a speech by President Nixon in 1972: “We need to work out a system that includes a greater emphasis on preventive care, sufficient public funding for health insurance for those who cannot afford it in the private sector, competition among both health care providers and health care insurance providers to keep down the costs of both, and decoupling the cost of health care from the cost of adding workers to the payroll.” It’s been a long time since we’ve seen a Republican call for greater public funding of health coverage for the poor.

Magee also calls out healthcare executives, physicians, and the American Medical Association. The worst criticism, however, is saved for pharmaceutical giants (it should be noted that Magee was a VP at Pfizer) who use profitability to determine which drugs will come to market. I highly recommend it, especially for newbies in the industry. It’s a steal at $16 on Amazon.

Road warriors take heart: London’s Heathrow Airport is installing new carry-on baggage scanners that can screen liquids and computers while they are still in your bags. Although some of us get a pass on the great unpacking routine in the US if we have TSA Pre-Check, perhaps this will clear the way to going back to a pre-2006 workflow at many more screening checkpoints. The story points out that it’s also an environmentally friendly option, helping cut plastic use since people won’t be using as many ziplocks. The technology, which is similar to CT scanners, has been in trials at Heathrow for two years and is also in use at several sites in the US, including ATL, ORD, and IAD although authorities still require us to pull out our baggies at those sites. I miss my road warrior ways, particularly since my airline status will likely sunset this year.

Speaking of road warriors, those of you on the clinical side might be interested in this Journal of the American Medical Association article on in-flight medical emergencies. I found it fascinating reading and learned a few things:

• Emergencies occur in approximately one per 604 flights.
• FAA-required contents of the emergency medical kit are rudimentary.
• The most common issues are syncope / fainting, gastrointestinal issues, respiratory issues, and cardiovascular symptoms.
• One-fourth of emergencies are handled by the flight crew alone,  half by physicians, and the remainder by nurses and other emergency personnel.
• Diversion to a different destination happens in only 4% of inflight emergencies.
• When flight crew request emergency medical services to meet the plane, only one-third of passengers are actually transported to a hospital and only one-third of those transported are admitted.

I’m a big fan of online medical journals, and this week I came across a JAMA Viewpoint piece explaining why we should consider eliminating or modifying the requirement for a Review of Systems (ROS) during patient visits. Although asking a variety of questions about body systems as part of the ROS has been part of the history-taking process for years, it became an annoyance a couple of decades ago when the number of systems reviewed was tied to the coding and billing process.

There hasn’t been much academic work looking at the validity of the ROS, although one study found that it only identified new diagnoses in 5% of cases. Other studies have noted that only a small percentage of issues identified during the ROS are even addressed.

The authors of the viewpoint article took into account that EHRs make the entry of ROS findings easy, especially if they are self-reported through a portal or kiosk, and wondered whether those findings that aren’t identified by the physician would be followed up even less. The authors go on to discuss “the fact that a complete ROS may be required by billing guidelines at times when it is clinically unhelpful.” They call for clinicians to “claim ownership of the determination of what clinical information is required for appropriate care in which setting.” Very few clinicians would argue this point. We’re tired of generating notes full of irrelevant information and we’re tired of reading it when we see it. Changing documentation requirements would certainly help with the “note bloat” we’re all subject to.

In that same train of thought, CMS is calling for additional input on its Patients Over Paperwork Initiative. The announcement claims that “since launching in the fall of 2017, Patients over Paperwork has streamlined regulations to significantly cut the ‘red tape’ that weighs down our healthcare system and takes clinicians away from their primary mission.” I spend at least half my time in the clinical trenches these days and haven’t noticed any significant change in paperwork or red tape during that time. I’m not sure where their purported 40 million hours and forecast $5.7 billion savings is happening, but it’s not on the average physician’s timecard.

It’s that time of year. Hotel registrations for HIMSS20 are open, and even though it’s barely June, my preferred hotel is already booked for my preferred dates. The HIMSS Call for Proposals is also open through July 15. No word on keynote speakers and actual event registration doesn’t start until August. HIMSS is in Orlando again this year, and I never thought I’d say it, but I’m actually looking forward to going back to Las Vegas.

Due to some unexpected scheduling issues, I’ve had to spend more time in the clinic than I normally do. This week was punctuated by an entire day of EHR malfunctions, including failure of the system to talk to the pharmacy search API, which meant that we couldn’t do anything but print prescriptions if patients didn’t want them from our in-house dispensing system. Over the last decade, patients have gotten used to us sending their scripts to the pharmacy directly, whether electronically or by fax. The idea of printed prescriptions led to many requests for us to phone in the scripts and I rapidly discovered that not a single person on my staff that day had ever called in a prescription. Needless to say, we had a lesson because I wasn’t going to spend all day calling Walgreens.

We also had multiple random Citrix issues, chronic slowness, and random popups about some index failing to call the SOAP note. There was even an error message that cited my email address and I have no idea why it would even be listed in the EHR. I’m seriously disappointed in my vendor and their response – no resolution within 12 hours for sure, and at one point they stopped taking customer calls altogether. My practice suspected it had outgrown our vendor and I’m hoping that this is a wakeup call that it might be time to switch.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/10/19

As much as clinicians complain about EHRs, they can be powerful tools for data analytics. I’ve worked with a number of organizations that have embraced the ability of the EHR and practice management systems to help them understand why their schedules are backed up and also to implement strategies to improve things. Sometimes it’s a patient panel that’s too big, or inefficient scheduling, or getting a late start in the clinic every morning.

Now there’s new data that shows that appointment scheduling isn’t just a point of frustration. It can actually impact patient care. The authors looked at screening for breast and colorectal cancers and whether the time of day the patient was seen makes a different on whether the patient actually receives a screening referral. Patients who were seen in the morning were more likely to be seen than those with afternoon appointments. The study looked at family medicine and internal medicine practices in a variety of settings in New Jersey and Pennsylvania during 2014 and 2016. Acute and sick visits were excluded, so these were times that physicians should have been managing preventive care or chronic health issues.

The authors cite factors such as lack of time (possibly due to physicians being behind schedule) and “decision fatigue” as potential causes. The latter occurs when clinicians are less likely to have screening discussions because they have already had similar discussions multiple times earlier in the day. There’s also concern that patients who decline screening earlier in the day may make it less likely for physicians to bring it up in later appointments. Additionally, patients who are seen later in the day may also be under time pressure and may not want to discuss screenings.

The authors recommend using non-physician care team members to assist in addressing screening gaps and adjusting clinic workloads so that physicians can better focus on patient care during visits. It’s tempting for physicians to have a knee-jerk reaction to these recommendations because they are used to being the primary point of contact with a patient. I continue to come across physicians that are resistant to team-based care even when they are stressed and burned out.

There are plenty of patient engagement solutions out there that can assist with encouraging patients to receive preventive services, whether they are blast messaging through an existing patient portal, email, or text system or novel apps designed specifically for patient engagement. Those reminders can reach patients when they’re not preoccupied with other discussions during an in-person visit. Of course, patients might be just as likely to blow off those asynchronous reminders, but it’s another tool for practices to use to try to better address patient needs in a way that doesn’t impact schedules.

These types of issues are also part of what primary care transformation programs are trying to address. Initiatives such as Comprehensive Primary Care Plus (CPC+) are designed to provide additional care management payments that would include coverage for these interactions. Other programs such as Primary Care First are designed to reduce administrative burdens and make payments more streamlined which theoretically should increase the capacity for practices to deliver patient-centric services.

Of course it will take time to gather data on these programs. The CPC+ program has been live for a little over a year and initial reports on the program indicate that it’s really too early to determine what kind of impact the program might have on overall spending related to clinical outcomes.

It’s not just screening services that are impacted by the duration of the workday. The study notes that other investigations “have found higher rates of inappropriate antibiotic prescribing and opioid prescribing later in the day. In each of these studies, behaviors improved slightly after lunch (a short break for most clinicians).”

Organizations that want to tackle issues like time pressure and decision fatigue need to be careful in how they address this with their providers. One author recommended that physicians set aside time for breaks throughout the day to address the problem. This is easier said than done in office settings where providers often don’t have time to take a break to eat a meal, use the restroom, or interact socially with staff because they’re just trying to grind their way through the day. Offering those kinds of suggestions without fully understanding the problem can come off as patronizing or antagonistic. Personally, the last time I ate food during a 12-hour shift that did not involve nibbling while charting was never.

Physicians are also becoming increasingly resistant to the idea that they are responsible for changing patients’ behaviors. Physicians are supposed to motivate patients who appear tired or uninterested in a conversation about screening. The study’s author commented that patients need to be convinced that their decisions have an impact and that physicians need to think about how to best organize discussions around patients’ health.

I know I’m not alone when I admit that I’m tired of trying to persuade patients who don’t give a damn about their health that they need to take charge of, or at least get involved in, their own health. There’s a dearth of personal responsibility in our society compared to what I’ve experienced in healthcare in other parts of the world. It feels like we are no longer practitioners of the art of medicine but cheerleaders, salespeople, and at times parent-substitutes for grown adults who should be able to at least participate in their own well-being.

I think this is a major part of why we see primary care providers defecting to the urgent care or emergency department care environments. They are not expected to manage anything beyond the acute issue in front of them. Providers who gravitate to direct primary care or concierge practices are at least being paid better for their time and effort, so there is higher satisfaction among my colleagues who have made that jump.

In the mean time, the study is important to illustrate that many variables affect patient care and we can identify ways to address some of them. There are plenty of relatively simple solutions out there that practices are still resistant to implement.

I was in an office the other day where the entire staff walked in two minutes to opening time. They were waiting outside because they’re not allowed to clock in before 7:57 a.m. There is no way that any of them were prepared for patients arriving at 8 a.m., but such was the office policy. Until we begin to tackle those obvious issues, addressing the more subtle ones will remain out of reach.

What do you think about decision fatigue, appointment schedules, and personal responsibility? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/6/19

The American Board of Family Medicine takes a step towards interoperable encounters of the professional kind by becoming the first American Board of Medical Specialties member Board to implement automated licensure updates for US licensees. Instead of Diplomates having to log in and update their state licenses annually, ABFM will receive the data directly from the Federation of State Medical Boards. Licensure details will automatically update monthly and providers will receive notification when updates occur so that they can confirm accuracy. It’s a small thing, but can be a big issue for physicians who fail to update. Automation makes it one fewer thing to worry about.

I truly enjoy working in the realm of informatics, but would miss patient care if I didn’t get to do it as well. Being in a patient-centric practice environment helps since we’re all working together to ensure our patients have a great experience. Even when it’s a difficult day, it’s still better than a lot of the days I have had with other employers.

Today I celebrated the best chief complaint ever and made sure to memorialize it in the chart: “Patient states: We were walking out of Starbucks and saw you open over here, so we decided to come in.” I probably wouldn’t have heard that one a decade ago, but it underscores that patients sometimes value convenience and accessibility more than other variables. The flip side of this was the patient who arrived at the front desk at 5:30 p.m. and wanted to be sure she could be out of the office by 5:50 since she had plans to meet someone for dinner at 6:00. We get 90% of our patients out in under an hour, but trying to squeeze it under the 20-minute mark is pushing it when there is only a single provider on duty and other patients are awaiting care.

Device of the week: Researchers conclude that the home use of video goggles that measure eye movements can provide an early and accurate diagnosis of vertigo. Patients were instructed to use the goggles to record eye movements that can help confirm which specific type of vertigo is occurring so that providers can determine the best course of action. Since vertigo symptoms can wax and wane, this would be a benefit to patients whose symptoms might be gone before they make it to a provider, or who have issues limiting travel to see a clinician. I’ve had vertigo that forced me to crawl through the house because I couldn’t stand, so I can’t imagine the frustration of patients who have symptoms frequently but may not have a definitive diagnosis.

Speaking of devices, it might be time to fire up those Fitbits. An article recently published in JAMA Internal Medicine and presented at the American College of Sports Medicine 2019 Annual Meeting shows that the risk for all-cause mortality fell among older women who walked at least 4,400 steps per day. As the number of steps increased, the risks continued to fall, leveling off at 7,500 steps per day. This is great news for individuals who might not be able to meet the oft-touted but poorly-researched 10,000 steps per day.

The authors note that current US Health and Human Services physical activity guidelines recommend a weekly time goal for exercise, but that counting steps may be more easily translated into real-world practice given the widespread nature of step-counting devices. The mean age of women in the study was 72 and they were followed for a mean of 4.3 years. The study adjusted for other risk factors including age, smoking status, alcohol use, general health, and 10 other factors related to risk for cancer or cardiovascular disease. As with many studies, there were some limitations – participants were predominantly Caucasian and of high socioeconomic status, which may have made them more active than the general population, so the results may not apply to different demographics or to men.

Telehealth continues to be a hot topic, and Epic recently added the American Well telehealth app to the App Orchard. The app is supposed to add one-click virtual consult functionality within the EHR workflow. It includes control of remote cameras and digital collaboration for non-Epic sites.

I have a couple of colleagues who use Epic and are trying to get into the business of virtual consults, but their organizations haven’t committed to allowing providers to block time to handle the requests. It is becoming just “one more thing” that causes time pressures in the office. It’s disheartening to see that administrators think they can just add these programs without a thought since that’s a recipe for employee dissatisfaction. One of my former employers tried to add evening appointments and it was a bust – patients didn’t take advantage of the appointments as much as was hoped and providers felt they were losing even more time away from family.

A reader sent me this article about health skills for the Amazon Alexa platform. Functionalities include diabetes management tracking, virtual physical therapy, and general health management.

Although I don’t doubt that personal assistant-based technology can be a benefit, especially for patients who have access issues or who otherwise wouldn’t go to a brick-and-mortar healthcare facility, I would caution people about changing to this manner of care without data that shows it’s at least equivalent. The virtual physical therapy in particular makes me nervous. I have several friends who are PTs and understand how difficult it is to get patients to do exercises correctly even when they’re present in face-to-face encounters. Doing PT incorrectly can not only lead to stalled progress, but it can actually cause harm.

The author notes one of the major consumer concerns about telehealth, that “my doctors have long answered my questions and dispensed phone and email advice for free.” It’s difficult for patients to accept that physicians are not only tired of doing this for free, but that the constant ratcheting down of healthcare payments and the addition of administrative burdens have made it untenable. You wouldn’t call your lawyer for free advice and even my auto mechanic won’t talk about my car without a diagnostic visit (which isn’t free).

She notes that her OB offered great advice, but probably doesn’t realize that OB care for a pregnancy is part of a global fee that the OB is paid for the entire episode of care. Virtually no one outside the industry understands those nuances of healthcare finance. She complains about a $235 bill for a virtual visit, but never says what the accepted amount or the actual payment was. I bet it wasn’t $235.

What do you think of the rise of personal assistants in healthcare? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/3/19

Maybe I am becoming less tolerant as I get older, but I seem to be very easily tired by people in this industry who talk a good game, but are unable to get any of their ideas to fruition. It’s especially tiresome when these folks are hired by major organizations at high salaries and they can’t seem to solve the basic problems that plague clinical technology projects.

I worked with one of these folks a year or so ago when he was hired by one of my clients as a senior vice president for clinical transformation. I had been doing clinical transformation work for them for almost a year, so I was excited that they were finally putting some leadership and visibility behind the effort other than just third-party consultants. What I immediately found, however, was that he had no experience with physician adoption or creating workable timelines. His only healthcare experience was in the finance realm, and he immediately alienated nearly everyone on the project who had been working hard for incremental change.

A lot of us asked ourselves how he was hired and came to the conclusion that the organization was looking for a social media wunderkind, someone who was an “influencer.” But it turned out he was only an influencer in his own mind. He curried favor with the physicians by agreeing with their (largely unfounded) complaints about the EHR and by offering to throw the entire project out and get the group moved over to Epic per their request.

This was during his first 30 days of employment. He didn’t bother to do the due diligence to find out that the EHR project was suffering because providers had contracts that financially rewarded them for bad behavior and refusal to use the EHR. He didn’t find out that the rest of leadership had no stomach for either changing the contracts or doing something else to change the behavior, but instead took the easiest route in condemning the vendor.

The organization is now in the throes of a significant software spend. They still have no governance, no change control, and no plan. But by golly, they’re going to be on Epic, so all their problems will be solved.

I continue to watch this individual on Twitter and am surprised he doesn’t have tendonitis in his shoulder from patting his own back so much. I still have some consulting work going on with the client, although thankfully outside of his area, and it’s been hard to watch the carnage. I wonder at times whether anyone above him has read the story about the emperor having no clothes. Most of the workers under and around him see through it, and I feel for them.

I was having flashbacks this week when I met someone at a conference who reminded me of him. He was full of great ideas about how his organization was going to use data to drive outcomes and change clinical behavior. It sounded great until it took a dark turn towards volume-based incentives. I watched others in the roundtable session nodding their heads and listening attentively and I wondered if they were missing the fact that he was talking about incentivizing providers for ordering more tests, medications, and procedures.

His independent provider organization is somewhat boutique-y and has a large population of young and middle-aged patients who value convenience. Due to their relatively low Medicare population, they’re not part of an Accountable Care Organization and they’re not worried about readmission rates. They offer a significant spectrum of cosmetic services along with all kinds of wellness testing that isn’t typically covered by insurance.

Essentially, his organization has come up with what I would consider bogus metrics, a “compassion index” that uses interventions as a proxy for good clinical care. Using point-of-care tests rather than medical knowledge or those pesky clinical decision rules raises a provider’s index. Prescribing multiple medications to treat patient symptoms also raises that index (however, over-the-counter medications that the patient might already be taking do not). He (and I assume the rest of the leadership of the organization, since the presentation was clearly bragging on their outcomes) has latched onto a word-track that “patients know we care by how much we do for them.”

I wondered for a minute if the presentation was straight out of The Onion. Certainly no one in the current healthcare environment would be talking about running up charges? As a former primary care provider, I always thought patients knew we cared by the fact that we sat down and talked with them, counseled them through their issues, and made sure they had follow-up.

I hid in the tall grass and waited for the opportunity to ask a question about what most of us would consider “real” metrics, such as antimicrobial stewardship or appropriate use criteria for advanced imaging. I asked it nicely, and it was fun to watch him blow it off saying that they don’t find those types of metrics to be relevant to their practice. You could see the light bulbs come on over a couple of the attendees’ heads because those types of actual clinical quality metrics have been so drilled into our heads, why would someone not use them?

He went on to describe some of their other metrics, which sounded more like defensive medicine than anything else. He explained their push for imaging as “patients feel better when they know beyond a doubt that nothing serious is going on,” which I immediately translated to “our accountant feels better when we radiate people.”

Nothing in medicine is “beyond a doubt” because there is great variability in patients and how their bodies react to various biological challenges. Medicine throws me curve balls all the time, including the patient last week who was very, very anticoagulated but still had a new deep venous blood clot form in his leg. Trying to use shotgun-style testing as a substitute for clinical intuition, experience, and evidence-based care is a dangerous construct.

He went on to talk about their interventions to drive clinician behavior and raise the “compassion index” alongside patient satisfaction scores. It sounds like they look for outlier physicians and sit them down and use peer pressure to try to raise the volume of order interventions. It didn’t sound like they overtly bonused physicians based on ordering volume, but instead use emotional hooks to try to keep clinicians on track. They do bonus physicians on throughput, which makes it easier for people to just order tests rather than sit down and explain a decision process to patients, since education and shared decision-making take time.

I found their bogus metric even more bogus when he explained that they judge the usage of interventions based on the documented chief complaint, not on the diagnosis. At this particular facility, the chief complaint is self-selected by the patient on a kiosk at check-in, so judging whether providers order testing based on that is particularly obnoxious. I’ve had patients who say their complaint is “throat pain” that is really poison ivy on the neck, so if a provider is going to be dinged for not ordering a strep test for throat pain that’s actually a neck rash, they’re fighting an uphill battle.

I can’t imagine working at a place like that. He did note that they have some issues with provider turnover. I’ve found that when people talk about their turnover issues, it’s kind of like talking about how much alcohol they drink – it’s likely to be underestimated.

I’m not sure how long payers are going to put up with this, or how long patients will keep coming back if they have to shoulder the bills for over-testing. Not to mention that over-testing is not a harmless intervention. Sometimes you find things that lead you to additional interventions when it would have been better if you hadn’t done the test in the first place. It falls into the “do no harm” piece of what we trained for as physicians.

I’m curious if this is a new trend or if this guy is as much on the fringe as I think. Have you seen anything like the compassion index in your area? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/30/19

I’ve been following Diasyst for some time and was happy to see their recent win at the Webit.Foundation Founders Games in Sofia, Bulgaria. Diasyst was recognized as a finalist and was selected by Microsoft for Startups for $120K in awards to support growth, including assistance with investments and partnership development. Diasyst has an elegant solution that assists clinicians with diabetes management and currently partners with Emory University, the US Department of Veterans Affairs, and Georgia Tech.

The state of Missouri closed its legislative session last week and remains the lone holdout in the US without a statewide prescription drug monitoring program. St. Louis County provides the leading workaround with its federally-funded voluntary PDMP; more than 70 additional jurisdictions including Illinois, Kansas, and Oklahoma share data with the system and it now covers 84% of the state’s population. Missouri legislators continue to cite privacy concerns as preventing Missouri from enacting PDMP legislations despite the support of new governor Mike Parsons. A Kaiser Health News piece covering the issue is worth reading. One of the main legislators who had opposed a statewide PDMP is a family physician, although he was finally term-limited. PDMP legislation has also been inexplicably tied up with gun rights issues. It should be noted that Missouri was also last to implement a statewide immunization registry. My favorite quote of the piece: “But if 49 other legislatures are saying ‘This is important, we need to save lives,’ I don’t understand why Missouri can’t find a way to compromise and do what’s best for its citizens.”

It’s already been mentioned in HIStalk, but I’m intrigued by Amazon’s foray into wearables that can read the emotion of the wearer. It’s a step up from a mood ring, but I wonder how well Amazon is really doing with understanding user emotions and experiences at present. The company needs to do a better job selling its data in a way that I don’t keep seeing ads for products I’ve already bought. The device would supposedly analyze user voice patterns to determine their emotional state. I’m just trying to get my Echo to recognize my commands when I’m moving across the room or when there is background noise.

Artificial intelligence continues to be a headliner for buzzword bingo and the US government continues to expand spending. Early adopter agencies such as the Defense Department, the General Services Administration, NASA, and the Department of Health and Human Services are using AI to reduce backlogs or increase productivity of existing workers. Additional departments looking to leverage AI include the Departments of Agriculture and Veterans Affairs, along with the National Institute of Standards and Technology. Additionally, the Patent and Trademark Office wants to use AI to screen patent applications against more than ten million patents already on the books.

A recent report on federal AI adoption highlights the need to make sure agencies have solid business cases for AI and that they’re not building solutions in search of a problem. It also notes that government needs to get “beyond the belief that AI is magic. It’s not – it’s something that’s evidence-based that uses data.” The report also calls for a unified ethics framework that addresses difficult issues around AI transparency and accountability. Previous projects involving analysis of drone footage have been controversial.

The US Food and Drug Administration (FDA) is fast-tracking an Apple Watch app to help individuals who experience nightmares from post-traumatic stress disorder (PTSD). The NightWare app uses biometric data collected during sleep and processes them with machine learning algorithms to identify the onset of nightmares. Vibrations are triggered to interrupt the nightmare without waking the user or interrupting sleep rhythms. The FDA granted “breakthrough status,” which is typically granted for life-threatening conditions with no approved treatments. Nightmares and nightmare disorder are linked to increased risk of suicide, heart disease, diabetes, memory loss, anxiety, and depression. An estimated 5 million Americans suffer from nightmare disorder. NightWare is conducting randomized clinical trials prior to applying for FDA priority review.

I’ve noticed an increase in the number of elderly patients who don’t have family nearby. They may continue to drive past the point where it is safe because they don’t want to be dependent on taxis or ride share services. As the Baby Boomers age, self-driving cars may be an appealing way to stay independent. IBM and British startup Cera Care are taking a deeper look at using the technology off the road to help elderly patients navigate within their homes. They plan to use lidar laser sensors from self-driving cars to monitor patient movements and daily routines. A change in movement patterns may indicate physical deterioration, psychological changes, or a fall. Lidar sensors are expensive at approximately $1K per room, but developers expect costs to fall over time.

The University of Michigan finds that the DNA of new doctors ages six times faster than normal DNA during the critical internship year. Researchers looked at segments of DNA called telomeres, which keep the ends of chromosomes intact. The interns were compared against a control group of college students. The study showed that telomeres in stressed subjects shrank in an accelerated way. The data could be applicable to other populations exposed to prolonged stress such as military trainees, new parents, and those working for startup companies.

I had the chance to connect with an old friend and industry vet this week. It was great to catch up and to commiserate about the problems we’re trying to solve out in the client community. Some of the issues we continue to run across include clients who want to do the wrong thing despite our best advice, such as failing to flag deceased patients in the system. Nothing says “patient engagement” like a family receiving a colonoscopy reminder after their loved one has died of colorectal cancer. As we use increasing amounts of information across numerous applications and data streams, the need to ask “is this the right thing for the patient” becomes more important.

Does your organization constantly keep patients at the forefront? What are your pitfalls or a-ha moments? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/23/19

Tech pet peeve of the week: time zones. I am working with some folks who don’t know their EST from their EDT, let alone how to work with people in localities that don’t participate in Daylight Saving Time. I’m thinking maybe we just need to all go GMT so we can get along. Either that or Microsoft needs to give us additional time zone display options in Outlook. Two is just not enough for those of us who work coast to coast or sometimes trans-Pacific.

Non-tech pet peeve of the week: recruiters who don’t know their audience. I was contacted by a recruiter from a payer (whose name I will keep anonymous to protect the guilty) who apparently had me confused with someone in another generation. “We believe that you, as a rising star, will use your unparalleled talents… fulfill your dream.” Last time I checked, most physicians don’t dream of working for a payer (although some people are really into it) but the flowery language screamed insincerity. That’s not how I’d approach a seasoned physician exec, but it made for a fun conversation when I decided to just mess with him.

EHR pet peeve of the week: having to respond to laboratory “Ask at Order Entry Questions” that should be hard-coded. How many times have I had to free text “throat” as the source for “culture – throat” in the CPOE screens of my EHR? Seriously, folks.

Clinical pet peeve of the week: my mammogram visit at Big Medical Center. I was greeted by a volunteer, then sent to waiting room purgatory for 25 minutes despite being on time. The registrar who called me over had a coffee-stained desk (right where I was supposed to lean over and fill out paperwork) and the base of her monitor hadn’t been dusted since the Bush administration. There were rubber bands everywhere on the desk and I can’t for the life of me imagine where rubber bands would belong in the workflow. I was asked to fill out a paper clinical history, including all my demographic information, by hand, and then she peppered me with registration questions while I was trying to fill out the clinical history. Perhaps my time in the waiting room would have been a better time to fill that out?

The registration system popped up a phone number that I’ve been trying to have removed from the system for almost 15 years. She had to find someone else to find out how to try to remove it. I asked why I had to put my contact numbers on the paper history and was told “if the techs have to call you, they never look at the computers.” That’s reassuring in this age of interoperability.

The worst part was being informed that I would receive my results “by mail in 7-10 days.” Despite Big Medical Center’s high-risk breast cancer program, I think I’ll be having my next study at Independent Imaging, where I used to go and where results were real time and in person. Independent Imaging at least used their EHR to pre-populate the clinical history form and have patients just update it, which is exactly what I would have expected at Big Medical Center since they just spent half a billion dollars (literally) going up on Epic. Let’s see if they contact me after I gave them free consulting on their comment card.

That’s certainly a greater number of peeves than I should be allowed this week, so let’s talk about what went well.

I’m part of a pilot project with the American Board of Family Medicine to see if doing quarterly board exam questions can be substituted for the in-person, high-stakes exam. I did my second batch of questions and think I finally have my strategy figured out on which references to use and how to approach the questions. The system is pretty streamlined and they did make a few tweaks between the first and second quarters, so I’m looking forward to see if they make any additional enhancements for Quarter 3. Those of us who have hitched our wagons to this paradigm are likely in it for the next three to four years, so hopefully the improvements will continue.

From a mental standpoint, I definitely prefer it to the testing center, where you have to turn your pockets inside out and are practically frisked if you take your allotted breaks. Let’s hope the American Board of Preventive Medicine considers a similar approach before I have to sit for informatics recertification in 2024.

I also caught up on some of my journals, including Applied Clinical Informatics, which published a study validating what most of us already knew – that physicians don’t always document key components of a visit in the EHR. The authors looked at the documentation compared to recorded office visits and concluded that for some clinicians, EHR documentation is more challenging than paper notes. Other factors influencing curated documentation include overbooked schedules and patients with complex medical conditions. Social and emotional health issues were often left out of the EHR, and while primary care physicians may be aware of these details, there are other clinicians who would not be able to access that information in a different setting of care. These omissions may prevent hospital or consulting physicians from creating a workable care plan because they don’t know about patient-specific constraints.

The study is relatively small, looking at 10 unique patient encounters from 2016. All were from the same medical center and documented on the same EHR. Patients had an average of 14 chronic conditions and were on an average of a dozen medications. Chronic conditions were documented 90% of the time, preventive 89%, acute problems 84%, and social/emotional conditions just 30% of the time. Looking at the breakdown of the recorded visits, physicians were having the conversations real time, but just not documenting them.

This is a great place where technology could help. What if we could actually accomplish what virtual scribes are doing, but actually do it real time in the exam room? What if voice recognition was as good as we need it to be? Of course, clinicians would still need to review notes for accuracy after processing, but it would be more valuable use of a computer than we are currently doing. I know Nuance is working on the exam room of the future that would be able to collect some of this information, but last I heard, they were going to pilot it with subspecialists rather than tackle the tangled world of primary care. How long will it take until we finally make it there? Only time will tell, and perhaps it will tell us in GMT.

What is your pet peeve of the week? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/16/19

We had some struggles at my clinical office this week. Our soon-to-be fossilized PCs running Windows 7 had a bad interaction with Active Directory and Citrix. The result was that nearly half of the physicians couldn’t access the EHR. When our IT team tried to fix it, they effectively eliminated access for the remainder of the providers.

It wasn’t pretty and caused a great deal of consternation as the staff tried to figure out how to execute downtime procedures when only half of the people were down. Staff continued to document electronically, but providers were on paper, except for the lucky providers at busy locations that had scribes assigned to them. Ultimately the situation was remediated, but it underscored the need for our leadership to get rid of Windows 7 since it is reaching the end of its support cycle.

Thanks to Dr. Nick van Terheyden for his kind mention of my recent Curbside Consult regarding employment-based health insurance and its impact on efficiency and fairness. He mentions one sad consequence of our US healthcare non-system that I didn’t mention — married couples who divorce when one of the spouses becomes seriously ill so that the surviving spouse is not saddled with medical debt. Another similar scenario that I’ve seen includes divorce from a spouse with serious (but non-terminal) health issues so that the ill spouse can apply for Medicaid or try to get Medicare coverage due to disability. People shouldn’t have to try to game the system in order to get the care they need.

A recent article in the Journal of the American Medical Informatics Association covers the evolution of knowledge and competencies needed by the clinical informatics workforce. A lot has changed in the years since board certification in clinical informatics was being designed. Survey participants spent approximately a third of their clinical informatics work time on improving care delivery and outcomes, while another quarter of their time was focused on leadership activities. Other blocks of time were spent working with enterprise information systems and on data analytics and governance. AMIA plans to reassess informatics practice every five to even years to ensure that their understanding of needs in the clinical informatics domain remains current.

I struggle sometimes with the requirements of board certification in clinical informatics, particularly the maintenance of certification ones. For those of us who are not employed by a hospital or health system, finding ways to meet the “Improvement in Medical Practice” MOC Part IV requirement is difficult. I don’t own the data of my clients and they’re generally reluctant to have their information used outside of their own organizations. As a consultant, I can’t steer projects to become something I need for informatics certification – I have to keep them between the lines of the client’s engagement.

I struggled with this is a family physician as well. One of the MOC Part IV requirements was to do a hand hygiene project that involved handing out surveys to patients about whether caregivers washed their hands. Guess what? My then-employer (who was a big health system) wouldn’t let me do the project in the office because they felt it would interfere with patient perceptions. Since I don’t have continuity patients, many of the other options were off the table. I have quite a few friends who are giving up on board certification, although it’s easier for them because they don’t practice clinically.

Whether you’re a clinical person or an IT person, most of us have spent many sleepless nights running upgrades, working on projects, or taking care of patients. A study published this week looked at the metabolic changes associated with sleep deprivation and whether “sleeping in” might help mitigate some of them. Nearly a third of US adults don’t get the seven hours of sleep recommended for us, but trying to make up for that isn’t as easy as we think. Researchers engaged a cohort of healthy adults and assigned them to a control group with sufficient sleep, a restricted (five hours nightly) group, and a restricted group that was allowed unrestricted sleep on weekends. The “makeup sleep” group only slept an additional three hours on the weekend despite missing more than a dozen hours of sleep during the previous nights. Those trying to catch up also experienced disruption to their circadian rhythms resulting in trouble falling asleep at the end of the weekend.

Sleep restriction led to decreased insulin sensitivity that was worse in those engaging in recovery sleep. Restricted individuals also consumed excess calories and gained an average of three pounds over the course of the study.

Given the fact that study participants were healthy, the authors question whether the results might be even more striking in patients who were older or less healthy. Even though it leaves a number of unanswered questions, the study shows that our bodies are negatively impacted by lack of sleep and it’s not easy to try to make up for it.

I was excited to start receiving the AMIA Daily Download, which includes a roundup of top news along with key issues in clinical informatics, bioinformatics, data science, population health, and social media highlights. They’re also including a link to HIStalk Morning Headlines, making it even easier to get your HIStalk fix.

We talk a lot about health insurance and many of us also deal with professional liability insurance, business continuity insurance, and more. I’ve seen some recent articles about data breach insurance. Most of the physicians I’ve spoken with have never heard of it. Policies typically cover expenses related to a breach as well as recovery services. We know that hackers find physician organizations to be easy targets and independent physician practices may be particularly vulnerable. I still see plenty of users writing down their passwords or using easily hacked passwords such as their children’s names. I see many practices that totally disregard the physical safeguards required under HIPAA as they leave server rooms accessible and allow users to put their own devices on the network without appropriate policies in place.

I’ve not been through the underwriting process for a data breach insurance policy, but I wonder if they look at how tuned-up your organization is to begin with. Do you they ask you if you have appropriate policies in place? Is it like auto insurance where they charge more for inexperienced drivers who are more likely to generate a claim? I’d be interested to hear from organizations that have been through the process and especially interested to hear from an organization (anonymously of course) who had to file a claim against their policy. Was it easy to get the coverage to pay out? Or did you have to fight them all the way? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/13/19

We as CMIOs are often called upon to try to use data, information, and knowledge to try to solve complex problems that are caused by specific factors within the US healthcare system. They might be tied to low health literacy, funding barriers, or the high cost of care. I’ve worked with people to try to strategize around school-based health centers, community outreach programs, healthcare for the homeless, and more.

Since I often see situations where health insurance coverage (or lack of coverage) becomes part of the care equation, I was interested to see this piece in the Journal of the American Medical Association. It asks the question: “Does Employment-Based Insurance Make the US Medical Care System Unfair and Inefficient?”

On the surface, it seems like the answer to the question is yes. I often see people trapped in jobs they don’t like or aren’t suited for because they are afraid of losing their insurance coverage. I see people staying in dysfunctional marriages or domestic partnerships because of the insurance issue. Insurance in general adds inefficiencies to our practice, as we have to hire a fleet of people to handle claims creation, management, denials, appeals, and other billing functions. The complexity of insurance rules and differences in coverage are significant and it’s nearly impossible for the average clinician to try to make sense of it without significant assistance.

The coverage offered by employers can differ in striking ways. I was privileged to grow up in a family that had excellent coverage that was tied to my father’s membership in a union, insurance that was independent of the contractor for whom he worked and which could be continued in the event of a job loss through credits that workers could bank over time. I didn’t realize until medical school how amazing it was that my parents still had a $5 co-pay and that they didn’t need a referral to go see a specialist. (Of course that was in the bad old days when you were kicked off your insurance when you finished college, so I didn’t think the coverage was that great when I had to pay out-of-pocket to have my wisdom teeth extracted after they caused issues during my first semester.)

This was during the time when HMOs were growing in the US and many patients were having to get used to the ideas of working through a primary care gatekeeper and of being restricted to certain groups of physicians or particular hospitals. Now that we’ve seen that approach wax and wane and morph into what we’re working with now in the realm of value-based care, people are still complaining about their insurance. Employers may limit the plans available to employees due to cost. Changes in coverage can lead to frequent switching of physicians that can cause fragmented care for patients with chronic conditions.

Having heard about those factors over the years, I was interested to see an academic’s impression of the situation. The author notes that in the US, “the interests of high-income individuals dominate decisions about what medical care is offered and how it is financed. The result is a less efficient and less equitable medical care system than in other high-income countries.” He offers a review of the history of employer-based insurance, which initially started as a benefit to recruit employees during World War II. Other factors fueled its growth, including group insurance and tax advantages for employer contributions to the cost of coverage.

Employer-based coverage is cited as a contributor to rising costs when it includes wide networks, fee-for-service payments, and self-referral to specialists. The author notes other cost factors, including a focus on specialty / subspecialty care, high-cost technologies, relatively low hospital occupancy rates, and better hospital amenities, including space and privacy. He goes on to note that higher-income patients might be likely to pay for those amenities, but that “many low- and middle-income households would be better off if medical care was less costly and they had more money for other public and private goods and services.” He likens the high-cost product of the US medical system compared to other high-income countries as the difference between Whole Foods and Walmart.

He agrees with rank-and-file physicians about the high cost of administering the US system and its “mix of employment-based insurance, other private insurance, numerous government programs, including Medicaid and Medicare, each with its own eligibility rules and payment schemes and out-of-pocket payments.” Because of that hodgepodge, it’s impossible to understand the true cost of care, either to the patient or to the overall healthcare system, because of financing across patients, employers, and government entities. Ultimately in the US, patients bear the cost as employers lower wages to cover insurance premium payments and as the federal government collects money for Medicare through payroll taxes.

He notes that the US could save a significant amount of money if administration were simpler or if the healthcare “products” offered could be tailored to create a lower-cost alternative. However, government regulations would need to change for this to occur. He concludes that additional exploration is needed, although it appears that the way our system is financed causes inefficiencies and unfairness.

Trying to move from this hypothetical state to one that actually has an impact on our medical system is a tall order. People aren’t going to be lining up for narrow networks, stripped-down experiences, or a return to general ward care. Hospitals are in a veritable arms race as they compete to put heads in beds by offering in-room services that rival some of the nice hotels I’ve stayed in. However, those services don’t change the rate of handwashing or operative complications regardless of how much they appeal to patients.

We’re also addicted to technology and that raises costs. I was working with a medical student last week who trained in China. He’s seeking residency training in the US and was asking for strategies and feedback to improve his chances of being offered a training slot. We had an extensive discussion about physical diagnosis skills and how in the US we often jump to technology rather than using our ears and eyes and brains when we order CT scans and echocardiograms. I suggested that his ability to manage complex patients in a low-tech environment might be appealing to residency training programs given the alignment of those skills with what is desired in value-based care. It’s not going to change the fact that patients want an MRI, CT, X-ray, or lab test because they trust it more than physician skill, but it creates interesting food for thought.

The JAMA piece only had one comment. I would be interested to hear what readers think about the role of employer-based insurance in our complex healthcare system. Is it a blessing or a curse? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/9/19

I hope EHR vendors are busily refining and provider organizations are busily implementing software that allows providers to see relative drug costs at the point of care, because we’re about to start seeing a lot more conversations around it. HHS Secretary Alex Azar announced regulations that will require pharmaceutical manufacturers to modify drug ads to include list prices if medications cost more than $35 for a one-month supply.

Since the list price often bears no resemblance to what patients actually pay for a drug because of pharmaceutical benefit manufacturer and pharmacy kickbacks, this is going to be confusing for patients. On the other hand, the price threshold might deter patients from asking physicians to prescribe everything they see on TV. The administration is apparently considering allowing US residents to import drugs from other countries under certain circumstances.

Although drug makers claim the requirement infringes on their right to free speech, Azar noted that the requirement is similar to requiring auto makers to display a standard sticker price. The top 10 most-advertised drugs have prices ranging from $488 to $16,938, which should give sticker shock to any patient who might be thinking about following the “ask your doctor” instructions. The mandate, which does not cover print or radio ads, applies to all branded (non-generic) drugs that are covered by Medicare and Medicaid.

The pharmaceutical industry spends over $4 billion annually on TV advertising. Interestingly, enforcement of the rule depends on drug makers suing each other for unfair trade practices. The regulations go into effect 60 days after being published in the Federal Register.

This comes right after the announcement that a new drug is coming to market that will sell for $2 million. The drug is for a rare muscle-wasting disease that typically kills affected individuals by the time they turn two years old. The gene therapy is produced by Novartis AG to treat spinal muscular atrophy. The manufacturer felt it could be cost effective at a price tag of between $4 million and $5 million, so the proposed $2 million pricing is a relative bargain. It’s impossible to put a price tag on the value of a child’s life, but the benefit is unachievable if none of the affected patients can afford it. Not to mention that even if insurance covers the drug, patients and families will almost surely go over their lifetime insurance benefit caps.

From Dallas Gal: “Re: your recent mentions of Fem Tech. Have you seen the NextGen Jane smart tampon platform?” I hadn’t seen it, but I’m wondering if the software company of the same name is having heart failure over the potential trademark infringement. The startup has raised more than $11 million to date. Users mail in a sample of cells collected during the menstrual cycle (which the company refers to as “a natural biopsy of the female reproductive tract”) so that they can be analyzed to determine if endometrial cells are present. The company’s font and logo color selection even mimics that of the EHR company before its last rebranding maneuver. The non-EHR product is being readied for commercial launch in 2020. I’m betting it gets a rename before that happens.

We’re finally out of the woods as far as flu season, now that it’s May. There are only three states experiencing widespread flu activity and ambulatory visits for flu-like illnesses are down to less than 2%. Even though overall activity is lower, there have been slight increases in hospitalization and an additional five pediatric deaths have been reported. I saw two patients today that I would have sworn would be positive, but they weren’t, so there is still a fair amount of influenza-like illness out there. Hang in there, clinical folks, the end is in sight.

Kaiser Health News reports on proposed regulations that would lead to the ability for patients to compare prices across hospitals and health care facilities using data sent to their smartphones. It could take several years to be able to handle the data in a patient-friendly form and it’s unclear how patients are going to be able to make sense of the craziness that is healthcare pricing.

We had a maddening encounter in the office today with a potential patient who was irate that we could not tell her the exact cost of a hypothetical urgent care visit for a hypothetical diagnoses that she had already arrived at herself. We can tell patients our charge, and we can tell them the price for cash patients without insurance, but we don’t have the ability at the point of care to see what various payers have contracted or where patients stand with regards to their deductibles. Our billing office can figure that out, but of course this patient was in the office after normal billing office hours.

The patient made a scene in the waiting room and my staff was extremely upset after the encounter. Despite doing all the right things, they couldn’t de-escalate the situation. Even the photocopier repair person who was there said the patient was out of control and offered to talk to our management to make sure the staff didn’t get in trouble.

The incident led to an interesting conversation with the staff later in the day about the commoditization of health care. My staff is representative of the average ambulatory practice staff and they have no concept of federal regulations, proposed rules, or comment periods. Since most of them are fairly young, they’ve had few experiences with the healthcare system outside of care in our practice, which waives co-pays and patient responsibility balances for employees as a benefit of employment.

Despite the feds continuing to beat the drum on transparency and portability, we’ve not been able to achieve electronic health records portability in the last decade and a half we’ve been working on it, so it will be interesting to see how long it actually takes. I’m sure at some point in the future I will look back on this post and either wonder where things continued to go wrong or be utterly surprised that we figured out how to solve the challenging problems that stand in the way.

What do you think about true price transparency? Will people really shop around for their healthcare? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/6/19

National Nurses Week is May 6-12 and I want to send a shout-out to all the nurses out there. I’ve worked with some phenomenal nurse informaticists over the years. Their perspective often varies from that of physicians and their input has been invaluable on numerous projects.

I’m also grateful to the clinical nurses who have had my back, whether it was in medical school, residency, or when trying to implement EHRs. Nurses have helped me formulate strategies to get physicians on board because they understand how clinical departments operate in ways that an administrator might not fully grasp.

We walk a lot about physician burnout, but we don’t always talk about nursing burnout as much as we should. Many nurses from my hospital have left traditional nursing and are instead working in fields such as administration, telehealth, case management, or with payers. One of my close friends became an elementary school nurse and another does case review for attorneys. In an anecdotal survey of why they left the patient care trenches, the top reasons include stress, unpredictable hours, and inadequate work-life balance. One who worked with me in the emergency department was mainly afraid of workplace violence, having been involved in several altercations involving patients or upset family members.

I had the opportunity recently to attend a seminar on workplace violence, which is something all of us that spend time in hospitals need to think about. Medical settings are the most common location for workplace violence. According to the Bureau of Labor Statistics, more than 70% of all workplace assaults happen in the healthcare and social services industry. Potential causes include the idea that healthcare has become less patient-focused and less personal; wait times have become longer; patients have unmet expectations; prescription drug abuse; and lack of mental health support services. Even with those facts, organizations tend to provide little education on how to de-escalate tense situations or how to respond when a violent episode occurs.

The seminar recommended that clinical staff receive formal training in spotting behaviors that could lead to violence and in learning how to manage situations so that they don’t escalate. Practices, nursing units, and facility departments should develop detailed procedures for addressing violent situations, including how to protect patients and themselves. They also recommended training in how to best interact with law enforcement should a violent episode occur. Last, they discussed conducting drills to test those procedures, much like an organization would have an EHR downtime drill or a mass-casualty drill. Although we hear a lot about intruder drills in the schools, we don’t hear a lot about them in healthcare settings. The speakers advocated the Run-Hide-Fight response to active shooter incidents, and I could tell these were new concepts for most of the people in the audience.

The majority of the seminar was spent on strategies for preventing violent encounters in the first place. We were encouraged to look for patients or family members with depressed mood, bizarre behavior, and changes in personality. These are readily identifiable by most healthcare professionals, along with findings such as paranoid ideations and delusional statements. Those were fairly subtle, but actual threats of violence also made the list of items that should trigger de-escalation maneuvers.

They went on to recommend that healthcare workplace training programs include situational awareness training during the onboarding process with annual refreshers. I would think that situational awareness would be one of the hardest skills to master in the healthcare setting since we often need to be laser-focused on the patient in front of us. We might not be aware of incidents occurring in adjacent patient rooms or at the clinical workstation.

When the situation is unfolding in front of us, clinical workers are encouraged to allow patients to verbally vent while showing empathy and understanding. If the situation deteriorates, we need to be able to alert others or get help; identify escape routes; and plan for self-defense. Like law enforcement teams, we were reminded to never turn our backs on potentially violent patients or family members.

The seminar also covered strategies for prevention that are fairly straightforward, such as securing doors, limiting non-employee access to critical areas of the facility, installing proper lighting in the parking lot, and changing door codes often if electronic locks are in place. Staff should wear name badges so they can be easily identified as belonging in key areas. The speakers also discussed the practice of “see something, say something” where everyone is empowered to bring attention to situations that might become problematic.

I’ve been in some tense situations and have encountered violent patients, but I’ve never personally experienced the types of violence that was discussed during several of the case studies. We were asked to role play various scenarios, including custody disputes, disgruntled employees, and unstable patients. We were challenged to create a draft emergency operation plan for our facility with ideas for policies and procedures on how to address various types of workplace violence.

Several of us had the most difficulty figuring out how we would protect patients as well as staff members, particularly if patients were immobile or critically ill. We talked about campus lockdowns and how to quickly alert patients and visitors to stay away from the facility if needed. We also talked about how to care for potential victims. Hospitals and emergency departments have different resources than ambulatory practices and we brainstormed ways to use the supplies on hand for different eventualities.

The last part of the course dealt with how to behave in an active shooter situation when law enforcement arrives. Especially if SWAT or other specialized resources are involved, those resources are trained to proceed in ways that might not seem intuitive to healthcare providers. Officers aren’t going to stop and render aid to wounded individuals until they are certain the threat has been stopped. They might treat everyone present as a potential threat while they gain control of the situation.

After the course, I was curious whether any of my friends that work for EHR vendors and routinely assist clients in healthcare locations had received any kind of training on workplace violence. Although my survey sample was small, no one had received any kind of training in workplace violence.

I’d be curious to hear how large technology vendors handle this and whether they provide formal training for staff members. Similarly, for hospitals and provider organizations, what’s your strategy? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/2/19

I’m continually surprised by the inability of EHR vendors to add fairly straightforward safety features to their systems. A reader sent in this screenshot that shows a patient’s pulse documented as 12,224 beats per minute. They also shared screenshots of other parts of the EHR with similar issues. The blood pressure field isn’t divided for systolic or diastolic entries, but rather requires the user to type a “/” between the values, leading to potential errors.

Since I’ve been on the vendor side of the house, I understand that it’s not as simple as it seems to make these kinds of corrections since they may require changes to the database. However, it’s not as difficult to make changes to the screens where data is entered. In this situation, they could limit the entered data to three characters. Frankly, if you need to enter a fourth digit, your patient has probably just died of rampant tachycardia.

When reporting these types of issues to vendors, we are often told that it’s not on the development roadmap, that it would be too technically difficult, or that it would require more development hours than are available. When we’re talking about data entry errors and patient safety, however, how much time is too much time to spend on something like this? Not to mention that if you’re trying to exchange data and want to be truly interoperable, this kind of bad data is going to be an issue for practices trying to consume data from flawed sources.

With all the certification requirements, why haven’t we mandated management of basic patient safety issues like this? As much as we’re told that paper kills, I doubt there were too many instances where a technician would have documented a pulse of 12,000 in a paper chart.

You know people are desperate when felony colonoscope theft becomes an issue. Two men and a woman burglarized a Philadelphia-area hospital and made off with tools from the colonoscopy suite. Police fear the devices may be sold on the black market. If that’s the case, I hope they go through a thorough cleaning cycle first.

I had a conference call today with a potential employee who dialed into the meeting from a shared work space with little privacy. There were people walking back and forth in the background during the entire call, and in a couple of instances, the interviewee even turned around to see what was going on behind him. If this is the best environment he could come up with for a job interview, I wonder what his daily work environment might look like. He mentioned that he likes to work away from home because “it’s less boring,” but failed to elaborate. That’s a trip directly to the round file for this candidate.

Other occupants of the round file include people who try to conduct their entire lives from their phones, leading to emails saying they can’t open attachments on their phones or have trouble accessing various resources on their phones. Mobile is a great extender, but if you’re going to do a serious job in IT, you have to understand when it’s appropriate to use a more traditional laptop, tablet PC, desktop, etc.

In response to my recent piece about Ovia and other fertility apps, a reader shared this Washington Post follow-up that discusses ways women protect their privacy on these apps. One woman drew the line at providing the name and date of birth of her baby – she was willing to share her own personal information, but not that of her newborn.

Over 100 women responded to a request from the Post. Respondents “often said they felt trapped by an unfair choice: They cared about privacy, but they also found the digital trackers too valuable to give up.” Women used pseudonyms, logged only a minimum of information, and modified some data to preserve anonymity. Others noted that the apps weren’t that helpful. One commented that they “led to micromanaging my body and habits, which led to stress.” Another noted deliberate gaming of systems used by employers who are trying to get data on staffers: “If my employer was offering money for pregnancy tracking, I would probably do the same thing I already do with the fitness tracking and just input false content.”

The reality is that personal health information is everywhere, whether people are providing it willingly with the understanding that they can’t control it once it’s out of their hands, or whether they want to use it for specific purposes. There is a great deal of discussion about the role of patient-generated health data in clinical care. Many clinicians are uncertain about its role in driving outcomes and contributing to clinical quality. There are also concerns about how to handle the data. Clinicians find the idea of receiving hundreds if not thousands of data points into their EHRs to be particularly daunting. Some of these physicians were concerned in the paper days about patients bringing in blood pressure or blood sugar logs, so it’s not surprising that they are uncertain about the data in the electronic world.

There are also concerns by both patients and providers about data security, but it’s hard to quantify the pros and cons. An article in the Journal of the American Medical Informatics Association notes that patients are open to various methods for data collection, whether it is through a medical history, patient questionnaires and surveys, or biometric and activity data. Researchers interviewed health system leaders, EHR vendor leaders, and leaders of third parties providing patient-generated health data tools to health systems. They also interviewed patients with chronic conditions, with half of those patients having experience with generating data. The number of survey participants was small, but the authors conclude that patient-generated health data really isn’t being pursued at broad scale, largely due to concerns about its value.

What do your providers think about patient-generated health data? Are you using it? Does it add more confusion? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/29/19

As much as we complain about our technology, there are days when I’m glad to have it. This week was one of those, when I was confronted with multiple patients who had been exposed to wild animals and I had to quickly determine whether rabies exposure was a risk in our area.

Barely a decade ago, this question would have required a fair bit of research and possibly a phone call to the county health department. Although we determined that being scratched by a squirrel wasn’t considered a risk factor because the incidence of rabies in the squirrel population in our area is relatively low, apparently the largest reservoir in our area is the woodchuck. I always thought they were a slow animal that doesn’t do much, but apparently when they are rabid, they will chase people. I’ll be on the lookout for any deranged woodchucks on my upcoming outdoor adventures.

It’s also fantastic to have data from the Centers for Disease Control at our fingertips – where we are in the current influenza season (almost done!), how many people have died this year (fewer than 55,000 compared to last year’s 80,000), and what the current recommendations are for our patients who are traveling to various parts of the world.

When I work with physicians who complain about having to use computers in the exam room, I challenge them to think of ways that computers are beneficial and how they might learn to better use the computer as part of the patient visit rather than fight it. Even the most reluctant physician can usually think of a handful of positives.

Some of the concerns I hear from physicians are part of a larger issue with organizational dynamics. I was pleased to see a recent editorial in the Journal of the American Medical Association addressing the need to build trust as part of relationships between clinicians and healthcare organizations. The authors note that although many books cover this in the business world, there is little addressing how it impacts clinician relationships with their employers or sponsoring organizations. They note that we have likely arrived at this place of mutual distrust due to the size of many healthcare organizations and the insertion of management layers between frontline clinicians and senior leadership.

Often changes that are being driven by payers or the market result in hostility towards organizational leaders. I see this often in the EHR trenches, as providers fail to fully understand the role of government mandates and payment incentives / penalties in driving EHR use.

The authors also cite poor communication as a key reason for lack of trust. I agree wholeheartedly with that assertion. I still see organizations that have fractured communication pathways. This may result in chain-of-command communications that reach clinicians at different speeds and sometimes not at all, or inconsistency in the messaging.

During some of my interim CMIO engagements, I’ve seen meetings canceled with no explanation, which leads to feelings of uncertainty and a lot of time spent by invitees in trying to figure out why it was canceled or whether policy has changed. It’s unfortunate because a simple explanation with the meeting cancellation would have created a lot of goodwill – “canceled due to schedule conflict, will be rescheduled” would go a long way to silence what I’ve seen turn into full-blown organizational conspiracy theories.

They note other drivers of distrust, such as “poorly conceived or implemented electronic health records, competing interests, and misaligned incentives” that add to the confusion. Other factors include a perceived lack of clinician input, overly rapid changes to processes or metrics, administrative burden, and inadequate support staff. They also note that clinicians struggle to buy in when standardized care processes are discussed along with other changes that might negatively impact clinician autonomy.

I agree with the authors that it is easy to violate trust and extremely challenging to rebuild it. They call on organizations to engage “leaders who are visible, available, and responsive and who know how to develop and foster positive relationships.” Having worked with several boorish leaders over the last several years, I’d also suggest that leaders be educated on their constituents and how they will perceive anecdotal stories that the leaders might throw out.

I worked with one CEO who constantly talked about his ski trips, his sailboat, and his house in Jackson Hole. Let’s just say that didn’t resonate with primary care physicians who were driving 10-year old Hondas. Nor did the story about the year he took off work to coach his son’s baseball team. Some background research on what made that particular group of physicians tick or what their economic status was might have been helpful and would have saved everyone a bit of angst.

I enjoyed the section that mentioned that “marketing slogans are no substitute for a clearly articulated purpose that is consistently and continually reinforced through action and policy.” One well-known health system had a campaign around “world’s best medicine made better.” What does that mean, exactly? What is the goal? How do frontline physicians play a role?

The authors note that although trust is a two-way street, “organizational leaders are best positioned to take the first step in establishing trust. Clinicians are unlikely to shift from suspicion and disengagement to being fully trusting unless they experience leaders who are trustworthy, but also must act in ways that engender trust.”

I was surprised that there weren’t more comments on the article, only one that identified lack of departmental meetings as a driver of distrust since face-to-face interactions were reduced. We used to have quarterly medical staff meetings at our hospital that were a big deal, with a catered sit-down dinner. Big issues were discussed and the majority of the medical staff made a point to be there. However, as costs were cut, those dinner meetings gave way to lunch meetings, which disenfranchised those of us who didn’t practice on the hospital campus. Those were in turn canceled due to “poor participation” and what used to be a vibrant discussion was reduced to the occasional email blast telling us about the hospital’s priorities.

I’m interested to hear what readers think about the state of trust in healthcare organizations. What is your organization doing well? What could use improvement? Leave a comment or email me. And watch out for rabid woodchucks.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/25/19

CMS was busy this week, dropping several proposed rule changes for the 2020 fiscal year that begins in October 2019. Last Wednesday, they released a proposed rule updating Medicare payment policies for facilities that fall under the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS). I love their language in how they explain what they are doing: “We are proposing to update IRF PPS payment rates using the most recent data to reflect an estimated 2.5 percent increase factor (reflecting an IRF-specific market basket estimate of 3.0 percent increase factor, reduced by a 0.5 percentage point multifactor productivity adjustment.” They plan to watch the numbers to see if they can further update the market basket and multifactor productivity adjustments in the final rule.

Then on Thursday, CMS released an update for the Inpatient Psychiatric Facility (IPF) Prospective Payment System and the IPF Quality Reporting program. There are more market basket adjustments to be found, including a proposal to “rebase and revise the IPF market basket to reflect a 2016 base year from a 2012 base year.” There are days that I wish I had taken more finance classes, despite spent a lot more time in the business school than my pre-med colleagues.

If you weren’t dizzy yet after those two, Friday brought proposed changes for Skilled Nursing Facility (SNF) rates. They’re proposing a new case-mix model called the Patient Driven Payment Model (PDPM) because we couldn’t possibly have had enough acronyms. The new model considers patient condition and care needs to determine payment amounts rather than the amount of care provided. As a physician, I’d think that ideally the care needs and care provided should be equal, but I suppose that’s not always the case.

The SNF rule also includes “sub-regulatory process for ICD-10 code revisions for PDPM,” which I’m sure has everyone excited. Friday’s festivities also included a proposed rule with updates for hospice payments, continuous home care, general inpatient care, and inpatient respite care per diem payment rates. Hospices that fail to meet quality reporting requirements will be hit with a 2% penalty on the annual market basket update for the year.

This Tuesday marked the release of a proposed rule to update Medicare payment policies under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS). The first push is for “Rethinking Rural Health,” by which Medicare plans to increase payments to so-called “low wage index” hospitals. The second set of buzzwords was “Unleashing Innovation,” which includes an increase to the new technology add-on payment when hospitals treat patients with high costs involving new technologies, such as expensive new antimicrobial therapies. As usual, CMS is accepting comments on all these proposals.

ONC was also busy with an updated draft of the Trusted Exchange Framework and Common Agreement (TEFCA) along with a Notice of Funding Opportunity for the Trusted Exchange Framework Recognized Coordinating Entity (RCE) Cooperative Agreement.  I just liked learning a new acronym since apparently I’d been ignorant of the NOFO until now. ONC also extended the public comment period for the 21st Century Cures Act proposed rule. It’s now open for an additional 30 days and comments are due June 3, 2019.

I’m extremely glad that influenza season is finally approaching its end, although we’re still close to December levels. My hospital logged only 15 positive flu tests this week, although other nasty bugs such as parainfluenza, rhinovirus, and enterovirus as still torturing people.

Although flu may be meeting its demise, the other big news around the physician lounge this week was the analysis that Medicare expects the hospital trust fund to be depleted in 2026. Social Security will exhaust its reserves by 2035, which is bad news for those of us who have many more years until retirement. Factors taking the blame include the rising number of beneficiaries as well as increase healthcare utilization (both volume and intensity). Until people understand what really happens in the hospital, we’ll continue to see tremendous (and often futile) expenditures in the last six months of life eating up the budget.

Arizona passed telehealth legislation this week, although it doesn’t go into effect until 2021. The new law adds asynchronous visits and remote patient monitoring to state guidelines for connected care and increases payer coverage for the services. Arizona needs all the help it can get since data shows it has one of the highest growth rates in the nation, but is near the bottom for access to primary care physicians. Arizona still prohibits audio-only telehealth calls, which I’d think would be more key to solving its issues than asynchronous communication.

Telehealth is potentially seen as a way to keep physicians in the workforce when they might retire or otherwise escape. There was a piece in the Washington Post a few weeks ago about when aging physicians should hang up their stethoscopes. During EHR implementations, I’ve run across many primary care physicians who should probably have called it quits long before the EHR ended up forcing them out. I don’t see that so much in the urgent care trenches, probably because the work is more physical and fast paced with more procedures than in a traditional primary care practice. I did enjoy one of the reader comments that most of the symptoms the article listed for potential cognitive decline “are the same as you see day to day from harried doctors who frankly aren’t paying attention.”

I saw three patients in the office today who had engaged in telehealth encounters, but weren’t getting better and had been told to seek in-person care. All three received telehealth services as an employee benefit. Two of the three had what I would consider appropriate care, but the third had a combination of medications prescribed that aren’t known to be effective for the condition for which they were given. Interestingly, none of them stated they received a copy of a care plan or any other written instructions, just prescriptions sent to the pharmacy. I was happy to steer them in the right direction with reassurance, a medication change, or an additional diagnosis.

What has your patient experience been with telehealth? Leave a comment of email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/22/19

I’ve been working with a large provider group and recently spent some time with them in a retreat format. Although the group bills itself as a topnotch organization from a clinical quality perspective, there is a great deal of physician dissatisfaction. The EHR is a major target of complaints, so I was brought in to do some workflow mapping and to help facilitate the sections of the retreat where workflow topics were discussed.

It no longer surprises me, but I’m still baffled by physicians who refuse to delegate or to use their support teams to actually support them. My workflow mapping revealed the usual operational failures: 

• Physicians doing staff-level work because they either don’t trust the staff or don’t want to spend the time educating staff on how they want it done
• Physicians who refuse to give a year of refills to stable, compliant patients
• Physicians who refuse to allow clinical staff to assist with refill management
• Lack of proactive management of lab and imaging results
• Overbooked schedules far beyond any chance of ever running on time

These are all paper problems that I suspect existed before the EHR, yet providers insist that the EHR is the reason they are working on charts at home. One physician I shadowed has his schedule blocked for 15-minute appointments, yet he consistently spends 20 to 25 minutes seeing each patient. He has a highly capable scribe and they work well together. However, he is always behind. Just doing the math, there is no way he is ever going to be able to get out of the office on time (nor will his staff) and he’s always going to have to do some work after hours. It wouldn’t matter what system he has. Until he can either figure out a way to see patients faster or is willing to adjust his schedule to match his actual cycle times, he’s always going to feel like he is under the gun.

(I suggested reducing the sports-related small talk that he engages in with every patient whether they seem interested or not, but that was met with a frosty stare from the physician, although the scribe seemed grateful for the suggestion.)

Physicians were frustrated by “missing results in the EHR” but failed to realize that it wasn’t that the results were misfiled, it was that the patient never had the tests performed. This is an issue that can be caught prior to the visit, either through pre-visit planning or an orders management process. Most of this frustration occurred when physicians were processing medication refills, which I would argue they shouldn’t be processing in the first place. They would be looking for cholesterol or diabetes labs so they could decide on whether to grant a refill or not, and were unwilling to task staff to do the hunting for them.

One physician is handling refills on his patients constantly since he won’t give them more than 90 days’ worth of refills at a time. That might be a necessary strategy for a patient whose conditions are not well controlled or who has issues with follow up, but the majority of patients can receive refills for a year without risk.

I discussed the number of organizations that successfully use refill protocols and the tools available to assist with ensuring patients are at goal before granting refills, but they felt that allowing anyone to approve refills other than the physicians themselves was “negligent.” We arrived at this conclusion halfway through the first day of the retreat, and it was all I could do to keep a straight face while I tried to figure out how I was going to get through another 12 hours with people that are not living in the real world.

We did identify a number of true EHR issues, mostly around lack of use of shortcut techniques and provider-level configurations. More than 50% of the providers I had shadowed didn’t even have favorites lists in their prescribing profiles, so they were manually searching for every single medication rather than selecting from a short list of medications that they commonly prescribe. Although providers agreed it would be beneficial to have such a favorites list, most of them said they were unwilling to create them on the fly, but instead wanted someone to build them for them either after a chart audit or through shadowing. We discussed how that could be a self-defeating strategy, because as they begin prescribing new agents or if their prescribing habits change, they wouldn’t be able to add those drugs without spending the time to explain them to a staff member or spending the time to log a help desk ticket.

We also found some issues with their CPOE system, including some confusing test names, and they were willing to come to a consensus to streamline that feature.

There were a number of issues on which we never reached resolution, but I did get to sit in on some of the sessions on non-operational topics so I could get a better feel for the culture of the group. There was an extensive review of their clinical quality metrics. Providers had previously received their reports only twice a year, but with the addition of the EHR, they began to receive them quarterly. At a previous retreat, they had asked for monthly reporting and were quite happy with it. However, it didn’t seem like anyone was willing to admit that it was only because of the “soul-sucking” EHR that they could ever have that level of transparency into their practice without spending a considerable amount of money on chart audits.

I also sat in on a financial workshop where expenses and provider compensation were reviewed. The providers weren’t terribly receptive to the CFO’s explanation that they had higher-than-market physician salaries with lower-than-average staffing costs as a possible explanation for why the physicians felt they were overworked. Unless they’re willing to shift work to team members, they’re going to be doing it at home in the evening or at times they’d otherwise prefer not to be working.

As an outside observer, it felt like the physicians were happier to spend the afternoon complaining about it rather than rolling up their sleeves and trying to find solutions since none of them were willing to take a lower salary for any reason. Although I do feel like we made some progress on a subset of quick-fix issues, I’m not sure this group is going to find its happy place anytime soon. I’m glad my role with them is limited and the engagement a short one although it was fun to be in the field after a long stretch at home.

Do you have persistent “paper problems” at your organization? Are providers willing to help address them? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/18/19

The largest US health insurer, UnitedHealth Group, has added its critique to the Medicare for All proposals currently being debated in Congress. We’re going to hear about this for the next year and a half, at least through the next presidential election, so I’m not surprised they’re putting their two cents in.

Medicare covers approximately 60 million people and UnitedHealth’s products cover nearly 50 million, so they conclude that Medicare for All would cause “wholesale disruption of American healthcare.” I’d like to remind the CEO making the statement that there’s more to the Americas than the US and we should be looking at many nations’ healthcare systems as we try to find a way out of our own mess. UnitedHealth posted revenues of $226.2 billion last year through insurance, physician practices, consulting, and pharmacy benefits operations. Medicare for All, or any universal coverage, plan would likely take a bite out of those revenues.

In the patient care trenches, I have a bird’s-eye view of the issues caused by employer-based health insurance. Patients staying at jobs they hate where they are abused because they are afraid of losing health coverage, particularly for pre-existing conditions? Check. Patients with complex medical conditions staying in abusive relationships because the spouse holds the coverage and they can’t afford it on their own? Check. Patients suddenly losing coverage due to downsizing, and not being able to afford individual plans? Check.

I saw all three of these this week. A discussion of the cost of care was part of the urgent care visit. Members of Congress need to walk a mile or two in their constituents’ shoes before making decisions on this complicated issue. Even the concept of Medicare for All means many different things depending on whose proposal you are looking at.

Mr. H asked recently for comments on “Health System IT Providers vs. Would-Be Disruptors: Unfairly Dismissive or Appropriately Skeptical of Outsiders” and I wanted to throw in my two cents’ worth based on a recent client project. It’s not only the outside disruptors who that make those of us in the IT trenches skeptical. It’s also the other outsiders that our organizations bring in, because either they feel that input from another industry would be useful, or that as one director told me, “You don’t have to know healthcare to manage IT systems in healthcare.”

That’s how I found myself sitting across a conference table from a “lab interface team” who was supposed to be helping create some custom orders management content for a boutique practice. As we were in the Motor City, it seemed that my team was entirely populated by former auto industry programmers and technicians. Confident in their ability to use algorithms to free the physicians from mundane data management, they had designed a flow for laboratory orders and results management and wanted my sign-off.

Unfortunately, they had no idea of how laboratory flags work or any concept that a lab that is technically abnormal might be perfectly fine for a given patient, or that one that is normal range might be bad for a given patient. The idea that results need to be interpreted in context not just based on normal vs. abnormal was a new one to this team, which appeared hastily thrown together by the hospital, which had acquired said boutique practice without really thinking it through.

Did I mention that they also didn’t know their OBR from their OBX from the proverbial hole in the ground? The look in their eyes at having a physician school them on the nuances of being an actual lab interface team was priceless. I left the meeting suggesting that perhaps they should learn something about HL7 capabilities and scheduled a discussion with their director about the team’s ability to actually get this project done on any kind of useful timeline.

I don’t doubt that non-healthcare people can learn and become healthcare people, but you have to at least understand the problem and the business case before you try to create a technology solution. I’ll be earning my money with these folks, for sure.

From Jimmy the Greek: “RE: Hide the women and their uteri….” Jimmy shared a Washington Post article covering health-monitoring app Ovia, which sells intensely personal (although de-identified) data to employers that include the app in company benefits packages. We all know how easy it is to re-identify that data, so it caught my attention. The app collects information on user mood, bodily functions, sexual activity, and ultimately labor and delivery. The article mentions a woman who was using the app in the delivery room to upload data. Were I not a hypothetically swinging single, perpetually 29-year-old clinical informaticist, using an app when I should have been contemplating the perfectness of my baby and his amazing existence would be appalling.

Employers can see aggregated data on health risks, question searches, finances, and return-to-work plans. Depending on the size of the company it might be easy to figure out exactly what employees are documenting. Users are also exposed to targeted advertising for dubious products, including nutritional supplements and special cleaning products. Privacy experts are worried that employers could modify benefits based on projected costs or that discrimination may occur against women seeking pregnancy. Not to mention that some coercion may be involved when companies pay workers to use the app as mentioned in the article.

As someone who previously provided maternity care and delivered over 150 babies, I’m also concerned at the psychological ramifications of this level of tracking in pregnancy. It’s a scary enough time for mothers without having their every move quantified. There is one popular pregnancy guide out there that I actually recommended the mothers under my care should avoid. It included recommendations that shamed mothers who weren’t baking their own whole-grain muffins and said that pregnant women shouldn’t use microwave ovens because of unknown risks to their babies. The so-called “femtech” market is apparently big business, slated to hit $50 billion by 2025.

The Ovia terms of use give the company a “royalty-free, perpetual, and irrevocable license, throughout the universe” to clearly use information for marketing however they see fit. They can also sell the data to third parties and I doubt many of the users actually review the 6,000-word disclosure.

Ovia also claims reductions in premature births and other outcomes, but the data is from an internal return on investment calculator rather than from appropriately constructed peer-reviewed studies. The company makes no secret that it’s delivering content that helps reduce medical costs and encourages women back to the workplace. While researchers are tempted by the availability of large data sets, they’re concerned about the applicability of the data to actual research.

The article mentioned a number of other women’s health apps, including period trackers and fertility trackers. I must admit I was woefully unaware of the size of that market segment. I’d like to see women be better educated about their bodies, but I hate to see some of these apps positioning themselves as something to help “demystify” normal biological processes.

If you had a daughter, would you encourage or discourage her from using apps like these? Would you use them yourself? Leave a comment or email me.

Email Dr. Jayne.