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Curbside Consult with Dr. Jayne 2/4/19

February 4, 2019 Dr. Jayne 1 Comment

Our EHR friend John Halamka, MD co-authored a piece in the Harvard Business Review earlier this month regarding strategies for making EHRs less time-consuming for physicians. Their ideas are sound, although I’d like to expand on them a bit from the trenches.

The first point made is the need to “standardize and reduce payer-imposed requirements.” On the surface, they’re talking about the documentation requirements for an office visit, which in the US is approximately 700 words. This is significantly longer than the average note in other industrialized nations, including Canada, Australia, and the UK.

CMS is attempting to provide leadership here in blending the codes for certain Evaluation and Management (E&M) codes, therefore “reducing” documentation in some areas, but it doesn’t go far enough. Instead of trying to describe complex rashes, why can’t we upload pictures and have that count for payer documentation? Instead of trying to describe a trauma or laceration, we could fully document it. In those situations, the adage about a picture being worth a thousand words is true.

Getting relief from onerous workflows in the EHR is one thing, but if you want to impact clinician satisfaction and reduce burnout, I’d go a step beyond to look at other payer-driven workflows such as pre-authorizations, pre-certifications, and peer-to-peer conversations that waste clinician time.

I was called recently to provide documentation to prove why I needed to order a CT scan of a patient’s abdomen since an insurance reviewer felt I hadn’t given the right information. I asked the reviewer if she bothered to look at the patient’s CT scan result. Perhaps the large pancreatic tumor that was discovered — based on my clinical suspicion and corroborating exam findings — should be enough to prove why the CT scan was necessary. She stated she didn’t have access to the reports. Instead of using their own resources to review the outcome, they wasted my time trying to prove something that turned out to be obvious.

The second point made by Halamka et al is that EHR workflows need to be improved. I whole heartedly agree with the need to remove non-value-added steps from the workflow and to minimize disruptive or unnecessary alerts. Information needs to be available to the people who need it, at the time they need it, and at the appropriate level of detail. Our EHR went haywire for a while and every user was seeing a popup declaring that “Eligibility Checking has returned on John Doe,” which was ridiculous and took several days to correct.

No matter how much improvement vendors make in their workflows, however, there is still the tendency for practices to misapply those workflows, either through lack of understanding or lack of skill. Our EHR continues to throw errors whenever we try to prescribe certain medications because the NCPDP codes aren’t mapped. I know our vendor uses the premier database for medications, so I have to assume that it’s poorly implemented in the practice. If there are risks that a client might not keep their formularies up to date or might have implementation issues, then vendors should consider process that provide automatic updates so that physician workflows are preserved. A nice side effect is that confidence in the vendor will increase, since physicians rarely understand that their own practice has misapplied the technology and tend to blame it on the vendor.

The team’s third point is that the EHR user experience needs to be improved. I don’t know of a physician out there who wouldn’t agree with this point. I continue to see EHR “upgrades” and “enhancements” that are downright silly. One EHR that was shown to me by a client had a title bar that was blue and displayed the patient’s name and information. Since the EHR would allow you to have multiple patient charts open at the same time in separate windows, the title bar was essential so you could not only see quickly which patient was loaded, but also so that you could tell which window was active. In the interest of making the screens more “vanilla,” the vendor removed the blue title bar, making it much more difficult to see which window was active, forcing users to go to the Windows taskbar and click on the different taskbar buttons to cycle them and reactivate them. The upgrade was definitely a downgrade, and since it’s been that way for a year, I doubt the vendor thinks it’s an issue.

Another EHR claims to be “mobile friendly” but the screens don’t fit on a standard mobile device, requiring right-to-left scrolling of popups, which isn’t very mobile friendly. When trying to use it on my Microsoft Surface, it won’t accept the native handwriting recognition input and instead makes me use a tap-tap-tap keyboard to enter data. What a waste of time. The same EHR doesn’t have restricted fields for blood pressures, allowing nonsense values such as 80/1000 to be entered. For years, vendors used the ongoing proliferation of regulatory requirements as an excuse for why they couldn’t develop “nice to have” features that end users had requested. Now that those requirements have slowed a bit, I don’t see vendors sinking vast amounts of R&D funding into usability.

I continue to see healthcare IT products that don’t include basic elements of usability, such as using indicators beyond color to indicate whether lab values are high or low. Someone who is red/green colorblind isn’t going to see your red/green schematic – they need other indicators, such as graphics or text, to provide meaning. I see vendors that include password requirements that don’t meet current NIST recommendations, such as requiring overly long passwords with high degrees of complexity or mandating changes every 30 days. Clients can’t opt out in many cases and are stuck with a vendor’s interpretation of security needs that is out of date or untenable. I see EHR searches that can’t handle partial strings or aren’t intelligent enough to recognize typos.

I can’t wait to get to HIMSS next week and see what vendors have been up to and whether they should move up in my Hall of Fame or should be relegated to the Hall of Shame. I’d like to see some bold new user interfaces with lots of bells and whistles intended to keep physicians happy. I hope I’m not sadly disappointed.

If you’re a vendor and have bells and whistles you want to show off, leave a comment or email me. I’ll be sure to drop by anonymously and check it out.

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EPtalk by Dr. Jayne 1/31/19

January 31, 2019 Dr. Jayne 2 Comments

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It’s officially HIMSS time, with the first set of party invitations hitting my inbox this week. I am sad to say that there is so much overlap I’m not going to be able to make half of what I’d like to attend – too many events on Tuesday evening, for sure. I’ve heard from several vendors who are also doing happy hours in the exhibit hall (one that even lets you start getting happy at 3 p.m.) so it’s going to be all about pacing yourself, along with having good shoes.

I’m also starting to get information about product launches or significant updates that vendors are featuring. If you want me to consider dropping by your booth, let me know what you’re showcasing at HIMSS and I’ll see if I can work you into one of my booth crawl schedules. So far, my list of must-see booths include HIStalk sponsors FormFast (#2121 )and perennial Dr. Jayne favorite First Databank (#1921). I’m also looking to attend a session about Vanderbilt University Medical Center’s efforts to include voice assistants within their EHR.

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I’ve also got Medicomp (booth 3901) on my must-see list, especially with their new OpEHRation Game. They’re giving away $100 every half hour, so I’m sure there will be lots of others checking it out. I’m looking forward to seeing how they deployed their Quippe Clinical Documentation solution within CareCloud’s platform. They have a dedicated HIMSS page, which was great for better understanding what they hope to accomplish at HIMSS and what they’ll be showing. I’ve heard they’re also getting into the HCC coding space.

I’ll definitely be strolling the hall with phone in hand, capturing the moment and the craziest things I see. After HIMSS, I’ll go back to my curmudgeonly self, keeping my phone out of sight and out of mind bolstered by research that continues to show that trying to capture the moment for posterity actually interferes with the experiences themselves. Research by faculty at the Olin Business School of Washington University in St. Louis also looked at texting during experiences and concluded that “behaviors, such as texting, tweeting, and posting on social media that surreptitiously distract people from the moment” result in “diminished enjoyment.”

I’m always exhausted when I return from HIMSS, so I’m wishing that someone would sneak in while I’m away and install this innovative new sleep platform that has been shown to improve sleep and memory. Maybe the sleep would be more restful – research subjects fall asleep faster when rocking and spend more time in deep sleep.

From Smoke ‘em if You Got ‘Em: “Re: recent piece Thanks for your recent piece on medical marijuana. You’re not the only one doing homework on the topic. Cleveland Clinic has also decided to Just Say No.” The Cleveland Clinic shared their opinion  earlier this month in an op-ed piece, stating, “We believe there are better alternatives. In the world of healthcare, a medication is a drug that has endured extensive clinical trials, public hearings, and approval by the US Food & Drug Administration. Medications are tested for safety and efficacy. They are closely regulated, from production to distribution. They are accurately dosed, down to the milligram. Medical marijuana is none of those things.” The piece calls on the US and Ohio governments to “support drug development programs that scientifically evaluate the active ingredients found in marijuana that can lead to important medical therapies.” I suspect the client I mentioned last week will likely decide along those same lines.

Planned Parenthood is entering the world of chatbots with its new offering Roo, which is designed to interact with teens 13 to 17 years old via text message. Topics include birth control and sexually transmitted diseases. The project was funded through a private grant with hopes that teens would embrace the anonymous nature of the chatbot to ask questions they may be afraid to ask elsewhere. When I was a medical student teaching sexual health in a school district where there was a high rate of teen pregnancy in their middle school, we used the low-tech “write your question down and throw it in the hat” to reduce barriers to asking questions. It was amazing what they didn’t know about their own bodies and how pregnancy and diseases can happen.

CMS has released the “What’s Covered” app to display what “Original” Medicare covers for patients. It distills some of the most-visited content from Medicare.gov into a format that can help beneficiaries and their caregivers see what is covered. I can tell you right now that most of my Medicare-eligible relatives have no idea whether they’re on Original Medicare or a Medicare Advantage plan, despite whatever any wording on their materials might say. CMS began its eMedicare initiative in 2018 to deliver information to its beneficiaries, noting that about two-thirds of them use the Internet on a daily or near-daily basis. Other tools are being designed to help patients sort through their coverage options and understand what their choices might do to their out-of-pocket costs. I hope that make those tools available to physicians, because half the time I can’t quickly find the information I need to best counsel patients and loved ones.

The institute for Medicaid Innovation is calling on EHR users to increase their use of ICD-10 codes to document social determinants of health. Z56 covers issues with employment and underemployment. I actually used Z56.5 (uncongenial work environment) last week to document a patient who was having issues with absenteeism due to a coworker harassing her. Z59 covers problems related to housing and economic circumstances including homelessness, poverty, lack of safe drinking water, and more. Both codes are non-billable, but help to quantify the number of patients facing serious challenges.

NCQA is redesigning its Patient-Centered Specialty Practice and Oncology Medical Home programs, with a launch scheduled for July 1, 2019. The redesign mirrors changes to the flagship Patient-Centered Medical Home (PCMH) program, redesigned in 2017. A crosswalk  matching the new PCSP program to the 2016 program is available along with a video summary of changes. Practices will engage in ongoing transformation with annual reporting instead of the current three-year recognition cycle. NCQA cites multiple reasons for the change, including increased flexibility for practices, simplified reporting, and better alignment with current public and private initiatives along with greater adaptability to future changes.

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As we tick ever-closer to Valentine’s Day (which some of us will be celebrating at HIMSS) I’ll be mourning the loss of conversation hearts. Candy producer Necco folded last year and the new owner Spangler Candy Company decided not to make any this year because it couldn’t ensure it could meet consumer expectations since the acquisition didn’t occur until September. Hopefully they’ll be back for the 2020 Valentine’s season, but until then, I’ll be looking for other options. I’m betting more than one HIMSS exhibitor will be handing out candy.

If you’re exhibiting, will you be incorporating Valentine’s Day into your booth swag? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 1/28/19

January 28, 2019 Dr. Jayne 1 Comment

I had a particularly gruesome Sunday in the urgent care trenches. Not with the expected cases of influenza, but with people behaving badly.

It has been years since I worked in the big-city emergency department, so I never dreamed I’d be searching for handgun-related ICD-10 codes at one of our sleepy suburban urgent care locations, but there I was today (in case you are curious, it’s the Y22 series of codes for handgun discharge, undetermined intent.)

These are the days you want to just head home, drink an adult beverage, and relax. But that’s hard to do when you are two hours past closing time and still seeing patients who waited until the last possible minute to be seen. Woman with the toddler that fell of the sofa and hit his head on the coffee table — no worries, we got this. Man who has been vomiting all day but waited until after a certain TV program was over before he came in — not so much. (Note for the future, we have large, flat-screen TVs in all our patient rooms and you could have been watching your show with some IV fluids and good drugs rather than vomiting into a trash can at home.)

I had several patients get mad that our independent urgent care is not part of the big health systems and doesn’t share data with them. It’s hard to explain to information blocking to patients, especially when it’s their much-loved hospital’s policy that we can only fax information to their practices and can’t send anything electronically. We can’t even get a directory of fax numbers for the owned practices or employed physicians, requiring us to call each office to track down a fax number if we don’t already have one in our file. If they won’t even receive our information, you can guarantee that they aren’t going to share theirs with us.

I experienced this acutely earlier in the weekend, when I had to refer a patient with a new cancer diagnosis and the potential need for an emergent surgery to the emergency department at one of those local powerhouses. I called six hours later and asked to be transferred to the nursing unit for patient X, only to be told “we don’t have her” by the switchboard. Apparently, that’s code for “she hasn’t been admitted to our facility” and the central patient directory service was unable to tell me if she was still in the emergency department.

It wouldn’t be unheard of to spend many hours in the ED during peak influenza season, so I asked to be transferred. There I was told that not only did they not show her as a patient, but they couldn’t tell me if she had ever even arrived because “we can only see patients in the system for up to two hours after discharge.”

I asked to speak with the charge nurse and summarized the situation back to her, saying, “Let me make sure I understand. She hasn’t been admitted and no one can tell me if she ever even showed up because the computer restricts access by ED personnel after two hours.” She confirmed that is what happens, which just floored me as a referring physician.

When I called the ED prior to the transfer to tell them about the patient, I had given the name of the patient’s surgeon. Since I know the surgeon well, I decided to call her to find out what was going on. It turns out they didn’t even call the patient’s attending surgeon, and you can bet that my colleague was livid when I called her to find out what was going on. Since she’s a faculty physician, she immediately accessed the EHR and I could almost hear the steam coming out her ears. Not only did they not call her, but they called a surgery resident to assess the patient in the ED. That resident in turn called the on-call surgeon (on-call for patients who don’t already have a surgeon, that is) rather than the patient’s surgeon. The on-call surgeon decided to send the patient home.

The patient had a couple of critical lab values and some ominous ultrasound findings, yet there was no consultation note from the surgical resident and no ED physician note in the chart to help anyone understand the thought process. We’re not sure what the patient understands about her care and what she thinks about being referred to a general GYN for follow-up care rather than the GYN-Oncologist she needs.

I’ve been trying to call the patient for two days. I’m sure she thinks her surgeon and I are either incompetent or clueless since we’re the ones that referred her to the hospital for potential admission and a possible procedure. She hasn’t returned my calls and I feel terrible. These kinds of episodes are becoming more and more common in our healthcare non-system.

At least in this case, I’m eternally grateful that my colleague was able to pull up the EHR chart (such as it was) on her phone while at her daughter’s sports practice so that we would at least know that the patient made it to the hospital and had some additional testing. Hopefully her office will have more luck reaching the patient than I have.

How different things would be if we had actual coordination of care and information sharing. I sent the patient to the ED with paper copies of all the tests we performed at our facility, along with a CD copy of her imaging studies. I wonder if the hospital even looked at what I sent (they certainly didn’t pay much attention to my referral report) or if they just started over? Our practice requires that the “business end” of each patient chart is complete prior to discharge – vital signs, exam, procedures, assessment, and plan. For patients referred to another facility or transferred by ambulance, we have to get the entire chart done and printed to go along with the patient. Even though the ED in question uses scribes, the note still wasn’t done more than two hours later. Despite every clinical employee having advanced communication devices on every shift, they still couldn’t make the right phone calls.

In this situation, I don’t even have anyone to complain to or share concerns with since I’m sure they don’t really care what a lowly urgent care doc at a competing facility thinks. All the technology in the world won’t help when you don’t have the right processes in place or the staffing isn’t optimized to support people doing the right thing. Unfortunately, the patient suffers. I’ve got seven more shifts before I head to HIMSS and I certainly hope they’re better than this one.

Have your own terrible tales of information blocking? Leave a comment or email me.

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EPtalk by Dr. Jayne 1/24/19

January 24, 2019 Dr. Jayne No Comments

I had a chance to sit in on a Medicare Chronic Care Management (CCM) webinar from Greenway Health while I was on site with a client today. It was nicely done, with a concise agenda and a strong presenter. The sales component was kept to a minimum, with the majority of time being spent educating attendees about chronic care management in general and only a small part was spent on the vendor’s solution. The webinar was also 30 minutes rather than the hour we sometimes see scheduled for these events, which made it easier for a busy practice to squeeze into their day. My client had a response to her follow up request within three hours of the end of the webinar, which was much appreciated.

While the US federal government shutdown rages on, there’s a bill pending in the Senate that would allow for importation of prescription drugs from Canada. When I first started in practice, we used to refer patients to an Ontario-based pharmacy to obtain a particular respiratory medication that had been proven effective around the world but wasn’t available in the US. For some, it’s not just about a potential cost savings, but about helping patients with access. It’s unlikely to get through the Senate, but it’s the thought that counts. Thanks to senators Chuck Grassley (R-IA) and Amy Klobuchar (D-MN) for giving it a bipartisan try.

The Food and Drug Administration is running out of money to fund reviews of new drugs, according to a Fortune piece online. During the shutdown, they’re not collecting user fees paid for drug and device reviews, so they’re trying to use leftover money from 2018 to keep the lights on. FDA Commissioner Scott Gottlieb plans to furlough more employees to keep things moving since drug reviewers aren’t allowed to work unpaid as they’re not considered “essential.” Gottlieb first caught my attention last month when he used Dr. Seuss-style poetic meter to warn against the hazards of eating raw cookie dough.

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It’s barely more than two weeks until HIMSS and they’ve released the #HIMSS19 Hashtag Guide. There are more than 20 of them, which is about 19 more than I’m going to be able to keep track of unless they come as part of a snuggly quilt like this one. I’ve already had my quota of below-freezing days this year and there is no end in sight, so it’s definitely time to pile on the blankets.

It’s the last week to comment on ONC’s draft “Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.” I hope they make the public comments available to all of us, because it will make for some excellent snow-day entertainment. You can comment through 11:59 p.m. on January 28. Get those creative juices flowing. Feel free to share any amusing entries with the rest of us while we wait for the full report.

I’m always excited to see startups or other vendors making it easier to diagnose and treat diseases, particularly ones that either (a) no one wants to talk about; or (b) those who want to talk about it only want to do so to make a political point. Nurx is best known as a telehealth company specializing in birth control pills for women, but now they’re moving into at-home testing for the Human Papilloma Virus (HPV). The test is limited to existing customers, but will be expanded to new customers in 2019. Commercial insurance provides good coverage, although there is a $15 shipping and processing fee. They also offer PrEp, a treatment that reduces the risk of acquiring HIV. These are areas where some of the more mainstream telehealth groups aren’t ready to tread, so hats off to them.

Speaking of telemedicine, the American Academy of Family Physicians (AAFP) blog “In the Trenches” says the Academy is “working to make sure telemedicine is real medicine.” There’s much greater insurance coverage for telehealth services of late, and most states require payment for certain services whether they’re delivered face-to-face or through telehealth technology. It sounds like their focus is on helping traditional family medicine practices to add telemedicine services rather than seeing how telehealth might fit into the broader scheme of things.

The blog author refers to solutions that compete with their ideal traditional practice as “leakage” and makes it clear that he thinks that patients using urgent cares, retail clinics, or direct-to-consumer telehealth services are part of the problem, specifically calling out vendor Teladoc and citing his own “Twitter rant” about its partnership with Aetna. He goes on to demonize telehealth providers as “Snapchat for antibiotics” and “basically Tinder for healthcare.” The gloves are off, apparently.

AAFP has a partnership with Zipnosis for telemedicine, but it is only available for “small, private practices with less than 20 physicians.” It doesn’t support billing when patients have telehealth coverage through insurance and doesn’t integrate with EHRs. They recommend physicians (or their administrative users) download a PDF of the visit (which is documented using a third-party platform) and update EHR medication and diagnosis lists manually. That’s not exactly revolutionary, and if AAFP is serious about having a great solution, I can recommend a physician informaticist who might be able to help.

Regardless of how much AAFP continues to preach about longitudinal relationships with primary care physicians, that scenario just isn’t the reality for many patients in the US. Insurance plans change, networks change, and then there’s the situation where people change jobs and get new insurance and have to switch physicians. Our culture has changed, and many patients don’t value that relationship with a physician because they’ve never experienced it or are turned off by the way that a lot of practices run. Convenience and accessibility trumps that relationship. People are willing to risk counterfeit products via online purchases rather than going to a brick-and-mortar store, and those kinds of sentiments spill over into other facets of our lives.

Not to mention that there are many physicians who have left traditional primary care practices because of lifestyle issues, relatively low compensation for long hours, and burnout. AAFP would do well to encourage physicians to explore practice situations outside the organization’s historical ideal in an effort to keep people working as physicians. As an urgent care physician, I’m part of their “problem,” but it’s gratifying to be the family physician (albeit temporary) for patients who can’t see their own. I’m starting to wish I hadn’t paid my dues for 2019, but I don’t think they give refunds. I haven’t seen that level of vitriol from professional organizations that represent pediatrics or internal medicine.

What do you think about the future of telehealth? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 1/21/19

January 21, 2019 Dr. Jayne 2 Comments

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Being a consultant who is also a physician, I sometimes have the opportunity to work on projects that might not happen if I didn’t wear both hats. This week I worked on a project that I never thought I’d be staffing – a comprehensive analysis of medical marijuana policy for a fairly large healthcare organization. I’m a year into an EHR consulting engagement with them as their independent “physician whisperer” to help physicians who are struggling with adoption, so I was surprised when they asked if I’d be interested in taking on another engagement on a different topic.

I’m pretty sure I was pulled in so that the project could be done somewhat off the books, allowing someone who isn’t a stakeholder to pull the facts together so that the actual stakeholders can have a focused discussion of their options. The organization has a policy that prohibits its employed physicians from participating in the state’s medical marijuana program, but the leadership is under pressure by a subset of physicians to change its position.

It’s similar work to what I did in the CMIO trenches and we wanted to research a new system or solution and determine what kinds of impact it would have on patients and providers. I had to dig into the people, process, and technology issues along with legal and regulatory ones. I am putting together pro/con documentation of the various risks and benefits along with cost modeling for implementation and support of this new service line.

I’ve also done some reference calls with other organizations to see how they are handling and documenting medical cannabis in their practices. It made for some fun voicemails. “Hey there, it’s Jayne. Hope you’re having a good New Year. I’d like to grab 15 minutes on your schedule to talk about marijuana.” Not exactly a sentence I ever thought I’d be saying, but it’s been an interesting project.

Since I’m mainly reaching out to informatics colleagues, they have ready access to data, which has been great. If their physicians participate, they can tell me how many recommendations, certifications, or referrals are being done over the course of a year and what conditions are most commonly being treated. It’s been great to get the objective data and not just talk about the policy piece.

Overall, it seems that a very small number of organizations allow their employed physicians to be part of state medical cannabis programs. Most of the folks I’ve spoken to that work in organizations that permit it have had to customize their EHRs to some degree to support the workflow, which makes sense given the different programs and requirements in the states that allow medicinal use.

One clinical informatics team is playing it both ways. The health system’s physicians aren’t allowed to refer for it, but the independent community physicians that are on the shared EHR platform have the autonomy to do what they want. That makes for some interesting permissions issues in the EHR.

My informatics connections noted that there have also been concerns from patients about privacy issues and whether information about marijuana recommendations become part of the record that is transmitted to other physicians. That can be a grey area. In many states, drug use is considered sensitive information, but if it’s considered a medical treatment, that might fall outside the realm of a sensitive authorization and might be sent without a patient having the ability to restrict such sharing.

Since I cast my research net pretty wide, I was surprised to learn that there is a robust niche for medical cannabis in the telehealth world. California, New York, and Nevada allow such visits to be done via telemedicine. One firm, PrestoDoctor, has conducted more than 50,000 appointments, with patients sending documentation from their local physician prior to an online consultation with one of its physicians. Pricing varies by state, from $49 in the Golden State to $139 in the Empire State. PrestoDoctor also sells various products and accessories on its website, including a bacon-flavored hemp extract for pets.

I also learned that there are cannabis-specific EHRs, along with specialized billing systems since many cannabis practices are cash-only. Other practices use traditional practice management systems and submit regular office visit codes to insurers.

There are plenty of specifics that have to be figured out. Since federal law still considers marijuana an illegal drug, states have developed mechanisms for physicians to “recommend” its use rather than prescribing it, or to “certify” a patient’s qualification under state law. Neither of those approaches fit nicely into the usual EHR’s selection of medication modules, durable medical equipment management, or referral / authorization workflows. States also have varying lists of qualifying conditions, and the small number of clients who might want cannabis content aren’t going to make it sensible for mainstream EHR vendors to support those workflows. I reached out to a couple of vendor friends to find out where medical cannabis might be on their EHR road maps, and the responses ranged from “what did you just say?” to outright hysterical laughter.

Now that the research is largely complete, I will be spending a fair amount of time creating documentation for the discussions and making sure that I have answers to the questions that stakeholders are likely to ask. I will also be putting together the cost modeling to determine whether it makes financial sense to add the service, along with recommendations for technology and workflow changes that might be needed to support an implementation.

I’d like to get permission to independently survey the physicians to determine what percentage would go through the process to be able to recommend medical marijuana, which would significantly impact the decision. I suspect that it’s a small vocal minority and that the majority of physicians aren’t at a place where they would want to do it, but the organization doesn’t want to get people agitated around the issue until it has more of a grasp on what it would entail. There’s clearly enough interest to engage a consultant and I’m not complaining about a bit of unexpected work during an unanticipated slow period.

Does your organization allow physicians to participate in medical cannabis programs, and if so what solutions have you had to employ? Leave a comment or email me.

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EPtalk by Dr. Jayne 1/17/19

January 17, 2019 Dr. Jayne No Comments

All is not quiet on the Congressional front, with the House Committee on Ways and Means sending a letter to CMS Administrator Seema Verma asking for greater transparency in the development of alternative payment models. The Committee notes that “significant policy changes made unilaterally by the executive branch without sufficient transparency could yield unintended negative consequences for beneficiaries and the healthcare community.”

The letter goes on to note that the Center for Medicare and Medicaid Innovation (CMMI) is tasked with consulting experts in medicine and healthcare management, yet the model development process doesn’t always follow the traditional rulemaking cycle that includes public comments. The letter requests that CMS provide a list of “models under active consideration by the agency,” including timelines, comment periods, etc. and gives the agency two weeks to deliver a response. I won’t be holding my breath to see what CMS says.

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The US Government Accountability Office has also been busy, releasing a report this week regarding challenges for matching patient records across provider platforms. The 21st Century Cures Act required the GAO to review current matching practices and ways in which federal bodies might improve things. The report highlights work by the Pew Charitable Trusts to improve matching, including standardization of demographic data such as addresses and how EHRs use that data and exploring how biometrics might assist in matching.

It’s clear that we aren’t going to see a universal patient identifier anytime soon, which makes it incumbent for members of the patient care community (including EHR vendors, hospitals, providers, and payers) to come together and create solutions. Having worked with multiple EHRs, I can attest to the fact that some of them don’t even follow US Postal Service formatting standards for addresses, which boggles the mind since they’re readily available and used in many industries. I’ve seen multiple online retailers use the address formatting technology, so I’d think that my medical records should be at least as important as the breadmaking supplies I ordered recently.

The game is afoot for organizations ready to submit 2018 Merit-based Incentive Payment System (MIPS) data. Those eligible clinicians who participated have until April 2 to get the job done at the QPP website. There is a new system in place with a compound acronym – the HCQIS (Health Care Quality Information Systems) Authorization Roles and Profile (HARP) system will be used.

I’d recommend logging in early to make sure your credentials from the previous Enterprise Identity Management (EIDM) system were transitioned correctly and to register with HARP if needed. On a lark, I checked my participation status using the QPP Participation Status Tool and was surprised to see it list a location where I have never seen patients. I’ll be taking the penalty, so will leave it up to my practice administrator to sort it out.

CMS also announced that the new Medicare card mailing process is complete, and that nearly 60 percent of claims are being submitted with the new Medicare Beneficiary Identifier (MBI) numbers instead of Social Security numbers. The final wave of mailings includes Medicare beneficiaries who live in Canada and Mexico. While the final transitions are being worked out, patients can use their old cards through December 31, 2019, although I hope those transactions quickly become few and far between.

Walgreens is uniting with Microsoft to create so-called “digital health corners” for its retail stores. Walgreens plans to begin using the Microsoft cloud and data centers, which means no business for rival Amazon. Walgreens CEO Stefano Pessina is quoted in the article as saying, “Healthcare is too complicated, too big, and if I can say, a little too messy” thus the need to “team up with many, many different, practically all, the players in this industry.” I guess they consider cosmetics service Birchbox to be an industry player since they’ve signed a deal with it as well. The “digital health corners” will be piloted in a dozen stores and are intended to promote management of chronic diseases along with sales of health-related devices. The deal also includes Walgreens signing on for Microsoft 365 services.

In other retail news, Walmart is breaking with CVS after a squabble over prescription pricing. Patients with CVS Caremark pharmacy plans will have to find other places to pick up their medications, although I suspect other providers can’t possibly compete with the loss of the people-watching opportunities at Walmart. In a confusing twist, Walmart-owned Sam’s Club pharmacies remain in-network, so you can still pick up your bulk items at the same time as your pills.

I’m helping some practices make the move to telehealth and have been poring through the literature looking for data on outcomes from virtual care vs. traditional in-person visits. A recent news release from Massachusetts General Hospital caught my eye, as their work was published in the American Journal of Managed Care. The authors found that video visits maintained the same perceived quality of care and communication as in-person visits, while being found more convenient. Mass General has been doing telehealth for more than a decade, with video visits being offered for the last five years for patients requiring follow-up care. Additional key findings included:

  • 79 percent of patients found it easier to find a convenient time for a follow-up video visit compared to an in-person office visit
  • 21 percent of patients thought the overall quality of virtual visits was better
  • 68 percent of patients scored the video visit at 9 or 10 out of 10, and those ranking it low typically cited technical issues as the reason.

Several of my close friends have reached out about HIMSS preparation, especially wanting to know whether I’m in full party-planning mode yet. Although I’ve received a couple of advanced notices from people who want to be sure their event makes my must-attend list, I really haven’t seen much in the way of invitations yet.

One of my usual HIMSS BFFs is likely not going to attend HIMSS this year. The value just isn’t there and it’s time away from work and family that doesn’t seem very productive any more. I have to admit I’ve had second thoughts about attending due to the cost and the general hassle factor, especially since my practice is being very grumpy about allowing the time away in the middle of flu season and the opening of two new locations. I held my ground on the time off, however, since by not going I’d sorely miss the opportunity for those once-a-year catch-ups that I really enjoy.

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Curbside Consult with Dr. Jayne 1/14/19

January 14, 2019 Dr. Jayne 2 Comments

I’ve always wanted to attend the Consumer Electronics Show, but have never been able to get my January schedule to cooperate. That puts me with the rest of the tech aficionados in perusing various blogs and write-ups to find the best new healthcare-related gadgets.

This year’s CES booked 25 percent more vendors with a health focus, which equated to nearly 15 percent more floor space for health tech offerings. I’ve been poring over reports and write-ups and there were quite a few offerings this year that generated a lot of attention. I thought I’d share some of my favorites:

  • Withings showed its Move ECG watch, which is kickily analog but still awaiting FDA clearance. As a physician, I’m not sure of the utility of real-time ECG monitoring for most patients, so it feels more gimmicky than anything else.
  • The Y-Brush toothbrush claims to clean your teeth in 10 seconds using precision nylon bristles positioned at an optimal 45-degree angle. The recommended two minutes for brushing isn’t really that long, however, and I’m not sure the mouth guard-looking device is going to get much consumer uptake.
  • The Hupnos sleep mask links with an app that listens to your snoring and triggers the mask to vibrate so that the wearer moves to a position that is less likely to result in snoring. The mask can also apply Expiratory Positive Air Pressure (EPAP) to help keep nasal passages open. I’ve been on a couple of flights lately where this device would have been a bonus.
  • The Opte Precision Wand from Procter & Gamble’s venture capital division uses blue LED lights to identify dark spots on the skin. Over 100 thermal inkjet nozzles then apply skincare serums, moisturizer, or makeup to even skin tone. They should also consider tattoo covering cosmetics for workers whose employees have restrictive grooming policies, which I’m seeing more and more often in healthcare.
  • Verde launched an electricity-generating treadmill that might let me generate enough juice to power the IPad that serves up enough Netflix to keep me sane on any treadmill-delivered workout.
  • The Chronolife vest aims to monitor vital signs and use machine learning to predict the possibility of an impending heart attack. It will be marketed to healthcare providers, researchers, and insurance companies. FDA approval is still pending.
  • Urgonight is a headset device that links with an app to track electroencephalogram (EEG) patterns to help train people how to generate sleep-enhancing brainwaves. Designers note that it takes three months of regular use to achieve results. It appeared on lists for both the coolest and weirdest devices at CES.
  • The Matrix PowerWatch 2 uses solar power and body-generated heat to power its heart rate sensors, GPS, and notifications while linking with both Apple HealthKit and Google Fit . Designers boast that the GPS will last long enough to run a marathon, but it doesn’t specify the pace. I’m betting my marathon time would be substantially longer than its capacity.
  • The EyeQue VisionCheck device hooks to a smartphone and provides data needed for vision-correcting eyeglasses. It skips the prescription, and at a price point near $30, it’s cheaper than a co-pay. For those of us who have uneven ears, it’s still worth the extra cost to have a real-life optical practice keep us seeing clearly.
  • DFree offers bladder size measurement technology which can help urology patients know when to go. It’s available for purchase at a hefty $500, but can be rented for a $40 monthly trial. DFree is code for “diaper free” and is marketed to help manage incontinence including notifications to both patients and caregivers.
  • Kohler’s smart toilet connects with Alexa along with an app-connected, spa-ready bathroom collection.
  • ReSound Linx Quattro is a smart hearing aid that uses artificial intelligence to learn the wearer’s preferences and to adjust sound profiles. It also allows music streaming through hearing aids via apps for Android and iPhone. The devices are more than twice the cost of typical hearing aids.
  • The Butterfly iQ is a personal ultrasound machine that uses an app to guide the user as he or she obtains images, which can be sent to the user’s healthcare provider. I’m sure physicians will be thrilled about that one.
  • Samsung’s Bot Care is a personal health care assistant that can monitor blood pressure and heart rate. Reports beyond that are slim, and the write-ups I saw made it look more like an alpha offering.
  • Other robots such as the ElliQ are designed to assist senior citizens while allowing family members to monitor from afar. It integrates a tablet to help seniors navigate social media, video calls, and texting, although it’s got a $1,500 price tag plus a monthly subscription.

Much like HIMSS, CES is full of demos and prototypes and the solutions aren’t always fully vetted or independently tested. It’s buyer beware with various startups and crowd-funding offerings. There were also some unusual products, including a Bluetooth diaper sensor to alert caregivers of recent deposits; a Sony outdoor speaker that includes integrated cup holders; a collapsible vintage cardboard camera; a robotic bread vending machine; a self-cleaning litterbox with text notifications; a bicycling safety vest with airbags; and a robot companion for dogs.

My favorite piece of non-health tech is the GoSun Fusion solar cooker, which can heat an oven to 550 degrees. It sports a Bluetooth thermometer to alert users when their food is done cooking and claims it can convert 80 percent of the sun’s light into heat while keeping the exterior cool. The company is also working on a solar-powered cooler unit, giving camping even more of a high-tech spin.

My thanks to CNET for the best coverage of CES and excellent links and photos. Maybe one of these years the scheduling stars will align and I’ll be able to request a press pass for CES. Las Vegas would be a lot more hospitable than the foot of snow I’m enjoying, so we’ll see what 2020 brings.

What was your favorite piece of news from the Consumer Electronics Show? Leave a comment or email me.

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EPtalk by Dr. Jayne 1/10/19

January 10, 2019 Dr. Jayne 2 Comments

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The US Food and Drug Administration has cleared the Embrace smart watch from Empatica for seizure tracking in children as young as six. The watch detects signals associated with generalized tonic-clonic seizures and alerts caregivers. Embrace had been approved for adult use last February, but the extension for children is a big plus for parents. The watch had a 98 percent accuracy rate for detecting seizures during clinical trials.

A Special Communication published in the Journal of the American Medical Association addresses the growth in medical marketing. From 1997 to 2016, medical marketing grew from $17.7 billion to nearly $30 billion, with direct-to-consumer messaging as the most rapidly-growing spending segment. Consumer-facing ads grew from $2.1 billion to $9.6 billion during the period. This includes $6 billion for direct-to-consumer ads for prescription drugs, a total of 4.6 million ads including over 663,000 TV commercials. Since 1997, there has been more than $11 billion in fines for deceptive marketing practices.

I certainly wouldn’t mind going back to the days when we weren’t peppered with ads for erectile dysfunction drugs and treatments for rare cancers while catching the evening news. The piece also addresses non-drug-related medical marketing such as disease awareness campaigns, noting potential harms caused by “medicalizing ordinary experience and expanding disease definitions without evidence of net benefit.”

The American Academy of Family Physicians (AAFP) is responding to the recent CMS proposed rule revising Medicare Advantage regulations. Although AAFP supports the use of telehealth technologies, it disagrees with the CMS plan to allow telehealth providers to count towards a plan’s network adequacy requirement. It proposes that only telehealth providers who also see patients in person should be counted in the payer’s network. AAFP encourages CMS to protect patients from “an encroachment of direct-to-consumer telemedicine not coordinated with the beneficiaries’ usual source of primary care.” AAFP has partnered with telehealth vendor Zipnosis to provide a platform for members who want to deliver their own virtual services.

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CMS is at it again, renaming things for no good reason. This time they’ve proudly announced the launch of the “new design for the CMS QMVIG Updates (formerly eHealth) listserv.” I had to dig through the entire email to figure out what QMVIG even stands for – apparently, it’s the Quality Measurement and Value-Based Incentives Group and it is part of the CMS Center for Clinical Standards and Quality. QMVIG is responsible for programs on meaningful measures development, health information technology, and quality compare programs.

The email made a point that “only the name and look of the listserv has changed.” During a government shutdown that is negatively impacting thousands of people, I’d think CMS would have priorities other than rebranding listservs. The January Health IT Advisory Committee meeting has been canceled as part of the shutdown and we won’t be seeing any interoperability rules since that task force was canceled as well.

I had the opportunity to use a different EHR this week and was surprised to see that the Body Mass Index (BMI) calculation was displaying to four decimal points. BMI is calculated based on a patient’s height and weight. Although it’s conceivable that if you measure height to the quarter inch and weight on a digital scale you might get those decimals in the calculation, it’s still distracting to see them since they’re not clinically significant past one decimal point. It’s just one more example of the noise that we see with the EHR. In a paper chart, most of us would have rounded it and called it a day.

The EHR had several other annoying features, including a laboratory results display grid that indicated results were “abnormal” instead of “out of range.” This led to additional discussion with patients as I reviewed their results so that they understood the values weren’t truly “abnormal” or anything to worry about. It also had a single blood pressure field that was free text rather than separate systolic and diastolic fields restricted to appropriate values, leading to staff keying things like 1400/80 and 12090. I’m glad I don’t have to use it on a daily basis.

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Being a CMIO isn’t always about the glamorous world of healthcare IT. Sometimes we’re pulled in by other medical leaders to help put data behind a pesky problem. Such was my lot this week when I was asked to gather some data about effectiveness of commercial laundry processes, particularly with our laundry vendor, after our COO read this article about pathogens surviving the wash cycle. After poring through some data, I’m thinking that I might want to investigate a laundry kettle for my own personal use to make sure I’m not tracking anything home on my scrubs.

While researching disinfection protocols, I came across this article discussing the presence of drug-resistant superbug MRSA on ambulance oxygen tanks. Disinfecting the tanks isn’t part of our standard office checklist, but maybe we should add it to the weekly task list.

Speaking of to-do lists, I’m finally starting to get serious about my HIMSS preparations, confirming my actual travel dates and letting my unneeded hotel nights go back into the available pool. I learned my lesson the hard way a few years ago when I waited too long and couldn’t get a booking for my preferred dates and had to leave early. Now, I book a room as soon as the attendee block opens and book it for the entire block, then adjust it in January once I know what my plans are. I have to say I’m a bit envious of exhibitor reps who have their rooms at closer-in hotels booked by corporate meeting planners.

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Sadly, I will be attending HIMSS without my trusted Ringly bracelet. I recently got a new phone and couldn’t get the Bluetooth to connect. When I tried to troubleshoot it, I learned that Ringly folded last January after four years in the wearables business. I enjoyed having a functional piece of jewelry that helped me manage my technology without being obnoxious – the color-coded LED blinks and vibration notifications were enough for me. My current Garmin watch can do a lot more than the Ringly, but it lacks the class and elegance. It also lacks the ability to filter notifications like the Ringly did – I could set it to only alert me to texts, emails, and calls from my inner circle rather than letting everything through. Farewell, Ringly as technology, although I’ll still keep you in the bracelet rotation.

What’s your favorite piece of wearable technology? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 1/7/19

January 7, 2019 Dr. Jayne No Comments

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The government shutdown has impacted some electronic media, including the National Zoo’s Giant Panda Cam and the National Park Service website. It hasn’t slowed CMS, which continues to send regular emails about the recent final rule redesigning the Medicare Accountable Care Organization (ACO) program. Referred to as “Pathways to Success,” it is designed to advance five goals: accountability, competition, engagement, integrity, and quality. The program modifies the participation options available to push ACOs toward taking on real financial risk faster than they had been under the previous programs.

I have been under the weather and tried to use my illness-imposed downtime to read my way through various fact sheets and documents around the program, but have had trouble making sense of some of it. The CMS press releases reference different announcements and rules that have been put out, including the Calendar Year 2019 Physician Fee Schedule (aka the November 2018 final rule). According to the release, the Pathways to Success final rule also takes a step back in time, finalizing policies for extreme or uncontrollable circumstances for performance year 2017, which were initially established via an interim final rule in December 2017. I had to read that part of the announcement several times since I’m not exactly sure how that works to modify a program year that ended 370 days ago. I thought maybe it was confusing because I was reading it while I was hopped up on cold medicine, but I eventually decided that it’s just confusing.

In trying to distill the communications, my assessment is this. Medicare has figured out that the majority of ACOs are participating in Track 1 for the maximum time allowable and some of them are generating losses. Track 1 is a one-sided model with sharing of savings without the ACO having to take on risk, therefore Medicare absorbs any losses. The original idea was for organizations to use Track 1 as a way to get their feet wet with shared savings in hopes that they’d quickly move to more risk-bearing agreements. That hasn’t happened, so now the proverbial stick has to come out.

The other existing ACO varieties (Track 2 and Track 2) are two-sided. Eligible ACOs share a larger portion of any savings, but in exchange they’re required to share losses if spending exceeds benchmarks. These programs have been shown to generate savings for Medicare and are improving quality, so Medicare wants to further those types of arrangements.

Medicare has also figured out that so-called low-revenue ACOs (mainly made up of physician practices or rural hospitals) are outperforming high-revenue ACOs, which typically include hospitals. There are challenges for the low-revenue ACOs to move to a more risk-bearing arrangement because those organizations may have less control over how their assigned beneficiaries use services and therefore spend money. Medicare piloted the “Track 1+ ACO Model” during 2018, with the goal of proving that a two-sided model with lower risk would be attractive. Its success influenced the construction of the new redesigned program, according to CMS.

The redesigned program offers two tracks, named BASIC and ENHANCED, which are open for five-year agreement periods starting July 1, 2019. The BASIC track lets ACOs start under a one-sided model and gradually accept higher risks as they move through five levels A, B, C, D, and E. Once they reach the highest level, they’d be recognized as an Advanced Alternative Payment Model (APM) under the Medicare Quality Payment Program. The ENHANCED track is based on the existing Track 3 and allows flexibility for ACOs willing to take on the highest levels of risk. The existing Track 1 and Track 2 programs will be discontinued, as will new application cycles for Track 1+. CMS feels those options would be redundant to the new program.

CMS aims to move BASIC organizations through the alphabetical levels (which they refer to as the “glide path”) by automatically advancing them at the start of a new performance year. Organizations would also be able to jump to a higher level faster if desired. The ultimate goal is to move all ACOs to the ENHANCED track, with high revenue ACOs being required to transition more quickly. There are also stratifications based on whether ACOs are identified as experienced or inexperienced with performance-based risk but to be honest I skimmed over those particulars in my pharmaceutical-induced fog.

The final rule updates the mechanisms for repayment when ACOs have shared losses. Both new tracks may start with lower repayment amounts based on a percentage of Medicare Part A and Part B revenues, with the amounts recalculated annually based on changes in the ACO participant list. Benchmarks will also be recalibrated, incorporating data from ACO experience and regional performance measures. The rule also aims to reduce “opportunities for gaming” by holding terminated ACOs accountable for pro-rated shared losses. ACOs are also able to choose between different beneficiary assignment methodologies and to change their selections for subsequent performance years. Starting in January 2020, eligible ACO providers will be able to receive payment for telehealth services for certain beneficiaries in certain situations. There are also changes to expand the Skilled Nursing Facility (SNF) 3-day rule waiver.

The redesign also allows ACOs under certain two-sided models to operate a beneficiary incentive program, which may allow for incentive payments of up to $20 to assigned beneficiaries who receive certain qualifying primary care services from ACO members. It also clarifies that under existing program regulations, vouchers and gift cards can be provided to beneficiaries assuming they meet other program requirements such as being connected to the beneficiaries’ medical care. There are a few other tidbits in the rule including updates to beneficiary notification requirements. Beneficiaries have to be notified of the opportunity to opt-out of claims data sharing along with how to change their assigned primary clinician. CMS is developing templates for these notices in an effort to reduce the burden to participating practices.

I’m only marginally involved in the ACO realm, so I’m sure those who are deeper in the process might have additional insights. I’ll be looking to read digests and summaries in the coming days until I’m on the mend. Until then, my next reading list involves chicken soup.

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EPtalk by Dr. Jayne 1/3/19

January 3, 2019 Dr. Jayne 1 Comment

I mentioned being tired from seeing patients the day after Christmas. Now that we’ve done our month-end close, I know why. We broke our own record and saw nearly 1,300 patients that day, 70-something of which were on my schedule. It truly takes a village to be able to care for that many patients and I’m grateful that my practice’s leadership believes in systems-based care and building teams so that they can run like well-oiled machines. The Centers for Disease Control lists nine states as having high flu activity and another 11 with widespread activity, so it might be a long winter.

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This article in the Journal of the American Medical Informatics Association caught my eye with its title: “Cranky comments: detecting clinical decision support malfunctions through free-text override reasons.” I’ve done my share of chart reviews where providers have entered interesting comments when faced with an alert, so I was eager to read more. The authors looked at their database to identify those clinical decision support rules that had at least 10 override comments. The comments were classified into three categories based on whether the user felt the rule was “broken,” “not broken, but could be improved,” or “not broken.” They also looked at the comment frequency and a “cranky word list heuristic” to rank the rules based on the override comments.

Parsing the comments uncovered malfunctions in more than a quarter of all the active rules in the system, which was higher than expected. The authors recommend that “even for low-resource organizations, reviewing comments identified by the cranky word list heuristic may be an effective and feasible way of finding broken alerts.”

For those who are curious, representative override comments included items such as “you are stupid,” “stupid EPIC (sic) reminder,” and comments with many exclamation points. Other cranky words include: dumb; idiot; please stop; why; misfire error, epic, and wrong. The authors note that “swear words were originally included but are omitted from this list because they did not yield comments. Other organizations may wish to include them.”

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I’ve heard a fair amount of chatter among physicians regarding the new rule that starting this month in which all US hospitals must publish their price lists online in a downloadable format. Nearly everyone I’ve heard from agrees that having the charges isn’t terribly helpful. What one would really need to know is the negotiated rate between the insurer and the hospital. Alternatively, knowing the hospital’s self-pay discount might be helpful.

Hospital lobbying organizations are concerned that patients might forego care if they see prices that are too high, not understanding that most services are discounted. Of course, there’s nothing stopping hospitals from publishing that data, but we’re not likely to see it soon. I poked around on the websites of the local health systems and within their patient portals but haven’t been able to find anything. I’d be interested to hear from readers who may have actually downloaded one.

On the flip side, CMS has put forward a proposal to require pharmaceutical companies to publish Medicare and Medicaid prices for drugs featured in TV ads. Physicians I’ve talked to are supportive of that idea, and many would like to see TV advertising of drugs eliminated completely. I don’t usually watch broadcast TV, but was exposed to it over the holidays at relatives’ houses. There certainly are a lot of drug ads out there and some of them aren’t even clear on what condition the drug is designed to treat or which patient population is being targeted. Print ads aren’t much better, and even some of the ads in physician trade publications are confusing.

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At the beginning of every year, I do some general office housekeeping tasks, including updating my filing and accounting systems for the year and making sure all my recurring calendar appointments are in order. As I was paging through the weeks, I realized that HIMSS is just around the corner and I’m feeling like the next month is really going to be a crunch. I have some serious shoe shopping to do before then, along with breaking in any new purchases. My favorite pair of “trade show shoes” met its demise last year and finding just the right kicks to get me through hours and hours of the exhibit hall will be a challenge. Advance registration discounts end January 14, so if you’re planning to go but haven’t registered yet, you can still save a few bucks.

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Working in healthcare IT has been a great way to meet people who work non-traditional hours. Some people make their employment choices based on their enjoyment of overnight shifts because it suits their personalities as “night owls.” Telemedicine and teleradiology have opened up additional options, which has led to the need for support personnel covering the physicians who are staffing those shifts.

I spent some time working at an observatory and know that I do well on the night shift, but only when I can completely tweak my schedule to support it long-term. The occasional night shift kills me. The New York Times recently ran a piece about businesses that are encouraging their employees to work at periods of maximal wakefulness as a way to boost productivity and to help avoid safety incidents due to fatigue.

The US Navy recently migrated the traditional 18-hour submarine schedule to a 24-hour one, and other companies are allowing employees to select day or night shifts based on their preferences. Working remotely can help as well. I know I’m more productive when I work in focused blocks of time outside of the office and having even a 20-minute nap in the afternoon makes a huge difference for me. That’s supported by the “window of circadian low,” which forecasts a midafternoon dip in wakefulness for most people, as mentioned in the article.

The piece mentions strategies employed by pharmaceutical manufacturer AbbVie, where employees go through a nine-hour program to identify their best times for creativity vs. low-energy tasks. Employees are encouraged to mesh their work and professional lives to harness those periods as well as to work around family commitments, leading to a dramatic increase in employee satisfaction with work-life balance. I’ve worked in several clock-punching organizations where even salaried employees were expected to put on a show of being at their desk at certain times regardless of whether they were actually doing anything productive.

Has your employer done any investigation into harnessing people’s most productive periods during the day? Leave a comment or email me.

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EPtalk by Dr. Jayne 12/27/18

December 27, 2018 Dr. Jayne No Comments

The holidays tend to bring out the best (or the worst) in people, depending on whether you work in the customer service sector and how harried your clientele might be. Healthcare has become less of a vocation and more of a transactional situation, where the customer is always right and ratings drive salaries as much or more than clinical outcomes might.

Our urgent care practice is open 365 days per year, although some of the locations close on Thanksgiving, Christmas, and New Year’s Day if they’re within five miles of another site that is open. We used to have every location open on those holidays, but it wasn’t an employee satisfier and closing a portion of the locations made a huge difference for our teams and their families. For those who do work on the holidays, we have catered meals delivered the day before so that staff can at least reheat something for lunch or dinner that might be marginally more interesting than a brown-bag from home.

My holiday rotation put me on Black Friday this year and also the day after Christmas. I knew I was in for a wild ride this morning when there were 10 people waiting outside my door before I even arrived. The situation must have been even worse at other locations, because my scribe was immediately redeployed to another site to work as a patient care tech and another tech was pulled to a third location. Several of our sites broke the records for most patient visits in a day.

I’m always glad that we’re there to help patients, but the unpredictability of surge volumes can wear out a staff pretty quickly. We had some patients who weren’t happy about the wait time and a couple who stormed out of the office because of it. Those are always difficult situations and the team took them in stride, although it always leaves a lump in your stomach when you know someone was unhappy.

The holidays also brought out some examples of the challenges we face in trying to coordinate care based on the way that healthcare is financed in the US. I saw one gentleman who had a work-related injury that occurred last Saturday. He wasn’t able to be seen because we have a worker’s compensation contract with his company and no one was there to authorize the visit. The practice couldn’t see him on his personal health insurance because he had already declared it to be work related and it would therefore be denied.

He wasn’t willing to pay out of pocket, so he went back to work. He couldn’t reach anyone in the authorization department on Sunday or Monday and the office was closed on Tuesday, so today was the first day he could be seen. Although he had tried to treat himself the best way he could, I suspect that he’s going to have a poor outcome because appropriate care was delayed.

I had a patient who required some specific follow up and I wanted to contact his physician through the after-hours exchange. Usually to accomplish this I ask a staffer to call the practice, listen to the after-hours message and get the exchange number, then have them put out a page for the physician to call my cell phone. It can take an hour or more for this process to happen, and in today’s care coordination non-event, it didn’t happen at all.

When my assistant called the practice, they hadn’t switched their phone system over from the usual “we are unable to take your call” message to the “we’re closed, please call the exchange at the following number” message. There was no voice mail available and the patient said he had driven past the office and found it closed. Without an exchange number, we weren’t able to reach his physician or another covering provider.

I had flashbacks from my days as a solo physician when I was the person who had to make sure the phones were switched over. I would call the office before I left to confirm it worked. I sent a task in the EHR to have tomorrow’s team try to do the follow up, but I’m sure that physician’s office is going to be slammed with calls tomorrow and I don’t envy my colleague in trying to take care of it.

We also had a patient come in late in the evening for a preoperative clearance visit, only to find out that her surgery was scheduled for the morning. Good thing that all of her labs were normal and her medical history didn’t have any concerning elements or that surgeon would have had a surprise on his schedule tomorrow. His office was working today, however, because they had called the patient and let her know that they hadn’t received her labs and x-rays, which prompted her visit to us.

We did see some genuine emergencies, including a patient who fell carrying a glass ornament that caused a fairly serious laceration when it broke and a patient with dehydration due to foodborne illness. We also saw some self-inflicted damage, including someone who was seriously ill after trying to “cleanse toxins” with a recipe she saw on the Internet. What she did was to partially cleanse her body of electrolytes, which we were happy to replete. Another gentleman had a raging fever, shaking chills, and poor oxygenation after failing to adequately treat his bacterial pneumonia with a vitamin B12 infusion given at a local spa.

We had two family members who were waiting with patients and decided to be seen “while we’re here.” They didn’t have urgent issues, but figured that since they were waiting already, why not? Neither of them had tried any over the counter or home remedies and both had minor problems that could have been treated for less than $10 at the drugstore. Convenience is king, however, and they both left with prescriptions so that insurance would cover it rather than spending the money out of pocket. They’ll also generate multi-hundred dollar urgent care bills.

It’s moments like that which become a bit depressing, when you are silently screaming that there is a patient in the room next door with an ornament shard stuck in their body, and instead of dealing with it, you’re writing scripts for athlete’s foot and cold sores. We also had patients themselves adding on medical problems after check-in, including one who wanted refills on all her maintenance medications while she was there for an ice-skating related fracture. The reason: “My doctor went on vacation the week before Christmas and never responded to the refill request.”

I felt sad for the nonagenarian who hasn’t felt good in a decade and whose chief complaint was, “I used to climb 14,000- foot mountains and now I’ve felt crummy for a couple of years” and who was brought in by his daughter. There’s not a lot we can do about that at the urgent care other than to offer sympathy, rule out any life-threatening issues, and arrange follow up care. I was grateful for the occasional strep throat visit or sinus infection and even the fractures since they didn’t involve family disharmony or complex psychosocial issues. I’m privileged to have elders in my own family who are generally in good health, and based on what I see at work, I don’t take it for granted.

There’s virtually no consulting work between Christmas and New Year’s, so I’ll be back in the trenches again tomorrow and then over the weekend. Let’s hope for primary care docs who have their phones set up, offices that are open, and sidewalks that aren’t slippery. My New Year’s wish is that the folks who concocted the influenza vaccine nailed it and that everyone has a happy and safe 2019.

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EPtalk by Dr. Jayne 12/20/18

December 20, 2018 Dr. Jayne 2 Comments

Big Data continues to be a buzzword and I enjoy hearing about novel applications. The Journal of the American Medical Informatics Association recently published an article covering a system that uses online Yelp restaurant reviews to identify foodborne illness. The system is currently in use by the New York City Department of Health and Mental Hygiene to monitor for foodborne illness complaints. It classifies review based on whether they indicate illness, and if so, whether multiple people are involved. It has identified 10 outbreaks and over 8,500 complaints.

Missouri is the only state in the US that doesn’t have a Prescription Drug Monitoring Program, and Governor Mike Parson has indicated he’d like to sign legislation that is “long overdue.” Parson, a cattle farmer by background, came into office following the resignation of the former governor following a scandal. He’s keenly aware that the state is the only one without it, although friends practicing in the state tell me that St. Louis County launched its own database that aggregates data for a large portion of the state. Maybe they can harness the existing system rather than re-create the wheel.

My state’s PDMP has helped me in the clinic more times than I can count, so I feel for those who don’t have access to the tool. Missouri also recently approved marijuana for medical use. When I called my former classmate to ask her about the PDMP situation, she noted that her office received 20 phone calls about it the day after the election. Good luck to those of you in the Show-Me State.

Speaking of controlled substances, a US Food and Drug Administration panel recommended this week that physicians who prescribe opioid drugs should also prescribe the overdose reversal drug naloxone. This would lend itself nicely to order set and clinical decision support functionality, although there’s quite a bit of debate as to its necessity and the amount it would add to overall healthcare spending.

There’s also debate about patients getting naloxone added to their pharmacy profiles since that data can be used for other purposes, such as life insurance underwriting. NPR recently reported on a nurse who was denied coverage because she carries the drug as a healthcare provider who is willing and able to use it should she come across a patient experiencing an overdose. The issue highlights the dilemmas faced by many of us in healthcare, where even the best-intentioned ideas can have numerous downstream consequences.

Users, beware: SplashData has published its annual list of the 100 worst passwords of the year, based on five million leaked passwords found on the internet. The worst offenders continue to include “123456” and “password.” Other new entries on the list include “donald” (which debuted at number 23 and may be inspired by our Commander in Chief), “sunshine,” “princess,” “charlie,” and “!@#$%^&*.” The old standbys of “admin,” “welcome,” and “iloveyou” remained on the list, although I’ve never been enamored of my computer or my job enough to consider the latter option.

Dr. Jayne’s inbox has been flooded with announcements from various companies who plan to participate in the JP Morgan Healthcare Conference in San Francisco. There are usually some interesting keynotes at the conference, whose attendees are clients of JP Morgan. It looks like there are several hundred presenters from startups to the usual big players. Another round of press releases will follow the actual conference, including transcripts and sometimes recordings of the presentations, so I have that to look forward to. I’d be interested to hear from anyone who has attended including what they thought of it and if they learned anything that they couldn’t glean otherwise.

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A shout-out to Jenn over at HIStalk Practice and her coverage of medical-themed holiday decorations at her local hospital. If you’re not including HIStalk Practice in your regular news roundup, you’re missing out.

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Workplace-themed trees aren’t unique to healthcare, such as this one made of used pointe shoes at the English National Ballet.

Jenn also clued me in to the rise of private equity funding in the medical apparel space, with recent funding of scrub manufacturer Jaanuu. The company has raised $25 million to date. The Nordstrom family also participated in the recent funding round. Although making scrubs and lab wear more fashionable is a goal, they’re also working to use odor-eliminating, water-repellent, and antimicrobial-treated fabrics to increase functionality. Company founder Sethi Young notes that medical professionals “need a ‘uniform’ that’s not uniform at all – no one style, fit, or fabric is going to be what you need to do your best each day, every day.”

It seems to me that perhaps there’s a disconnect between the company’s vision and the realities of work within a hospital, medical office, or other clinical setting. Workers don’t necessarily get to choose what they’re going to do each day, but rather need clothing that can handle anything that’s thrown at them in an often-unpredictable environment. I don’t wake up envisioning, “I’m going to have to suture a lot of lacerations today, better wear the stain-fighting pants in case I drip Betadine on myself” or wanting to be glammed-up by my scrubs. The initial thought that there’s a disconnect was reinforced when I read of their desire to become a “lifestyle brand.”

I’m going to stick with my sub-$40 lab coats and the durable scrubs that I know I can just about boil. I’ve been wearing scrubs for the better part of two decades and have had hospital-issued ones, personally-purchased ones, high-performance designs, extra-cheap designs, and one double-breasted scrub top I had to wear during a transplant team trip that made me think I was in a sci fi movie. I guess I’ve been lucky that I never felt that they had a “negative psychological impact” while I went about doing my job.

The only problem I’ve ever witnessed with ill-fitting scrubs was during an emergency C-section, when the pregnant obstetrician had her overly large scrubs pulled up above her belly. When she ran down the hall, they slid down, almost making her trip. Since they were hospital-issued, OR-mandated scrubs, it’s not like she could have strolled in wearing fashion maternity scrubs.

What do you think about lifestyle brands in the healthcare space or the concept of lifestyle brands in general? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 12/17/18

December 17, 2018 Dr. Jayne No Comments

I recently had an invitation to attend a webinar on artificial intelligence in medical imaging. There was a recent article on the same topic that’s still sitting in my “to skim” pile, so I thought it might be good to go ahead and take a peek.

I have to read diagnostic images as part of my day job. It’s one of the more challenging parts of my practice, primarily because I didn’t do it for a decade and was out of practice. Most of the images we encounter are x-rays we’ve ordered on our own patients, which seem easier to read because we have the whole clinical picture and know what we’re looking for on the images. For quality purposes, we also over-read the studies ordered by other physicians at different locations, which can be challenging because you don’t always have the whole clinical picture.

The most challenging images however are the CT scans. We’re not doing the primary readings on those, but due to some quality issues with our virtual radiologists, we’ve been asked to review all of our images. Given that my formal radiology training was a two-week rotation more than two decades ago, I’ve been seeking out educational resources to help improve my skills.

Still, each time I come across an image that has questionable findings — whether it’s a CT or a regular x-ray image — I can’t help but think that having some computerized support would be beneficial. Most of the articles I’ve seen on the topic are specifically directed at the incorporation of AI into radiology workflows. I haven’t found very much research looking specifically at AI within primary care radiology workflows.

In getting AI technology approved, studies look at whether the technology can identify the correct findings at least as well as the radiologists, who are usually residency trained and board certified. I’m sure there’s a preponderance of academic medical center radiologists reflected in the studies, and I would suspect that outcomes might be different in those institutions where radiology is highly specialized compared to community hospitals, where radiologists may be more generalists. There may be even different outcomes in accuracy of readings when you throw emergency physicians, internists, pediatricians, and family physicians into the mix as they read films in their offices and various outpatient settings.

Several of the potential solutions being evaluated in radiology involve support prioritizing the radiologist’s work list. Some algorithms analyze screening tests where the majority of studies are negative and highlight those images where an abnormality may be present. This is being done for studies like mammograms, where imaging technology is moving from 2D to 3D images, creating additional image volume and requiring additional time to read each study. The goal is to prioritize those that are the most high-risk so that they are addressed quickly and carefully. Other solutions are looking at areas where an abnormal study poses a high risk, such as post-trauma head CT scans.

Even though they’re not studying readings by primary care providers, there’s some exciting work being done with chest x-rays. One effort looked at 1.2 million images working to create an algorithm that would assist in “low-resource settings” without radiologists, which would certainly apply to my practice. Once the system was trained to identify specific findings — such as heart enlargement, calcification, presence of fluid, and opacity — it was tested against a panel of radiologists looking at a set of 2,000 x-rays. The system reliably identified the findings roughly 90 percent of the time. I wonder how it would score against non-radiologists looking at the same images.

There are particular types of x-rays that I still struggle with, because they can be difficult to read just because of the body part you’re looking at. Rib x-rays are an example and are challenging because the ribs sit on top of dense parts of the body (the heart, the spine, and major blood vessels) and because they curve and angle, which causes overlap when you’re trying to figure out what you’re looking at. They’re also tricky when you’re dealing with larger patients, who have more tissue for the radiation to penetrate.

I had a patient with some trauma who came in sounding like he had a broken rib. Normally, I’d prefer to order a CT scan because it gives you much better pictures of ribs without overlap. However, I was working at one of our outlying locations that doesn’t have CT, so I went with the plain film. There were indeed some rib fractures. I identified what I thought were two separate issues, but my partner doing the over-read didn’t agree — she thought there was only one. Regardless, the one looked strange enough that I felt a CT was indicated to fully define what was going on and transferred him for the study.

Within 20 minutes we had a radiologist on the phone telling us he had three fractures and also a collapsed lung, which neither of the initial reading physicians picked up on the x-ray. In hindsight you can see it, but it’s a really subtle finding and the border of the lung overlaps with the edge of a rib, right at the top of the chest where there’s a lot going on in the film. It’s likely that both of us were focused on the indication of “rule out rib fracture” and even though we did assess for lung issues, we didn’t see it.

That’s the problem with human brains and how we process information. We’re constantly prioritizing what we’re working on and rapid switching is a factor when we’re addressing multiple tasks (I had eight assigned patients I was covering at the time I was looking at the films). As a physician, you feel terrible when something like this happens, but it does happen.

I’m grateful that the only issue here was a brief delay in diagnosis. The patient’s condition had not deteriorated in the time it took to get the CT can and he had normal vital signs and oxygenation the entire time we were evaluating him. The biggest challenge I had was finding a hospital to accept his transfer, since his preferred hospital suggested that I send him elsewhere because “our folks don’t like to take care of that.” Not exactly a ringing endorsement, but the closest Level 1 Trauma Center was more than happy to accept him.

I look forward to the day when I have some AI helping me out in the trenches. Hopefully we’ll get to that point before it’s time for me to retire.

What do you think of AI in diagnostic imaging? Leave a comment or email me.

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EPtalk by Dr. Jayne 12/13/18

December 13, 2018 Dr. Jayne No Comments

CMS announced an upcoming outage of the Open Payments system, in advance of the data submission for Program Year 2018. The system will be down January 3-6 and then again January 14-26. CMS notes that the outages “coincide with enhancements which will enable a better user experience,” but I suspect that they won’t be revolutionary enough to justify 17 days of downtime.

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I felt like a fish out of water in my practice this week, as my state’s Prescription Drug Monitoring Program database had some technical glitches. Apparently, connectivity issues impacted the accuracy of the dispensing data for the past week, leaving physicians wondering whether their patients had actually picked up controlled substances more than the website showed. It can be amazing how dependent we become on technology and how much we miss it when it’s not working.

On the other hand, we rolled out some new technology that isn’t working quite as planned and it led to a great deal of aggravation. We switched online check-in platforms and it’s been difficult for both patients and staff to adjust. Our old platform was pretty basic, allowing a patient to provide demographic and insurance information along with a brief history. It also added the patients to a queue so we could bring them into the EHR when they arrived.

The new platform promised much more functionality, including an “appointment time” so that patients can wait at home, avoiding other sick patients and remaining comfortable. However, we’re still trying to see patients quickly as they arrive and aren’t set up to hold an exam room for a patient with a pending appointment time. Despite the wording on the online check-in page, patients have been arriving at the office with the expectation that they’ll be seen at their appointment times. This has led to some friction at the front desks and to a couple of outright confrontations. We’ve been working with the vendor to see if we can change the nomenclature to something like “estimated visit time” or “estimated treatment time” rather than an “appointment time” but it doesn’t look like it can be done.

Our leadership is contemplating going back to the “virtual line” product, which happens to be integrated with our EHR. One of my partners asked about using a system like restaurants use, where a patient can leave the office and be paged when it’s their turn. I have mixed feelings about that approach for patients with infectious conditions. If they’re sick enough to be seen, they don’t need to be moving around the community or visiting retail locations adjacent to our offices.

They’re also contemplating telehealth options, which could help to reduce congestion in the office. I’m personally excited about that option, as flu season makes me dread the inevitable upper respiratory infection I’ll get regardless of how much handwashing I do, and would reduce the number of sick people traveling around the community.

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A friend who works at a software vendor clued me in to a recent New York Times piece about our collective obsession with innovation. I was pulled in by its tagline that “some of our best ideas are in the rearview mirror.” It further hooked me with this:

We are told that innovation is the most important force in our economy, the one thing we must get right or be left behind. But the rear of missing out has led us to foolishly embrace the false trappings of innovation over truly innovative ideas that may be simpler and ultimately more effective. This mind-set equates innovation exclusively with invention and implies that if you just buy the new thing, voila! You have innovated. Each year businesses, institutions, and individuals run around like broken toy robots, trying to figure out their strategy for the latest buzzword promising salvation.

That seems to sum up a good portion of the healthcare IT market, especially in the lead-up to HIMSS. There’s a lot of “shiny object syndrome” going on, and by looking for the next buzzword-enriched solution, we may be missing what the article describes as true innovation:

It is a continuing process of gradual improvement and assessment that every institution and business experiences in some way. Often that actually means adopting ideas and tools that already exist but make sense in a new context, or even returning to methods that worked in the past. Adapted to the challenges of today, these rearview innovations have proved to be as transformative as novel technologies.

How many new technologies have hospitals partially implemented that might be revisited to ensure they deliver their additional promise or might be pushed to provide additional benefit for users? Can we glean additional return on our investment or find new uses for it? Are there ideas where some old-school thinking might be of benefit?

The article mentions swings of the pendulum in urban planning and the return of previously marginalized solutions such as farmers’ markets. It mentions the rise of craft beer, heirloom vegetables, and artisan baking as ways that we are moving forward by looking back.

There are plenty of problems that we can solve in healthcare that don’t require technology, and many organizations aren’t even thinking about them. At one large multi-state integrated delivery network, physicians aren’t allowed to delegate refill authority to trained staff even for routine maintenance medications for blood pressure or high cholesterol. Although there are some great systems out there to help with refills (healthfinch, anyone?) an organization first needs to decide that physicians should have support completing those types of routine tasks. Until they arrive at that point, it doesn’t matter what technology is available.

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The intersection of technology and policy made me want to scream this week. One of my clients recently changed their password security requirements. I’m wondering if I missed a new release from NIST because some of the requirements are directly contrary to what had been released earlier in 2018. This hospital has adopted some particularly onerous guidelines. Not only must the password include upper- and lower-case letters, it must also include numbers and special characters. They’ve also reinstituted time-based changes every 90 days. Passwords can’t be reused for at least a year. Worst of all, at least five of the eight required characters must be changed for every new password.

NIST has said previously that requiring periodic changes and arbitrary complexity isn’t helpful for security and that it just frustrates users. On the flipside, the helpful people at LL Bean recommended that I write down both my password and the answers to my security questions. If you’re a hacker looking to score some durable polo shirts or “wicked good” boots, have at it.

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Curbside Consult with Dr. Jayne 12/10/18

December 10, 2018 Dr. Jayne 5 Comments

The physician lounge was abuzz on Friday due to a piece on CNN claiming that Australian researchers have developed a “10-minute cancer test.” Supposedly it “can detect the presence of cancer cells anywhere in the human body” and stems from research looking at the structure of cancer DNA when placed in water. Physicians were mostly grumbling about having to respond to patient questions about such a sensational announcement when the ink on the publication was barely dry. Patients tend to take hold of these kinds of announcements, especially if they have a particular concern about cancers for which there aren’t good screening tests, such as ovarian cancer.

There’s always more to the story when these announcements are made. Despite author Matt Trau’s statements that the study “led to the creation of inexpensive and portable detection devices that could eventually be used as a diagnostic tool, possibly with a mobile phone,” in this case, the test hasn’t even been used on humans. People tend to hear the part about diagnosing cancer with their phones and miss the part about animal studies. The authors are excited and with good reason, but it’s a long way from where they are with this test to having it available at the primary care office.

The test mentioned in the publication, which was released this week in “Nature Communications,” has only been used to detect lymphoma, along with cancers of the breast, prostate, and bowel. It’s also only been used on around 200 samples, although it did have 90 percent accuracy. Researchers using high-resolution microscopy noted differences between the structure of cancerous DNA fragments and non-cancerous fragments when the DNA was placed in water. The test uses colloidal gold particles to bind to cancerous DNA, creating an electrochemical reaction that can be quantified.

One of the urologists around the table was particularly vocal about suggesting that this test could be used for prostate cancer since there has already been a fair amount of controversy about prostate cancer screening. We’ve seen the Prostate-Specific Antigen (PSA) fall in and out of favor – first approved by the FDA in 1986 to monitor prostate cancer progression, it was approved in 1994 to be used along with a digital rectal exam for screening of asymptomatic patients. Over the next two decades, we saw patients with “abnormal” tests who underwent procedures that may have been overly aggressive given the slow-moving nature of prostate cancer, not to mention the non-cancerous conditions that can cause PSA elevation. Over time, we learned that the test was being relatively overused certain populations without definitive evidence that it drives outcomes in a beneficial way, leading to recommendations that we don’t just order it, but rather have a risk/benefit decision between the patient and the physician before deciding to test.

As we consider new technology and new tests, we need to heed the lessons of the past and proceed with caution, guarding against “shiny object syndrome” and the assumption that just because we can theoretically use a smart phone to do a test that it’s a good idea. CNN ran a similar piece back in January, covering a test developed at Johns Hopkins University that screens blood samples for eight common cancers by detecting cancer proteins and gene mutations. That test, called CancerSEEK, is still being studied to determine its applicability in clinical medicine and whether it can be widely used to screen patients who aren’t experiencing symptoms. CancerSEEK was evaluated in a much larger study that included humans with almost 2,000 patients participating. The test was 70 percent sensitive among the eight cancers, but the range of accuracy for individual cancers ranged from 33 percent in breast cancer to 98 percent in ovarian cancer. The Hopkins team also used an algorithm to evaluate the source of the cancer for positive tests, but the ability to pinpoint a source was only 63 percent.

It will take a tremendous amount of money to bring either of these technologies to the point of care, and unfortunately with medical research, the money doesn’t always follow the hype. Even when tests are promising, they have to be shown to be effective and to be able to make a difference across large patient populations before payers will cover them, which often the main barrier to patients receiving new tests and treatments. EHR and other healthcare vendors follow these discoveries closely since they need to stay ahead of the curve for supplying appropriate clinical decision support information and including new discoveries into order sets and EHR content.

Those changes don’t happen overnight. I work with one EHR vendor that still hasn’t incorporated standard-of-care screenings that were recommended by the United States Preventive Services Task Force (USPSTF) back in 2007. It’s understandable that providers are frustrated when it takes more than a decade to update the EHR.

The conversation about detecting cancer DNA quickly segued into one about the recent “gene-edited baby” announcement coming out of China. A scientist claims to have used the hot new CRISPR gene-editing technology to alter two human embryos to be resistant to HIV. The babies have now been born and the news led to significant outrage from the international scientific community. The processes of announcing the research has broken with the standards of research, with the information being revealed via YouTube rather than through rigorously-reviewed scientific channels. That’s not surprising in the era of social media, but should be viewed with caution. There are many other concerns with the research, including lack of appropriate Institutional Review Board protection for the participants, lack of documentation of the work actually done, and the lead researcher owning patents around the techniques used in the process. It wouldn’t fly in the US or in many other nations.

The conversation came full circle when one of family medicine docs at the table spoke up. She said she felt sad that everyone was excited about these media sound bites around research whose practical use was years away, but she has difficulty getting medical professionals engaged around her work with school-based clinics and mobile outreach to our city’s homeless population. I mentioned working with providers who struggle with EHR adoption and the challenges of trying to get them to use the guideline prompts and alerts that are already in the system for tests that are proven to be clinically effective as well as cost effective. It’s certainly something to think about in this world where we’re used to getting our information 200 characters at a time and the deeper discussions sometimes elude us. Physicians don’t have the time to pull the original articles and read the primary source data, so it’s unlikely that patients asking about these new advances are going to have done so either.

Given our work in healthcare information technology and the seemingly relentless push for innovation, we often become skeptical (if not cynical) about developments. We’ve seen plenty of creative new technologies fizzle and watch the industry continue to search for the next big thing. And we understand how hard it is to take technology from the idea stage to practical use at the patient bedside whether physical or virtual. It will be interesting to look back on these developments in a year, or five or 10, and see where we have landed.

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EPtalk by Dr. Jayne 12/6/18

December 6, 2018 Dr. Jayne 3 Comments

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Following the ONC annual meeting at the end of November, I received an email that the slides and webcast would be “made available in the near future.” This always aggravates me after conferences, because by the time they make the content available, people have moved onto other things and momentum is lost. Especially with a relatively small (two-day) meeting, it shouldn’t be that hard to get the materials together since presumably people had to submit their slides in advance for review and approval. Webcasts also aren’t that hard to get online, especially if they’re not edited. Making the materials available quickly would help engage those who couldn’t be there and allow them to be part of the discussion.

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I finally had some time to dig into the draft “Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs” document that ONC issued last week. It offers three goals for reducing clinician burden, including reducing time and effort to record information, reducing time and effort for reporting requirements, and improving EHR functionality and ease of use. I’m not sure whether or not I should read something into how those goals were constructed, since fixing the third goal would likely solve a big portion of the first one. When you dig deeper into the document, it becomes apparent that the first item refers not only to documentation effort, but the fact that the documentation required for billing is a burden above the documentation required for clinical care.

The usability discussion specifically addresses poor design of clinical decision support tools, including pop-ups that require “excessive interaction.” It also mentions poor implementation of electronic summary of care documents, lack of standardization around the presentation of clinical content, and the need for improvements to configuration and implementation processes that should “proactively engage the end user.”

One of the problems here is the fact that EHR vendors simply don’t want to spend as much money as would be needed to make EHR systems substantially better. I worked with one vendor that had a limited development budget, which essentially meant that the only work they could afford to do was that which was mandatory – either required for them to maintain certification or to address severe patient safety defects. Even minor patient safety defects were put into the deferred maintenance bucket to sit until more development hours became available, which often meant that they didn’t get fixed. When there’s not enough money to fix patient safety issues, that means that the “nice to have” and usability enhancements logged by customers over the years rarely made it to the requirement stage.

They also go in-depth about reporting issues and the fact that “regulatory requirements and timelines are often misaligned across programs and subject to frequent updates, which require significant investments from clinicians to ensure annual compliance. Government requirements are also poorly aligned with the reporting requirements across many of the federal payer programs in which clinicians may participate …” How about this — let’s put a freeze on federal reporting requirements until the federal payers can get their own houses in order. Present us with a unified set of reporting requirements that make sense clinically and actually allow us to drive the needle for clinical quality rather than just make us report for reporting’s sake.

While we’re at it, here are my other suggestions to solve the issues (although I’m sure they’d never be accepted): First, allow physicians to bill office visits based on time. Not the current “greater than 50 percent of this visit was spent in counseling and coordination of care” nonsense, but actually billing on time like a lot of businesses do, including attorneys, accountants, auto mechanics, and the guy who does my hair. If you’re more complex and take more time, allow us to be compensated for what we do. If you’re a quick visit, let us see you and get you on your way. One might say this may lead to abuses, so let’s put reasonable caps on it, such as a maximum of 16 hours a day. It can’t be any worse than our current system that doesn’t even detect fraudulent physicians that are billing many more procedures than they could possibly do in a day.

Second, let’s also address the usability issue by requiring vendors to issue standardized reports to their clients on how much development time is spent on regulatory requirements, remediation of software defects, patient safety issues, usability, new content, and the like. I know vendors hate this idea because they’re afraid the information will wind up in the public eye, but it’s important for customers to understand whether their vendor is really putting their money where their mouth is. This is hard for publicly traded companies, since actually spending money on development eats into the profit margin. Still, there has to be some kind of accountability for where the millions of R&D dollars are being spent.

While we’re at it, let’s also think about adding some requirements that will just make everyone’s lives easier. Let’s standardize to LOINC for laboratory orders and results. It’s there, it works, and it would save time for hospitals and healthcare organizations. Not just in the EHR, but with the laboratories – I’m tired of federal mandates that put the onus on the physicians, but don’t do anything to make lab vendors comply. I can’t even count the number of practices I’ve worked with whose vendors aren’t sending LOINC codes with results, but the practices have to have the codes mapped in the EHR, so much manual mapping occurs. Why not just fix the problem at the source? The strategy does allude to this a bit with standardization of medication information, order entry content, and results display conventions, but it’s shameful that we’re still talking about this a decade after the start of Meaningful Use.

What about patient matching and interoperability issues? There’s no federal funding for a universal identifier, but what if the vendors came together and created a voluntary one? Let patients opt in or opt out, but if they want to opt in, let’s give them a unique ID they can carry around to their providers that can be used to assist with matching. It’s clear that it’s never going to be a federal priority even if they blockages in front of it are cleared.

I ended up having to stop reading the document, because what I thought was going to be a quick blurb about it has rapidly turned into a semi-angry rant about the state of things. I’ll have to refine my thoughts before I enter my formal comments, which I will certainly do before the January 28, 2019 deadline. ONC plans to post all the public comments that are received, which should make for some entertaining reading in front of a nice fire on a snowy evening.

If you were in charge of all things healthcare IT, how would you fix these problems? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 12/3/18

December 3, 2018 Dr. Jayne No Comments

My former employers at Big Hospital System recently reached out to me, requesting some assistance with practices they’ve acquired. In the years since I left, they’ve consolidated their empire onto a single EHR platform and have streamlined a number of IT departments including the EHR implementation team that I used to manage. The current implementation team is relatively green, having been hired with job descriptions that only allow them to address the new EHR, and not to think critically about or assist with any other systems. They’re also a relatively small team and their time is spoken for over the next 120 days. Whoever made the decisions to restructure the team this way apparently didn’t talk to the business owners of the employed physician group, which has continued to acquire independent practices at a rapid pace. These practices are then left in limbo because they can’t get a deployment slot on the new EHR for months and months, but they still have to try to run a practice either on their legacy system (if they owned rights to it and can keep it) or possibly even on paper.

The acquired physicians are frustrated and rightfully so. Being added to the main health system EHR platform was part of the decision-making for employment for many of these struggling independent practices, allowing them access to a repository of information about their patients along with professional referrals and communications. Several of them were already frustrated with their existing EHRs, and the idea of having to stay on broken systems for another six months is unacceptable. Unfortunately, they either didn’t understand or overlooked the contractual agreement regarding EHR migration, which clearly gives the health system control of the timeline for retirement of their current systems and movement to the mother ship’s platform.

I was asked to do some contract work with these practices, trying to reduce the frustration factor on their existing EHRs while they wait for migration. The health system also asked me to look at the installations from a support perspective, to determine the best strategy to handle upgrades and issues with the systems in the interim. I asked myself why this wasn’t done during the courtship process, and of course it has to do with money and convenience for the employer. That’s the way many physician contracts are these days, unless the contracting practice reads them with a careful eye and is willing to walk away if they don’t get an acceptable outcome. There’s also the factor of the physician group’s leadership assuming that the health system’s IT team would be willing and available to support the new practices and failure to gain an understanding of existing migration and implementation resources before setting a verbal (and unenforceable) timeline in front of the practices they were wooing.

I was happy to take on the work, not only because it was local and would keep me from having to travel much during the holiday season, but also because I know some of the impacted physicians personally, either on a professional basis or through community organizations. The work has been a flashback to my early days as a medical director for informatics, as I’d go out with recently-implemented physicians and try to optimize their day-to-day workflows. It’s always gratifying when you find quick wins that can impact physicians in a positive way – maybe they’re not using medication favorites or order sets. Those findings are common among small practices that may not have had dedicated EHR super users or that may not have spent the money and time needed for advanced training.

I’ve also had some flashbacks about working with systems that don’t seem to have a lot of clinical oversight. When I saw some of the workflows, they made me wonder whether a physician at the EHR vendor performed user acceptance testing before the content went out the door. One of the more obnoxious “features” I saw was part of a lab interface, where the ordering user has to handle those pesky but necessary “ask at order entry” (AOE) questions. For many tests, there should be a 1:1 relationship between the test code being ordered and the specimen type. For example, if you’re ordering “Stool for Ova and Parasites” the specimen type is “stool” and it should only have to be entered once. In one system I worked with, the ordering user (the provider in this case) had to enter “stool” as the specimen type twice for the same test. Since she was a GI doc and was ordering three different stool panels, she had to enter a specimen type of “stool” no less than seven times, even though each test was prefixed with “stool.”

I thought maybe it was just a configuration issue since there are situations where there still needs to be a more specific specimen type entered even though there is specimen information in the test name. For example, urine cultures – even though “urine” is in the test name, one has to specify whether it’s a clean-catch or catheterized specimen, etc. It was clear that it was a design issue, however, when we got to the blood tests, when the user had to select “venous draw” for all seven tests in the basic metabolic panel. That’s pushing absurdity, and no wonder the providers are frustrated since the BMP characteristically is performed using a single blood tube, not seven different samples.

I also ran into some examples of management absurdity. One practice has been performing weekly backups from their server, which resides in a data closet in the office. I asked them if they ever restore from the backups, and they said no. We talked a little bit about the need to practice downtime procedures and to make sure the backups are working properly. They agreed to do some downtime testing, and we restored the most recent backup to their test environment. I thought it was a bit weird that their test environment was hosted outside the practice but their production server was still in the closet. When we restored the backup, the most recent data entry was from June 2013. This led to some detective work, and after burning through some billable hours I was able to determine that they had been migrated from their self-hosted server to a cloud-based platform in the summer of that year. No one must have understood the significance of the migration, because the practice had been paying a third-party IT resource to perform regular backups of a server that was no longer being written to and had spent tens of thousands of dollars over the last five years for no reason. They were grateful that I figured out that they could stop with the backups, but were fairly aggravated about the whole situation.

I’m glad I can help some local physicians, but I hope they realize this is just the beginning of their relationship with Big Hospital System. The grass may have seemed greener on the corporate side of the fence, but now they’re just a handful of physicians among thousands. Despite what they may have been told during negotiations, they’re going to have to wait their turn for everything including migration to the shiny new EHR. In the meantime, I have a feeling we’re all going to get to know each other rather well as I spend some time on the helping side of the help desk.

How does your health system handle practice acquisitions? Are they live on the communal EHR day one? Leave a comment or email me.

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