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.

Curbside Consult with Dr. Jayne 4/15/19

I was out with a friend on Saturday, at least until he had to leave to go to a planned downtime event at work. He mentioned that in all the years he had been with his company, it was rare for a downtime or disaster-recovery prep event to go as planned.

Maybe his industry has less tolerance than we do in healthcare, but it got me thinking about the impact of downtime in the patient care environment. The Journal of the American Medical Informatics Association published an article on this recently: “Clinical impact of intraoperative electronic health record downtime on surgical patients.”

Many of us just read the abstracts, and a quick pass yielded some interesting information. Researchers looked at the impact of EHR downtime events lasting more than an hour over a six-year study window. Specifically, they looked at adult patients undergoing surgeries more than 60 minutes in length during an inpatient stay lasting longer than 24 hours. Since it’s hard to do certain kinds of controlled studies on events like this, they matched more than 4,000 patients exposed to one of 176 downtime episodes with 4,000 patients who weren’t similarly exposed.

Looking at the math superficially, this means that the facility was averaging more than 29 downtime episodes a year, each lasting more than an hour. That’s pretty striking – approximately one every 12 days. I’ve never worked in a facility that had that kind of downtime and I can’t imagine the anxiety that clinicians might feel in that situation.

The authors found that although the patients exposed to a downtime event had operating room times and postoperative length of stay that were slightly more than unexposed patients, the 30-day mortality rates weren’t any different. In short, there wasn’t an appreciable link between the length of the downtime event and significant adverse events.

I wondered whether the sheer volume of downtime episodes might have been protective in this facility and decided to dig deeper than the abstract to find out more about the study site. The devil is in the details in this scenario, especially since the data was gathered at the Mayo Clinic. The identified downtimes could have occurred in any of the seven applications considered core clinical systems in support of the operating room. These included the anesthesia information management system, PACS, CPOE, clinical documentation, an integrated clinical viewer, the surgical information recording system, and the surgical coordination system.

Researchers categorized the length of the downtime as well as its impact, whether limited functionality was available or whether it was a complete outage. Scheduled downtime events were excluded as were those less than 60 minutes long. When matching exposed and unexposed patients, the team looked at day of the week as well as time of day to control for any variation in staffing, facilities, and EHR load. The patients were also paired according to surgical specialty, emergency / non-emergent status, and physical status.

The typical downtime was on a weekday between 7 a.m. and noon and was not a complete outage. The most commonly impacted systems were the integrated clinical information viewer, PACS, and CPOE. Surgical subspecialties most commonly impacted included general surgery, orthopedic surgery, and cardiac surgery. The median age of patients was 61 years, with a range of 49 to 71.

Although 30-day mortality wasn’t impacted by downtimes, interoperative duration was about 10% longer for the procedures where there were outages or interruptions. Longer operative times have been linked to greater risks of complications and also can lead to higher costs to the facility. In my experience, this also impacts physician morale, with surgeons who feel their schedules have been delayed becoming irritated and at times agitated. The operating suite is one of the parts of the hospital where the adage about time being money is truly applicable. They also noted a 4% increase in length of stay, which also has cost implications. Both increases underscore the need to have strong plans in place to help staff contend with unplanned downtime.

The authors further conclude that there is a need for future studies looking at scheduled vs. unscheduled downtime and parsing it down to specific systems to determine impacts at a more granular level. They also note the need to look at data from different facilities and healthcare settings. They also identified a limitation in the matching, namely that procedures weren’t matched year by year. Since there are constant changes in surgical technique and significant changes in some procedures, the year could have been a confounder. They also noted that, “In this context, it is not possible to generalize the results of this study at our institution to the potential impact of resilience and specific contingency planning to other hospitals.”

I don’t see other facilities planning to line up to bare their downtime data. Additionally, investigators at other institutions may not have the robust longitudinal downtime data that these authors had access to and they may not have the full cooperation of information technology staffers. I still see hospitals where the culture of fear is alive and well and efforts to study incidents in order to improve processes may still be met with suspicion. There are also those where downtime processes are fairly disorganized and they wouldn’t be suitable candidates for study.

I got a surprise Saturday evening when my friend reappeared unexpectedly from his downtime event. His comment about his company’s events not going as planned was prophetic because they actually canceled the downtime before it even started. It was good for a chuckle, although the theoretical risk of downtime events in the patient care environment is no laughing matter.

I’d be interested to hear what readers think about this EHR downtime study and whether they believe their institutions would be willing to undertake that type of analysis of their own data.

Got downtime? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/11/19

The World Health Organization (WHO) has released its draft strategy on global digital health. Their goal is to “improve health for everyone, everywhere by accelerating the adoption of appropriate digital health.” The strategy calls for a united approach to the awareness and understanding of the role of technology while tailoring solutions for each country. The strategy has two major components: the first outlines four strategic objectives while the second creates a four-part framework for action. WHO is accepting public comments through April 30.

I had the chance to meet up for lunch with a former residency colleague who has also gone through the looking glass to health information technology as a career. He was interested to discuss the dissolution of Google’s AI ethics board less than one week after it was formed. The external advisory board, dubbed the Advanced Technology External Advisory Council (ATEAC), was designed to monitor how Google uses artificial intelligence, but the selection of members became problematic. There is so much to keep up with in the tech world that I hadn’t realized Google had been criticized for its role in a Pentagon drone project and since has said it won’t work on AI-related weapons systems. Google plans reconsider the role of an advisory board entirely, stating it “will find different ways of getting outside opinions on these topics.”

Since he works for a major health system, we also had a chance to discuss our thoughts on accountable care organizations and the shift towards value-based care. He wasn’t aware of recent survey data that shows that more than one-third of participants in the Medicare Shared Savings Program (MSSP) are considering leaving the program. Our friends in governmental organizations love renaming programs, but I’m not sure calling it “Pathways to Success” isn’t going to make it any more palatable for organizations that are concerned about their ability to take on higher levels of financial risk. This year’s survey data represented approximately 40 of the 200 ACOs. Those that are more likely to consider leaving the program included hospital-led ACOs, which have tended to perform below their physician-led ACO peers.

We also had some good conversation around whether medicine is still a vocation or whether it’s becoming commoditized like many other industries. He’s no longer in clinical practice, and like many of our peers, attributes the decision to hang up his stethoscope to the moral injury that healthcare providers face on a daily basis. The reality of clinical informatics is that you don’t have to tell anyone that they have cancer and that their insurance won’t pay for treatment, or have to try to figure out how to help patients pay for their medications when they’re barely covering the rent. I think a string of practice and hospital mergers and acquisitions probably also contributed to his lack of zeal for the primary care trenches.

He hasn’t lost his sense of humor, though, and one of the funniest comments of the day was about trying to address governance and adoption issues while his health system’s physicians are spending a great deal of innovative energy finding new ways to try to say no to technology. We discussed what it would look like if people spent that time learning and mastering a system or re-engineering their practices rather than just raging against the machine. The bottom line is that even across the country and with a different physician population, many of us are facing the same issues every day.

Over the last several decades, the healthcare industry has been increasingly concerned about the role of government in healthcare, so I was excited to see an editorial in the Journal of the American Medical Association on “Building Trust Between the Government and Clinicians.” Co-authored by former CMS Administrator Donald Berwick, it notes that building such trust “requires understanding, empathy, and humility.” It encourages clinicians and policy-makers to walk the proverbial mile in the other’s shoes. The piece calls out several data points that are important – that the US spends nearly double what other similarly-developed nations spend on healthcare without significantly better outcomes or quality.

It goes on to note that some policy makers focus on clinicians who put self-interest above the needs of our society, resulting in the creation of systems to “guard the public from them.” It uses the example of Medicare recovery audit contractors who are paid based on the number of issues they find, putting all physicians on the defensive when only a few are committing fraud. The authors note that “out-of-control oversight and policing for the 1% who warrant this type of scrutiny burdens the daily work of the 99% who do not.” I think most of us in the trenches would agree. In 20+ years in practice, I’ve never had a prior authorization request or precertification request denied, yet I have to continue to jump through hoops to order medically necessary tests.

The editorial calls on clinicians and policy-makers to find common ground that supports both stewardship of resources and the patient care mission. This resonated with me. For policy-makers, achieving fewer and more efficient regulations would be more likely if they spent time understanding the position of the clinicians whom their policies affect. The realities clinicians actually face should provide a lens to view and judge new policies. Unless and until policy makers trust with their heads and feel in their hearts that the vast majority of physicians and other health professionals are well intentioned, they will continue to design policies around the exceptions rather than the rule. Policy-makers should regularly spend time visiting physicians’ offices and hospitals to better understand the ripple effects of policies on those providing care.

It’s similar to having software engineers actually visit clinician practices using the systems they design and create, so that they’re not operating in a vacuum. I’d love to see them observe the folly that my staff had trying to get a CT scan approved after the fact (emergencies don’t occur during normal business hours) when the payer was pushing back because my documentation of the patient’s abdominal pain did not use the word “severe.” I finally asked if anyone at the plan had actually looked at the scan results. Had they done so and seen the enormous and life-threatening pancreatic tumor that was found, maybe they would have toned it down a notch. Instead, they were arguing over semantics. Perhaps they would have preferred to care for a catastrophic event when it eroded through a blood vessel rather than the controlled hospital admission we provided.

They also call on clinicians to learn how the other half lives, understanding policy needs and learning about healthcare spending during medical school. In turn, “the vast majority of physicians who deserve to be trusted” would be rewarded with fast-track of pre-check systems like those used by the TSA. It remains to be seen whether legislators and other policy-makers will heed this advice, but we can be ever optimistic that perhaps someone will see through the money and special interests and give it a shot.

I’m constantly re-engineering my home office and it’s easy for me to take a break because I can just wander to the sofa and put my feet up. Having spent entirely too much time in cubicles and small circulation-less conference rooms, I was intrigued by the idea of a nap desk. Naps are supposed to help improve mental awareness, but I’m not sure I would want to sack out under my desk even if it is made of stylish lacquered wood, metal, and leather. The desk is just a prototype for now, and unless you have your own office, I can’t imagine it would be terribly restful.

What’s your strategy for catching a couple ZZ’s during the work day? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/8/19

I recently attended my medical school class reunion. It was my first time attending, and since it was a “big year” for our class, I figured I should go. I didn’t know what to expect, but it turned out to be a great experience.

The way our school handles reunions is that it has a major reunion event every year, celebrating the classes every five years starting at the 10-year mark. This year was primarily for the classes of 2009, 2004, 1999, 1994, and so on. Once you hit a certain point (possibly 50 years?) they welcome you at every year. We had about 20% of my class attend, and according to the organizers, that was a pretty good turnout.

The festivities started on the hotel shuttle from the airport, where we got to see members of the class of 1969 figure out that they were sitting next to each other and had no idea they were in the same class. Watching their faces light up as they figured it out was hysterical. They immediately started swapping stories about what it was like to be in school 50 years ago. For us relative youngsters, a lot of it was the same, even though times have certainly changed.

We had a member of the class of 1954 on the bus. In her class were four women, and she was delighted to learn that our class was the first one to have more women than men (even if it was only “more” by one person.) Doing the math, we figured she had to be close to 90 years old, but you couldn’t tell. She had a walker, but was carrying it folded up rather than using it.

From there, it was on to a cocktail reception, where two members of the third-year medical school class plopped down at our table. One of my classmates started probing them on “what is it really like to be a millennial,” which was pretty funny. We learned that most of the class doesn’t actually go to class since all the sessions are preserved on video. Back in our day, we had a “note-taking service” that tape recorded every class. The class then took turns transcribing it and highlighting the key points, leaving you with a great set of notes. Although the new students don’t have to attend class, they miss out on the distillation done by their peers, so I’m not sure they’ve really built a better mousetrap.

We must not have scared them too much since they stuck around for most of the reception, although I think they were relieved to not have to attend any other reunion events after that one.

The next day was full of continuing education sessions and tours of the medical center, parts of which have become unrecognizable in a research grant-fueled construction boom. The medical library has very few actual printed materials any more, with the stacks having been replaced by individual study spaces and administrative offices. A new computer lab allows for computerized administration of the tests that have to be taken during third-year rotations, and student-focused spaces now include lounge areas, video games, and areas for extracurricular groups to meet. It’s definitely more student friendly, although there should be more student-friendly resources given the more than doubling of the tuition since I graduated.

Our tour guide,  a fourth-year student who will be graduating soon, seemed surprised by the state of medical education back in our day. We were thrown out into the world to learn our craft on “real patients,” but they have state-of-the-art simulator labs where they are put through a variety of proctored scenarios so they are better prepared for their internships. The latter half of the fourth year provides opportunities to complete life support and trauma certifications, where we had none of that exposure until we walked in the door at our internships.

I have to say I was a little envious about the preparation they are receiving, I think it will make internship a lot less shocking. Our guide was surprised to learn that as recently as we had graduated, we were not subject to duty hour limitations. Her eyes were wide at learning how often we took call and for how many weeks of the year. On most of her rotations she didn’t take call, and when she did, it was one day a week and the shift was limited to 18 hours.

There were presentations from various medical school leaders, where we learned about upcoming curricular changes that are aimed to better prepare students for the realities of medicine. My school has a strong track record for cranking out researchers and academicians, and I was interested to hear that they’re attacking precision / personalized medicine as a way to reduce costs. I had never really thought about it in the way it was presented, that even with the high cost of some of those treatments, the real savings is in patients you’re actually not treating with standard therapies that might not be effective. It will be interesting to see how that plays out in reality. There were also discussions about whether our school will join the club of schools that are providing full tuition scholarships for the entire student body.

Of course the highlight of the reunion was hanging out with classmates and learning what everyone has been up to in the new century. Some are wholly career-focused and driven, others have dropped out of medicine entirely, and there are several of us in-between. As much as physicians tend to talk about the importance of work-life balance, I was surprised to hear one of my classmates make a negative comment about women who had children during their residency training. Instead of celebrating their ability to juggle that level of complexity, he commented “what a strain that must have been on the residency program.” He backtracked a bit when one of the women mentioned that she only took four weeks off after childbirth, because that was the amount of vacation allotted to all residents each year and she didn’t strain the system any more than her counterparts who went to the beach.

Based on our interactions with current students, I suspect there is going to be a lot more tolerance for work-life balance concerns. There may be a steeper learning curve in residency due to the changes in work hour restrictions as students are exposed to scenarios they haven’t seen before because they simply weren’t in the hospital overnight. On the other hand, they may learn faster or better because their brains won’t be mush from working hellish schedules.

I had the privilege of talking with a 90-year-old urologist and getting his thoughts on how things have changed over time. Based on his family history and state of health, the odds are good that I’ll be seeing him again in five years.

Have you ever attended a class reunion? Would you do it again? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/4/19

CMS has launched an Artificial Intelligence Health Outcomes Challenge. The three-state competition is planned to “accelerate artificial intelligence solutions to better predict health outcomes such as unplanned hospital and skilled nursing facility admissions and adverse events.” The CMS Innovation Center plans to use the data “in testing innovative payment and service delivery models.” Partnering with the American Academy of Family Physicians and the Laura and John Arnold Foundation, CMS will award up to $1.65 million during the three stages.

CMS has decided to be confusing by naming the three stages “Launch,” “Stage 1,” and “Stage 2” rather than just numbering them. Launch is essentially an application phase, with 20 participants selected to advance to Stage 1, where challengers will design and test their solutions using Medicare claims data. Up to five participants will move to Stage 2 where they can refine their solutions using additional Medicare data sets. The grand prize winner will receive up to $1M with a $250,000 award to the runner up. Launch is already underway and the program will run through April 2020.

If you’re wondering how to further translate the CMS-speak, the goal is to build “explainable artificial intelligence solutions to help front-line clinicians understand and trust artificial intelligence-driven data feedback to target scarce resources and improve the quality of care.” CMS Administrator Seema Verma explained this further: “For artificial intelligence to be successful in healthcare, it must not only enhance the predictive ability of illnesses and diseases, but also enable providers to focus more time with patients. The power of artificial intelligence will truly be unleashed when providers understand and trust the data and predictions.”

I was talking about this with a colleague, particularly the focus on diseases rather than health and prevention. There are so many factors that could immediately impact both individual and population health parameters that don’t require a challenge or competition. We already know what needs to be done, but lack funding to do it. These not-so-sexy solutions involve things like public health education, social workers, and strategies to eliminate food deserts and improve healthy behaviors. AI is a pretty distraction from the difficult work that could (and should) be happening.

Speaking of the challenges found in trying to improve healthy behaviors, there is much speculation on whether financial incentives make a difference. Many organizations including my own hospital have done this by increasing insurance rates for smokers or offering discounts for non-smokers or those who complete a biometric profile. Discounts for non-smokers seem to make sense because we know smokers have more illnesses thus higher healthcare costs; the benefits of a biometric screening, however, have not been proven. I know that for me personally, going for the biometric screening did nothing to change my behavior, but cost me a half day out of office.

A recent article in the Journal of the American Medical Association looks further at the effect of financial incentives on improving healthy behaviors. In a recent US-based randomized trial, lottery-based incentives tied to medication compliance didn’t lead to a significant reduction in cholesterol levels. Another study found lack of reduction of cardiac events or hospitalization even though patients could earn more than $1,000 for being compliant. Other studies including those looking at smoking cessation in pregnant patients do show some benefit for financial incentives.

The article looks at reasons why studies might not show successful incentive use, including bias created when patients self-select for a study, since those who self-select are more likely to be motivated to change behavior whether there is an incentive involved or not. These motivated patients “rarely represent the population most in need of support, yet they are most often targeted by trials.” There are also issues creating control groups and in timing study enrollment based on patients transitioning through “hot and cold states in which their motivation varies, potentially determining their response to incentives.” Another issue is offering an incentive that is too small for the desired behavior change, which can be a negative motivator when higher incentives may actually drive change.

The authors conclude that when incentive-based interventions are being designed, subtle factors need to be considered, including the size / frequency of the incentive, how it’s positioned, and whether the target population fully understands the incentive and the desired behavior.

From Midwest Afficionado: “Re: pastry therapy. Here’s some for you, Dr. Jayne, in the form of an edible book festival.” Apparently, this is the third annual edible book festival at Washington University School of Medicine in St. Louis. Although submissions were welcome from any genre, there was a special award category for “Most Edible Medical Book.” Submissions will be eaten promptly at 2:30 p.m. Previous entries included a “Checklist Manifesto” Rice Krispy Treat and a tribute to “Grapes Anatomy.”

Data from a recent Kaiser Family Foundation tracking poll indicates that patients aged 18-29 believe EHR technology has led to increased quality of care and has improved provider communication. The age bracket caught my eye since if you consider the pre-MU era (pre-2009) to be solidly pre-EHR, most of these patients weren’t even adults, so it might be a difficult comparison. General public perception of the benefits of EHR has decreased – in 2009, 67% of patients believed EHR would improve care, but a decade later, only 45% believe it has actually happened.

Still, only 6% of respondents said they felt EHR has worsened quality of care and 7% felt communication has worsened. More than 20% of patients said they or a family member has found an error in their chart. More than half of respondents voiced concerns about unauthorized access to the medical record, although younger adults (that 18-29 year age group) are less likely to be concerned than other age groups. I suspect that group is used to having their data used or mined by third parties, or that perhaps they’re just so used to hearing about data breaches that it is less concerning.

The American Medical Association shares sound advice on the use of wearable health devices in practice. They note four main possible issues that should be considered when adding devices to the care plan. Patients might disengage before the benefit can be realized, either due to convenience or perceived lack of benefits. They might also ignore symptoms and rely too much on devices. Others may obsess over the data, resulting in anxiety. Last, they might try to interpret the data without physician help, leading to false-positives and additional intervention. It was a nice little review of what to think about, and should be helpful for physicians who don’t have a lot of experience with wearables.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/1/19

It’s time for a trip through the reader mailbag. I apologize that I’m not able to respond to emails as often as I’d like, but sometimes it’s hard to manage not only a full-time job but my HIStalk gig and the volunteer work I do. I love hearing from readers and I feel like I’ve really gotten to know a handful of them even though we’ve never met or spoken. I’m always impressed by the thoughtful comments that people send my way.

Props to Epic’s MyChart team, who reached out to me in response to last week’s Curbside Consult detailing my experiences with Share Everywhere. They are concerned that it seems to not be working as designed and offered to troubleshoot it for me. I don’t want to risk de-anonymizing myself by revealing the institution, but they did have some good questions to help me further explain what I’m seeing so they can take a look.

I also asked them to help me understand how patients are supposed to report issues since the hospital hasn’t seemed interested in the past at hearing about technical problems I was having with the billing side of MyChart. I would be interested in hearing from readers at other Big Health Systems on how they handle patient concerns about their patient-facing systems, whether Epic or not. It might make for a good post.

A reader sent some comments on my experiences with Share Everywhere vs. MyChart, further illustrating the issues with client-configurable features.

Like many tools made available by Epic, the healthcare organization makes choices and configuration decisions regarding MyChart, Care Everywhere, Share Everywhere, and Lucy. At our organization, problems, allergies, medications, test results and immunizations are all displayed with date information at the summary level as well as at the visit or encounter level. I had not looked at Share Everywhere for some time and was surprised that we do not display provider office notes in the Share Everywhere view. We do make office notes available to our patients, however. We need to explore whether this is an Epic limitation or a configuration option that we have not enabled. New functionality that we are almost ready to enable is sharing radiology images across the Care Everywhere network. Again, Epic provides the capability, we are responsible for configuring and enabling as is every other Epic customer that has chosen to participate in Care Everywhere. We also must choose to make incoming images available to our caregivers, just as other organization will need to decide if they choose to accept and make available images.

No props for the handful of emails I found in my box from people asking if I’m interested in guest posts from the people they represent or asking how they can contribute to HIStalk. It’s immediately obvious when I see those that they’ve never actually read the site or they would know about Readers Write.

Props to the couple of people who reached out to wish me a happy Doctors Day. Although it’s celebrated on March 30 in the US, other days are used in other countries. For example, Iran commemorates it on Avicenna’s  birthday, at least according to Wikipedia. In the US, it recognizes the anniversary of the introduction of general anesthesia using ether in 1842. I’m truly glad we don’t have do bite-on sticks after a slug of whiskey and that we now have less-flammable options.

However, I’m giving negative props to the American Academy of Family Physicians, whose celebratory email offered a discount on AAFP products and conferences, but only for the day. Most physicians I know have AAFP communications routed to their work email addresses and it was a Saturday, so I wonder how many takers they had. I would think they’d have a better handle on how busy their members are and consider offering the discount for at least a couple of days to allow people to take advantage of it.

One of my favorite correspondents sent some thoughts on interoperability and mental health and substance abuse data. They also sent their comments around my mention of the Duke whistleblower settlement:

As to whistleblowing, I was much more idealistic in my youth and pointed out issues to people in authority at my institution that I thought were problematic (generally related to serious patient safety issues, occasionally compliance issues).  Suffice it to say, these minor attempts at whistleblowing never went well for me and never resulted in any significant changes either. I’ve been tempted to “drop a dime” on my hospital to Joint Commission or the department of health, but they always seem to eke through CMS visits with immediate jeopardy in the balance, so the likelihood of any action on a higher scale seems minimal.  It is clear that hospital and departmental leadership can be vindictive to people who throw shade on them despite touting a “just culture.” Without an airtight case, which is virtually impossible to get, whistleblowing seems like more trouble than it’s worth. For every person who gets a big cash payout for whistleblowing, I’m sure there are many more well-intentioned people who will struggle to find another job as a result of their efforts.  For these reasons I’m much more circumspect in my old age and focus on flying under the radar and not making waves.

I’ve had that experience as well, being branded as “frequently dissatisfied” in an evaluation by one member of my residency’s faculty because I used to bring suggestions for improving the program or making things better for the learning environment. I learned quickly that they didn’t see feedback as a gift and that any suggestion would be received as a criticism. Needless to say, when I was selected to be chief resident, my first order of business was to implement the majority of things I had been asking for since I was an intern. Rumor has it that the “New Intern Handbook” we created that year is still in circulation, providing information that no one tells you in medical school, such as how to pronounce a patient dead when you get that call in the middle of the night.

On the topic of EHRs being responsible for the downfall of the patient-physician relationship:

Not too long ago, our group surveyed members and only one person made any remarks about the computer and that was “the EMR sucks.” Everyone else mentioned low salaries, poor communication from leadership, deteriorations in workplace safety and increased staff injuries, excessive emphasis on RVUs, and lack of respect for clinicians by leadership. I really don’t believe EHRs are the root of all evil.

I didn’t have to worry about anonymizing the comment, since those are the same issues I heard at the last meeting I attended of my hospital’s emergency medicine attending physicians.

I’m going far into the wayback machine on this one, but I posted in February about my flashback on the Addressograph machine. Apparently extinct technology is a hot topic:

The addressograph brought back memories! One of my first tasks in healthcare was to write program for the machine that produced those cards. We reprinted those cards every other day for inpatients because the numbers and letters would wear out. Later when I was in management I worked to replace them with stickers. The ward clerks did not want to give up their addressograph machines!

Addressographs were definitely a lot of fun! (Though the smell wasn’t quite as good as freshly printed mimeograph,) They were also very practical in terms of quickly getting an index card with the key patient info at the top that could be used to keep signouts much more efficiently than our current electronic physician handoff page. A saved index card was also like gold when the patient bounced back, unlike the current physician handoff that gets deleted at discharge.

I had forgotten about those signout pages. For those of you who are not on the provider side, when the resident physicians leave for the day, they sign out to the on-call team, which is responsible for covering patients they may never have met. In the olden days, we would meet with the on-call resident before we left the hospital. We would pull those sheets from our white coat pockets and give a brief rundown on the patients we had been caring for. The sheets might have included med lists, labs, problem lists, and other tidbits of information that would help the on-call team know what to do if an issue came up with the patient. Some of us even got fancy and created templates for our sheets to ensure we wouldn’t forget important information. The size limitation forced you to be concise and only focus on the most important information, which is probably becoming a lost skill from the voluminous charting we have in the EHR.

Another reader waxed poetically about dial up modems:

I also found there was something satisfying about hearing the sounds that meant your modem had connected and the old acoustically coupled dialups (where your phone receiver went into the rubber connector) were very amazing at the time.  It definitely beat standing in line at the computer center with a giant stack of keypunched cards (praying that you didn’t drop them and have to put them back in the right sequence.)

The “antique” technology that had the most mentions isn’t antique at all since it’s still in use at many hospitals — the beeper:

My favorite old technology has to be the old versions of beepers. When I was an intern, beepers just beeped. Nothing else. You called the paging operator and they gave you your message. These beepers had two advantages: you could cross your arms in a boring lecture and surreptitiously turn them off and back on again, which would make them beep. Then you could quickly escape to go outside to the hall phone and address your “page.”

The Motorola Adviser was my workhorse pager during residency, and according to one reader:

It has been granted eternal life. We still have them (and fax machines). Everyone has been saying for years that we should switch to cell phone “paging,” but there are cell phone dead zones and the beepers have much better coverage.

I’m closing up the mailbag for now. Keep those virtual cards and letters coming!

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