EPtalk by Dr. Jayne 2/8/24

I appreciate the fact that my health system of choice promptly shares visit notes with its patients. I’m less appreciative, however, of the fact that some physicians continue to refuse to follow documentation best practices, which have been designed for patient safety and improved patient experience.

As always, I dutifully completed the electronic check-in process well in advance, verifying my insurance coverage and ensuring that my pharmacy was up to date. When bringing me back to the exam room, the first thing the medical assistant asked for was my pharmacy information. She didn’t log into the EHR using the workstation in the room, but was instead working from a sheet of paper.

It would be one thing if the paper had my information printed and she was simply verifying, but this didn’t seem to be the case since she asked me to provide the address and phone number. I politely declined, stating that I had just updated them in the EHR the day prior.

I’ve been to this office many times before, and the physician has never used the EHR in the room. She uses a scribe and is good at verbalizing the exam so that the scribe can capture it. However, the practice continues to use templated documentation that doesn’t reflect the work that was done during the visit. My most current documented a “comprehensive Review of Systems” which was not performed and included a reference to “see scanned document completed by patient” which doesn’t exist, since I certainly didn’t complete one. I wonder if the physician understands that documenting work that wasn’t actually done is fraud.

As always, I noted my concerns when the inevitable Press Ganey survey arrived, so hopefully someone will see it and take action. In the mean time, I’ve decided to leave the practice, not only due to this, but due to poor appointment availability and annoyances with the billing processes, such as refusing to collect your co-pay at the time of service, leading to more work on my part down the road. This practice is crying out for process improvement work, but it’s unlikely that will commence any time soon.

From Public Health Nerd: “Re: the recent Senate hearing on social media’s impact on youth mental health. Here’s some data for your consideration.” The statistics provided included a dramatic increase in teens who report “persistent feelings of sadness or hopelessness,” especially among girls. There has also been an increase in diagnoses of depression and increased suicide rates among teens. Although rates of social media use correlate with these changes, it’s difficult to prove causation, especially considering all the other changes happening at the same time, including community violence, rising income disparities, racial tensions, global conflict, and high-conflict political processes. More studies are definitely needed.

From Coffee Klatch: “Re: return to office programs. Keep up the good work exposing them as the power grab that they are. If companies want people to come to the office without complaint, they need to make it a place people want to visit. Nearly all of my colleagues use travel mugs, which don’t fit into the new coffee makers that our company purchased. I tried to bring a ‘shortie’ travel mug, but it was too wide. We all end up using paper cups to transfer coffee to our mugs. So much for the company’s commitment to sustainability initiatives, since we’re creating more greenhouse gases driving to the office and now using a bunch of paper cups we didn’t need before.” I’m sure some people thing this is a small thing, but it’s just one more example of how decision makers who are out of touch with their workforce are contributing to employee resentment and potential turnover.

I’m sure no one was surprised to hear the news of Amazon’s planned job cuts at its One Medical and Amazon Pharmacy units announced earlier this week. Executives who may have had lesser degrees of healthcare experience prior to entering our industry often find out quickly that it’s much harder to get those big wins and revenue bumps than they were used to with their previous employers. Amazon promises to continue to hire providers for frontline care delivery, but it looks like they’re primarily focused on building their midlevel provider workforce rather than hiring physicians.

I’ve had several patients follow up with my practice in recent months after receiving interesting diagnoses from online practitioners who conducted asynchronous evaluations that resulted in what was ultimately a misdiagnosis. Sometimes a picture is worth a thousand words, but other times you really need to have a conversation with the patient to fully understand what is going on. Our society puts the responsibility of making sure their provider is high quality largely on the patient, which is hard to do when you’re placed in an anonymous queue and have no idea who you are going to see until they are actually participating in your care.

Last week was Groundhog Day, when many in the US traditionally look towards a rotund woodland mammal for predictions on upcoming weather. Since reaching a point in my career when I have the flexibility to provide behind-the-scenes medical support for events and gatherings, I tend to keep an eye out for how that plays into any large happening.

This year, officials predicted that up to 30,000 people might try to see the venerable Punxsutawney Phil, gathering in the cold dark morning at Gobbler’s Knob, Pennsylvania. Planners had approximately 20 professionals from five emergency response organizations standing by. In the past, problems have included hypothermia (not unexpected in years when the wind chill has been well below zero), cuts and scrapes, medical emergencies from patients who didn’t take their medications due to the early start of the event, falls, and even the occasional heart attack. There have also been issues with intoxication, even given the typical 4 a.m. arrival for some attendees. I guess it’s never too early to get the party started when groundhogs are involved. Props to Allegheny Health Network and Punxsutawney Area Hospital for their onsite support.

Does your area have a local groundhog, and what was its prediction? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/5/24

I was invited last week to an onsite meeting at the local office of a national company, where a “return to work” policy had recently been enacted. Employees are expected to be in the office at least three days per week if they live within a certain radius of an office, regardless of whether their teams are located in that office or not.

One of the attendees was grumbling about the fact that he is the only member of his team that works in this market, so he essentially drives to the office and sits in a cube, where he attends video conferences most of the day. He mentioned that despite the policy, he’s often the only person in his part of the office, which doesn’t do a lot for building employee morale or enabling the growth of the company’s culture.

I was interested to see all the amenities in the building, which included a nice-looking cafeteria and an area that could be configured with courts for indoor sports and lawn-style games. I suspect that they pre-date the era of remote work, when everyone was in the office and people weren’t coming back in a fragmented way.

Given the fact that for this company, proximity to an office determines the need to return to in-person work instead of being part of a specific team or holding a specific job role, it’s no wonder that people are not thrilled about the return to work policy. It will be interesting to follow up in a few months to see whether more people are embracing in-office culture or whether it’s just causing more bitterness. Expecting people to collaborate in an office where there aren’t any team members simply makes no sense.

Having worked in environments that are in-person, completely remote, and various combinations in between, I’ve seen how company culture is governed more by people’s behaviors than by whether they’re interacting in person or online. For example, in remote environments, particularly when people are working in multiple time zones, it can be easy to overlook people’s posted work hours and schedule meetings that are too early or too late for them. I’ve had to do that on occasion, but try to only do it when there’s an external constraint, like physician attendees who work from one of the coasts and need to accommodate clinic hours, or something like that. I always reach out to the impacted people rather than just sending the appointment, so that people know it’s coming and can let me know if they can attend the meeting or whether we need to make other arrangements. Using that approach, most people are willing to adjust their schedules to accommodate an early or late meeting, but it’s the fact that you discuss it that helps build rapport, teamwork, and by extension, company culture.

Whether in-person or remote, it’s also important to have a culture where people can put focus time or work blocks on their schedules and have those times be respected. Those blocks need to be created in a way that respects existing standing meetings or important team meetings, but no one should ever be made to feel bad that they want time during their scheduled workday during to actually do their work. Remote employees often struggle with failing to achieve work-life balance because they are always at their workplace, and creating an expectation for them to spend time after-work hours playing catch-up due to overly full schedules isn’t a culture builder.

It was interesting timing to have this meeting since several articles about the topic were published this week. Gizmodo had a headline offering “There’s More Proof That Return to Office is Pointless,” highlighting a study from the University of Pittsburgh that demonstrated that return to office policies don’t positively affect productivity. Researchers looked at a sample of S&P 500 companies and concluded that such policies were more about corporate control than stock performance. They found negative correlations between returning to the office and key indicators such as employee satisfaction, ratings of work-life balance, and opinions of senior management.

Companies allege that returning to the office builds trust, but I have found that trust is best built, regardless of work location, by doing things such as giving employees the resources they need, ensuring that employees have adequate time away from work (such as uninterrupted lunch breaks), not requiring employees to have their cameras on 100% of the time, and assuming positive intent when employees seem to be asking a lot of questions.

Another colleague I talked to is convinced that her company’s return to office policy is a play to make good on bad real estate decisions that were made when people failed to realize the impact of remote work during 2020, 2021, and 2022, when others modified their leases due to the impact of the COVID pandemic. One of the companies I worked with in 2020 saw the proverbial handwriting on the wall and made the decision to unload countless square feet of real estate. They made it clear that they wouldn’t be going back to in-person work, and unsurprisingly, employee satisfaction continues to be high and turnover numbers are smaller than they have ever been.

Fast Company also had an article on the topic that highlighted results from a recent survey that indicated that half of potential employees wouldn’t even apply to a job if it was entirely in-person. Flexible work can be a tremendous asset for neurodivergent employees or those with disabilities, chronic medical conditions, or high commuting costs. There’s also the issue of environmentalism and the potential to reduce carbon emissions when fewer people are driving to a physical office.

I’m not saying that allowing employees to work remotely is all sunshine and lollipops. I’m wondering if some of the movement towards return to office policies has to do with declining professionalism. I’m sure many of us working remotely have done the “business on the top, pajamas on the bottom” wardrobe look and that’s OK. The people I work with regularly either have tidy home offices or use electronic backgrounds, although I do get distracted by those that have animations such as rain or snow on the windows.

However, in attending meetings for professional organizations and committees, I see a lot of people whose home lives have become part of their work lives, including interruptions from children and pets. Life happens, but when your kids are wandering in and out of your call, there’s always the option to turn off your camera, make an apology for the disruption, or even step away.

There’s also evidence that virtual meetings aren’t being done optimally, causing employees to become fatigued and inattentive on calls. Researchers looked at employee engagement during calls, along with physiological measurements, over two working days, encompassing nearly 400 meetings. They cross-referenced their data with questionnaires about work attitude and engagement, finding that fatigue during calls is due to mental underload and boredom in the workplace. They found that disengaged employees have a harder time maintaining focus in meetings where cameras are off, leading to multitasking behaviors and further distraction. They mentioned that highly automated and non-cognitive tasks such as walking can be carried out during meetings, and I suspect that extends to the knitting and crochet that I see some of my physician co-workers doing during committee meetings.

I know of a number of hospitals and health systems that allow technology workers to live anywhere in the US, even though their patient care sites aren’t nationwide. It would be interesting to specifically compare their outcomes to those that require workers to do the same jobs in person that others do remotely. Only time will tell whether organizations will back off on their return to office mandates.

Have you recently been subject to a return to office policy? If so, how is it going? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/1/24

Physicians who care for children — including pediatricians, family medicine physicians, and psychiatrists — have been sounding the alarm for years with regard to the negative impacts of social media on the health of the world’s youth. I’ve been following the recent hearings in the US Senate Judiciary Committee this week on the topic of child sexual abuse. Executives from TikTok, X, Snap, Discord, and Meta were grilled by senators about the platforms’ role in child exploitation.

For those of you who might not be following the issue closely, abuse and exploitation of kids via social media platforms is more than cyberbullying and child pornography. The list of problems continues to expand, and includes not only the sharing of images and videos, but also predators grooming children for abuse and potential trafficking.

Drug use is also a serious concern. I’m sure a lot of parents don’t know that you can use Snapchat to buy fentanyl. As an urgent care physician, I’ve seen the faces of parents who can’t believe that the pricey TikTok-promoted cosmetic products they gave their pre-teen daughters for Christmas have caused the horrible rashes that resulted in a $100 co-pay and prescription medications.

I continue to encounter parents who are willing to help their children lie to gain access to social media even though they’re not old enough to meet the age restrictions, because they are terrified that their children will be ostracized if they’re not keeping up with their peers. I also see children who have zero parental limits on social media use, which can manifest with sleep disturbances, poor academic performance, and serious behavioral health issues.

One hot topic during the hearing was the Kids Online Safety Act, which only two of the five platform leaders were willing to support. Others claimed that the Act contains provisions which are too broad and may clash with free speech issues. The act includes language not only addressing abuse but also predatory marketing and would potentially reduce the power of notifications and auto-played videos that trigger users’ dopamine pathways and contribute to compulsive and addictive behaviors.

YouTube was notably absent from the hearing, despite the platform’s popularity among teen media consumers. Unfortunately, the hearing ended without consensus or clear solutions and those of us who have seen countless children harmed will have to continue to wait for yet another bill on Capitol Hill to finally get passed.

I received a message from the CDC’s V-safe program this week, inviting me to participate in health check-ins for the updated COVID vaccine. Unfortunately, one has to register within six weeks of receiving the vaccine. For those of us who are frontline physicians of a certain age who received the updated vaccine shortly after it became available, I guess we’re out of luck as far as participating in vaccine surveillance. Seems like that should have been something they coded and released to time appropriately with the vaccine’s arrival in retail locations.

Unfortunately, this is just the kind of food for thought that conspiracy theorists latch onto, since it can be used to try to support the assertion that that “government really doesn’t want us to know about how many people are harmed by these vaccines.” I serve on the health advisory board for our local school district, and most of us are still seeing COVID-deniers in practice. Many don’t want to seek medical care because they’re afraid they’ll be tested for COVID. Maybe someday health literacy in our country will improve to a place where clinicians can spend more time rendering care and less time refuting medical misinformation.

As a telemedicine physician, I’m concerned about the conflicting priorities that our industry faces, including balancing patient satisfaction and perceived convenience with elements such as clinical quality and antibiotic stewardship. One of the challenges is the lack of telemedicine-specific metrics, which leads organizations to try to mold in-person clinical quality measures to virtual care. The Agency for Healthcare Research and Quality has created the AHRQ Safety Program for Telemedicine, which will help prescribers look at antibiotic usage over an 18-month period starting in June 2024. The program will provide educational sessions to providers, including scripts for navigating patient concerns about not having their wishes met when they request “a Z-Pack to nip things in the bud since we’re going into a weekend,” which universally makes physicians cringe. Providers are expected to perform better on antibiotic-related quality measures after participating in the program, and continuing education credits are available. There is no charge to providers to be part of the program, which is a welcome element for those of us already spending too much to maintain board certification and other recognitions.

Mr. H recently mentioned concerns by developers such as Microsoft and Google with regard to the cost of the computing power needed for AI projects. I’m a bona fide space nerd, having once wanted to be the first physician living permanently in space. Instead, I’m content to watch from the sidelines as scientists execute cool projects that I could only dream of. I’ve followed NASA’s Ingenuity helicopter, which nearly every journalist describes as “plucky,” especially since it was planned for less than a half dozen missions and eventually flew 72. Ingenuity weighs less than 4 pounds, but provided an amazing amount of data about the ability to achieve powered autonomous flight on another planet.

A headline about the craft caught my eye this week, noting that the craft “packed more computing power than all other NASA deep space missions combined.” This was a challenge given its small size, with engineers having to forego heavy components whose design would mitigate radiation damage and the extreme temperatures on Mars. Instead, designers specified off-the-shelf components, including the brain of the helicopter: the Qualcomm Snapdragon 801 processor, which was used in smartphones nearly a decade ago. Here’s to those IPhone 6, Blackberry Passport, and Google Nexus 6 users whose daily calls shared NASA-worth technology and they didn’t even know it. Photo credit: NASA/JPL.

What was your childhood dream? Are you working in a related field or would you give up your meeting-filled days for a ride into outer space? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/29/24

I’m a big fan of virtual care. It has the potential to revolutionize healthcare if we can get patients, providers, payers, and state regulators all on the same page.

Unfortunately, there’s still a lot of disagreement on how reimbursement should work for the typical “outpatient” telehealth visit. Provider organizations are having to grapple with state licensure issues, especially if they are on a state border or have large numbers of patients who frequently travel away from the brick and mortar delivery site, or if they have large numbers of patients who live elsewhere but travel to the facility for care. It seems like most of the research articles I read are about that method of delivery, so I’m always interested when one comes up that features a different use case for telehealth.

This week’s JAMIA featured an article that looked at community tele-paramedicine (CTP) and how it can impact patient experience and patient satisfaction when varying levels of health disparities are present in a community. When I was a medical student doing ride-along shifts with our city’s fire and rescue squads, we spent most of our time transporting patients to the emergency department even though they didn’t have truly emergent medical conditions. A fair number of patients used EMS for transportation since they felt they didn’t have other options due to economic and geographic issues.

As a future physician, I felt powerless. It seemed like there should be a way for the paramedics and emergency medical technicians to deliver a basic level of care, such as a dressing change, without transporting the patients. However, the regulations and economic realities of the time left them with limited options.

Fast forward, and now that telehealth has become just another care delivery modality, healthcare professionals who are used to first responder roles now have other options for helping patients. New York City has embraced this, using community-based teams to deliver home-based care. Although the most visible parts of the team include community paramedics who can evaluate patients and facilitate video visits with emergency physicians, the teams also include care managers who are registered nurses that have with additional training in patient education and motivational interviewing. They coordinate with patients’ primary and subspecialty care teams, social workers, and others to make sure patients get the follow up appointments or home health services that they need. The paramedics also have additional training in the management of chronic diseases and assessing patient home environments.

Given the growth of the program and its interaction with patients who are part of vulnerable populations, the authors set out to look at patient satisfaction across areas of the city that were classified into high, moderate, and low health disparity Community Health Districts. As part of another clinical trial, the patients who were selected for this study were diagnosed with heart failure. The community paramedics who were part of the program had additional training on heart failure that included both lectures and case-based learning to simulate patient visits.

The service was available for home visits seven days per week, with nurse care managers staffed five days per week. The physicians who provided coverage for the video visits all had at least five years of post-residency experience and were certified by regional EMS officials to serve as online medical control for medics.

Patients were referred to the program after either a hospital admission or an emergency visit. Referrals could be initiated by ED / inpatient / ambulatory physicians as well as social workers and care managers, and referral was triggered within the EHR. Patients were deemed ineligible if they had active substance abuse or psychiatric issues, had been discharged to another medical facility, or were unhoused. Patients, family members, or the care team could request a home visit at any time using a triage process. Patients typically remain in the program for three months, and the program has completed 5,000 home visits since 2019.

Patients received a 12-question satisfaction survey that electronically collected anonymous data after each visit. Although medics could help patients access the survey, they could not help with completion. The authors found high levels of patient satisfaction that were similar across areas with different community-level health disparities.

They also conducted a small number of qualitative interviews, which identified some differences in how valuable patients found the service.  Those in high-disparity areas made comments that aligned with improved health literacy and more engagement with the health system, where those from areas with less disparity were more likely to comment on convenience.

The article includes direct quotes from the qualitative interviews, which touches on themes that we have known have influenced healthcare for a long time: transportation, the need to have someone to check on patients between scheduled appointments, medication education and tracking, and convenience for patients who have a large number of healthcare encounters, such as dialysis patients. 

The authors note that the program used in the study is “specific to our institution and geographic location” and that results might not be generalizable to other cities. However, I would hazard a guess that any large metropolitan area could conceivably achieve similar results. They also noted that the specific design around a heart failure diagnosis may create issues with trying to generalize performance to other chronic conditions. I would also guess here that other chronic conditions such as pulmonary disease, kidney disease, or diabetes may yield similar outcomes. However, we won’t know for sure unless we study other conditions in other geographies.

I’m hoping that other institutions might see this publication and consider conducting research on their own populations, or seeking funding for similar programs that might tell us more about healthcare in rural or other underserved areas.

Additionally, if you couple studies about these kinds of programs with cost savings data, we can build a stronger case about why telehealth provides good value in an environment where healthcare spending is constantly on the rise. We can also couple it with outcomes data to identify cases where care is not only equivalent to in-person care, but where it might actually be better. I think that if we fast-forward another five years, we will be able to make a lot stronger conclusions than we can make today.

Is your organization considering a community paramedic program or does it already have one in place? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/25/24

I had dinner the other night with a group of family physicians. It was an interesting bunch. Three of them have left employed practice models to open their own primary care practices. One is practicing with the local visiting nurse association. Another is working as the medical director for a local hospice. Several are on faculty at residency training programs, and two of us are clinical informaticists.

As one can imagine, telehealth was a hot topic. One of the physicians who is employed by a local health system was complaining about how her organization has brought in a third-party vendor to perform urgent care telehealth visits. In particular, she feels that continuity of care has suffered. One of our colleagues mentioned a recent study that was published in JAMA Network Open that looked specifically at virtual visits that were performed by the patient’s own family physician compared to those that were performed by an outside family physician.

The authors looked at 5 million Ontario residents who met criteria for having a family physician and for having had a virtual visit. They concluded that visits with an outside physician were 66% more likely to be associated with an emergency department visit in the next seven days compared to those visits that were conducted by the patient’s own physician.

If you dig deeper into the results, they looked at a matched subset of patients and found that the changes of an emergency department visit in the next week was even greater for patients with “definite direct-to-consumer telemedicine visits.” They specifically excluded virtual visits that were performed by another physician in the same group as the family physician, since they “sought to contrast the highest-continuity virtual visits (own physician) with lowest-continuity virtual visits (outside of group).” The authors go on to conclude that the findings “suggest that primary care virtual visits may be best used within an existing clinical relationship.”

The authors noted that increased emergency department utilization that were associated with low-continuity visits suggest that “virtual visits may serve a triaging function, allowing for the identification of patients who would benefit from an in-person assessment.” It would be interesting to see a similar study performed in the US, since there are likely differences in service utilization due to the payment landscape here. When patients are worried about co-pays and emergency department costs, they often make different decisions than they might if they were part of a system where they were at less exposure for unexpected healthcare bills. The authors noted that one of the limitations of the study was the lack of ability to identify patients where access was an issue, such as hours of clinic operation, physician availability, or scheduling difficulties.

The next time I see them, I’ll have to get my family medicine colleagues to weigh in on “The Case of the Disappearing Thank Yous,” which was published in JAMA Health Forum earlier this month. It begins by detailing a physician’s dissatisfaction when her employer began to filter messages from patients that said, “Thank you.” Although some may feel that such messages represent clutter, including EHR vendors who have acted on client requests to suppress them, this physician found them meaningful.

It’s the classic case of whether the good of the one outweighs the good of the many, but the author went on to discuss other ways that he feels that appreciation of accomplishments is lacking in healthcare. As an example, he mentions that Medicare costs have stabilized and that important public health worth continues to progress despite the persistence of negative headlines.

He mentions what most of us already know – negative news tends to generate more clicks than positive news. It’s all about monetizing those eyeballs. He notes that “a failure to appreciate past victories can also jeopardize efforts to tackle the health challenges of the future,” especially in the setting of low trust for government agencies which includes those that are involved in public health.

Especially for healthcare workers who have really taken a beating over the last several years, it’s important to feel appreciated. Employers tried to say thank you by issuing challenge coins and sending pizza, but it’s time to figure out how to demonstrate appreciation in a meaningful way. I know I would like to grow old in a society with highly qualified nurses that love their jobs, but the chances of that being a reality are becoming smaller every day. Here’s a challenge to administrators to start figuring out what really matters and putting their money to work.

I’m always on the lookout for healthcare technology that has an interesting backstory. Habit Camera is a wireless camera that is designed to allow users to inspect areas of the skin that they might not otherwise be able to see. Daily skin inspection is important for many patients, including those with diabetes, limited sensation, or active wounds. The camera connects to a smartphone app to enable live viewing of high definition images as well as video and image capture for sharing with clinicians or caregivers. The company is led by a US Marine Corps veteran who was paralyzed while serving in Afghanistan. He and his wife run the company, which employs veterans and their family members to assemble the devices.

I particularly liked the answer to one of their FAQ questions, which asks, “Is my clinician going to look at pictures if I send them?” The response: “It depends! Your clinician may be interested in doing this, but some may not. If you can’t share an image or video with your clinicians, then it can be really hard to explain what you see over the phone. Until a clinician can see it with their own eyes, they probably will ask you to make an appointment and come into clinic. This can be a bit of a hassle, especially if you have to take off of work and drive far, so we hope that pictures and video can help reduce unnecessary visits. A picture is worth a thousand words.” I don’t care how much a company pays for its marketing experts; you really can’t portray the patient experience any better than that.

What technology vendors have the best messaging? Is there a particular one that you feel just tells it like it is? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/22/24

Many organizations are focusing their healthcare IT and clinical investments on Social Determinants of Health. This could include configuring patient portals to gather relevant information, enhancing EHR workflows to allow clinicians to view and act on patient-specific factors, and looking at the data from a population-based perspective.

For some organizations, the return on investment that is needed to gather the data is clear. For example, a community health center might be the recipient of a grant that provides funding for gathering the data and taking steps to improve outcomes based on that data. For others, the return on investment might be less obvious.

A recent article in JAMA Health Forum reviews the need for benefit-cost analysis as organizations look at making investments in care related to social determinants of health. The authors note that there are many examples of the links between social factors and health outcomes in the literature and that organizations have responded by focusing on those with the strongest links. However, adding benefit-cost analysis to the review process would allow comparison of different interventions to determine which would be likely generate the most benefit.

This approach would allow greater understanding of the importance of spending your healthcare dollars in the right place, with the authors noting, “An effective intervention to address a minor risk factor may generate much larger net benefits than a less effective intervention targeted at a major risk factor.” We all have examples of health systems and other care delivery organizations that have fallen under the spell of shiny objects and then struggle to get return on their investments.

Sometimes those projects are more exciting than others and might bring more publicity, but there may be less clarity around how they will actually improve health or reduce morbidity and mortality. On the other hand, certain interventions can have tremendous outcomes, but aren’t seen as exciting. For example, how many people think that nutrition education is sexy? Talking about balanced meals or food deserts or the benefits of community gardens certainly isn’t as exciting as seeing your orthopedic surgery practice mentioned on the wall of the local baseball stadium, that’s for sure. But which one is likely to drive improved health outcomes for the long haul?

The authors discuss this in the context of organizations that focus their attention on return on investment goals that have short time horizons. This leads to failure of visualization of potential long-term gains. We see this with payers denying expensive therapies that may lead to savings many years down the road, when the patient might be on Medicare and offer no calculable benefit for the payer. The authors summarize this: “In contrast, benefit-cost analysis is generally conducted from a societal perspective and considers benefits and costs across all sectors and populations and over extended time horizons with appropriate discounting of future benefits and costs.”

This got me thinking about how we sometimes don’t give full consideration to the longer-term impacts of the healthcare IT projects that we are doing. Leaders are often under the microscope to show positive financial outcomes almost immediately after a project goes live. They are expected to demonstrate shocking reductions in costs or dramatic increases in revenue, and projects that fail to deliver such splashy results may be at risk for being canceled, or even worse, placed on pause and left in limbo. With complex processes, however, it might not be appropriate to push for a dramatic change.

When there’s a significant change happening, I’m a big fan of using pilots to make sure that process “improvements” aren’t going to create unintended problems. However, the pressure to constantly deliver results may make technology leaders less likely to consider piloting or a slower rollout of change.

Alternatively, an intervention might deliver significant results, but then teams move on to other projects, preventing forward movement in the cycle of continuous improvement. In other situations, the maintenance phase is skipped and processes slowly drift back to inefficiency, ultimately eliminating long-term gains.

If organizations focused more on longer-term analysis and ensuring sustained change, would it make a difference in the projects they select? Unfortunately for many, being able to target long-term goals is a luxury given the fact that a results-oriented culture actually means one of immediate results rather than truly designing models that will be sustainable for the long haul. We see this phenomenon often with the rip-and-replace approach to solutions, when we know in our hearts that the organization never spent the time, effort, or money that was needed to make the first solution successful.

I saw another example of this shortsightedness in my community earlier this month. A local hospital that was looking to reduce headcount decided to shutter its medical weight management clinic. Given the obesity epidemic in the US, this doesn’t seem to make much sense at first glance. However, in our community bariatric surgery is seen as more exciting than medical weight management, primarily because it generates higher operating room utilization and therefore greater hospital revenues.

Unfortunately, patients now have fewer choices and might be pushed towards interventions that aren’t right for them. It would be interesting to look at the modeling of both service lines looking at a three-year, five-year, and 10-year horizon to examine not only which one is more favorable from a revenue standpoint, but which one is likely to deliver the best clinical outcomes. I wonder if they even looked that far.

Other organizational cuts occurred in pediatric and women’s health service lines. That looks like it will create a significant gap in services for local families. It will be interesting to see if other hospitals in the area are able to increase access in the service lines that were cut or whether families will just be left with longer waits for services that were already scarce at times. Even without a detailed analysis, I can’t imagine that making it more difficult for women and children to receive care is in the best interests of the community in the long term.

The organization is classed as a non-profit, so we will see the community benefit statements they put out over the next couple of years, detailing their efforts to serve the underserved. I suspect they hope that no one is looking, and given the way that other hospitals in the area behave, I doubt anyone is.

Is your organization looking at the longer term or bigger pictures, or is the focus on delivering results in the next two quarters? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/18/24

The Lown Institute has released its 2023 Shkreli Awards, highlighting “the worst in healthcare profiteering and dysfunction.” The selection panel includes clinicians, journalists, patient advocates, and health policy experts.

In case anyone doesn’t recognize the name, the award is named after so-called “pharma bro” Martin Shkreli, who earned notoriety and scorn by purchasing the rights to manufacture a well-known antiparasitic medication and jacking up its price by 5,000%. Full descriptions along with the judges’ comments can be found on the Lown Institute website, but the winners are below. Given the nature of the activities, I can only imagine what was going on in those that didn’t make the cut.

1. Columbia University interferes with patients filing sexual assault complaints against one of its physicians.
2. Stunning CEO salaries at nonprofit hospitals (CommonSpirit Health is specifically called out, but they’re far from alone).
3. Pharmaceutical companies claim that price negotiations for Medicare drugs are unconstitutional.
4. Hospitals partner with private equity-backed companies to offer high-interest medical credit cards with rates up to 26%.
5. Vascular specialist allowed to continue to practice despite discipline in numerous states and failing to be able to write the essay needed to pass an ethics course.
6. GlaxoSmithKline hides evidence that its heartburn medication Zantac may cause cancer.
7. Indiana cardiologist accused of implanting unnecessary cardiac stents, including 80+ stents in a single patient.
8. Hospitals “dump” homeless patients who are unable to fully care for themselves.
9. Device manufacturer Medtronic incentivizes surgeons to implant devices in patients that may not benefit, all in the name of education.
10. Lehigh Valley Health – Cedar Crest Hospital threatens to medically deport a comatose patient receiving expensive care

From BlackBerry Forever, iOS Never: “Re: BlackBerry. I appreciated the picture of your old-school device. I also had the Torch and it was the best of both worlds – touch screen with a keyboard. Did you see the buzz about add-on keyboards at the Consumer Electronics Show?” Clicks Technology is offering the keyboard, which comes in either “Bumblebee yellow” or “London Sky,” which is decidedly grey. The accessory connects via the standard charging port and will start shipping on February 1. I haven’t met anyone who is remotely interested in buying one, so if you like the idea, feel free to weigh in. Personally, I loved the tactile BlackBerry keyboards and could type on them way faster than a touchscreen model. The roller ball mouse thing, not so much. There have to be others out there like me, so we’ll see if this results in an appreciable number of sales.

Another reader clued me in that BlackBerry is exhibiting at CES 2024, accompanied by a Monty Python-esque “I’m not dead yet” meme. Indeed, the company even has a website highlighting its participation, and it looks like it’s mostly tied to automotive technology. I have to admit I haven’t followed the company since my former employer killed off its BlackBerry server back in the day.

Other interesting items coming out of CES include the Withings BeamO multiscope device. Although it reminds me a bit of an early generation Wii remote, it’s designed to quickly produce vital signs data for use during non-office healthcare encounters. It can deliver temperature, oxygen saturation, heart rate, and electrocardiogram data that can be sent to healthcare providers using an app. Withings has an application in for FDA approval of certain features, such as detection of atrial fibrillation. The device is expected to hit the shelves in July and will retail for $250.

Speaking of cool devices, I see all kinds of wearables out on the trail and at the local YMCA. A recent Stat opinion piece calls for a “data diet” to help curb the growing obsession with data. I’m sure there’s a boom in sales during the early part of the year as people seek digital help tracking their progress towards various New Year’s resolutions and annual goals. The article confirms this, noting that fitness app downloads are more than a third higher in January than at other times. It also notes that the fitness tracking industry rakes in $45 billion annually and that there are 400 personalized nutrition companies out there. The article questions the role of fitness trackers in trying to curb the obesity epidemic and the increase in chronic diseases. It suggests that we’re tracking the wrong data, and that in order to harness technologies like AI to better use our data, we need higher-quality data in the first place. The author shares vignettes of several patients gaming their fitness trackers, one sitting in a meeting but waving his arm trying to clear an alert telling him to move. It will be interesting to see how the fitness tracking movement evolves and whether we start getting better data or just more mediocre data.

I’m always looking for interesting new companies and was excited to run across CareLuminate. Their premise is straightforward: if one understands how nurses feel about the care being delivered in their workplaces, one can better understand clinical quality and help reduce healthcare costs. CareLuminate can help those who are paying for healthcare (such as employers) steer their workers towards facilities with higher quality. The company’s founders have background in clinical outcomes and industry research, coming from the nursing world and from KLAS Research and specifically its Arch Collaborative. By interviewing nurses directly, the company generates independent and current data that they note hasn’t been “gamed” by health systems. Some of the measures captured in interviews and through available data include nurse perceptions of care safety, patient satisfaction, infection rates, and readmission rates. I’ll be watching them closely to see how they gain traction in the industry. They’re worth checking out.

Speaking of checking companies out, I was happy to book my first celebrity Booth Crawl for HIMSS24. Since I’ll be the only member of the HIStalk team in attendance at the show, I feel particularly responsible to capture the glitz, glamour, and exhaustion of the event. It’s my first time to schedule a booth crawl on the opening day of the exhibit hall when people are fresh and should be eager to chat.

What are your hopes for the HIMSS24 conference? Is there anything you’d recommend as can’t miss opportunities? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/15/24

I’ve been practicing in the telehealth space since before the pandemic. We deal with a lot of situations that other physicians don’t want to deal with – patients calling for antibiotics, patients with questions about lab results they received through their patient portal after most physician offices are closed, and requests for refills on chronic medications for patients who haven’t been seen by their physicians in a long time period.

Most of the primary care physicians I talk to are grateful that we are out there as a buffer, allowing their patients to receive care without having to be on call 24×7 themselves. However, this week I discovered that apparently a subset of physicians thinks that those of us who practice telehealth exclusively are less than “real” physicians. A newly formed physician education program refused to let me join because I didn’t have an ID badge that has a hospital-style “PHYSICIAN” designation on it. In fact, I don’t have an ID badge at all, which was also an issue.

I submitted a copy of a different photo ID along with a copy of my state medical license, thinking that would suffice. Instead, they asked me for my National Provider Identifier number, which was particularly silly since that can be found via a web search. Once I provided that, they wanted copies of my medical school diploma and residency completion certificate. I’m not sure why a state license wasn’t sufficient, and I hope they had fun trying to read the Latin on my diploma. I had to go digging for those documents since I’m not one of those folks that has them hanging on my office wall. Next time I’ll just use the magic of computers to make a simulated ID badge and be on my way.

The entire experience was annoying, though, and impacts not only telehealth physicians, but any physician who isn’t working in a clinical setting. One doesn’t stop being a physician because they’re not seeing patients. I am definitely going to address this once I am established in the program.

Speaking of annoyances, I had to deal with some annoyances from CMS this week. I received an email from the CMS Identity Management System telling me that my account was going to be deleted due to inactivity. I attempted to log on but couldn’t, and the password recovery system presented a security question that I swear I’ve never seen in my life, because I would have said it was ridiculous if I had. It asked me to provide a telephone number for a relative that was not my own number. I tried to guess when it was that I had set up the account and tried some numbers, which of course were not correct, and the account was locked. The system unhelpfully told me that I needed to call the help desk associated with the application I was trying to access, which was also silly because I have access to multiple applications through the CMS Enterprise Portal. Each of them has their own help desk.

Of course, I was trying to do this at 10 p.m., so I waited until the next business day when I had a gap in my schedule and started calling help desks. The first one was closed because their office hours are only until 4 p.m., and the second one allowed me to hold for 11 minutes and then disconnected me. I called right back and went directly to an agent, so I can only assume their phone system was having a momentary malfunction. The agent clearly had no idea how to help me and was reading from a help desk manual and couldn’t even pronounce some of the application names. He provided another phone number to call. That agent asked me for a bunch of personal data. I finally interrupted and asked whether she’d like to know why I was calling. She seemed surprised that I would want to tell her that. I told her my story, and she said, “Oh, so you just need a password reset?” Bingo! She switched gears and did the reset, giving me a 15-character complex password that I had to write down.

Fortunately, she stayed on the line while I did the reset. The process requires two-factor authentication. I chuckled when I got to the screen that recommended Google Authenticator because it’s supported for “iPhone, Android Phone, and Blackberry.” I wonder how many Blackberry devices they get accessing their system these days. Finally, I was able to set a new password and was on my way. The agent disconnected and I went to set a new security question, since I still had no idea what the answer was for the one with a relative’s phone number.

The list of security questions had some interesting choices. Not only were they strange, but they’re also things that change over time for many people, which doesn’t make them a good security question. The highlight reel:

• What did you earn your first medal or award for? Hmmm, was it swim team or horseback riding in elementary school? I have no idea.
• What is your favorite movie quote? I’m at a point in my life where I can barely remember the things I’m supposed to remember, let alone the specific grammar and syntax of a movie quote.
• What music album or song did you first purchase? I seriously have no clue since it was more than 40 years ago.
• What was the first computer game you played? Truly have no idea here either, although I was tempted to put Oregon Trail due to the lack of good questions.
• What was your grandmother’s favorite dessert? I can’t wait until I’m old enough to have a grandchild call and ask me this.
• Where were you on New Year’s Eve in the year 2000? I think the better question for healthcare workers was where we were on New Year’s Eve in 1999, since many of us were in Y2K hell.
• Who is your favorite book/movie character? I read more than 50 books a year, so I wasn’t touching this one.
• Who is your favorite speaker/orator? I can’t remember the last time I saw the word “orator” and was tempted to put Abraham Lincoln, but I knew I wouldn’t remember that down the line either.
• What is your favorite security question?

I couldn’t believe it when I got to that last one. Again, how would I ever remember the syntax if I selected that one? Maybe “what is the answer to your favorite security question” would have been a better option, since it wouldn’t involve more than a word or two. Still, the entire experience was bizarre and fortunately I was quick enough to grab a screenshot of the list of crazy questions. I sent it to one of my favorite online security experts who replied with four different kinds of eye-roll emojis and GIFs. You can’t make this up, folks. Thanks to CMS for keeping it real.

What’s the weirdest security question you’ve seen? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/11/24

Masks are back on at my local hospitals. Our area is seeing a surge of COVID, influenza, and RSV patients. We’re seeing full intensive care units. Nursing exhaustion is approaching pandemic levels.

Across the US, hospitals are experiencing staffing challenges, which often cause beds to be unavailable because they aren’t staffed. This rolls downhill in the hospital, landing in the emergency department that has to board the patients until beds are available. In turn, this can back up ambulances, which leads to delays in 911 calls. For my friends working in EMS, this is starting to feel a lot like 2020, and in my community, the COVID-related hit to EMS staffing is still present.

If you’re on the healthcare IT side and the clinical staffers that you are interacting with seem frazzled and distracted, it’s because they are. One of my ICU nurse colleagues commented, “It’s like people forgot what we went through and just don’t care about healthcare workers any more.” Let’s remember to wash our hands, stay home when you’re sick (or wear a well-fitting mask if you can’t stay home), and look after each other. We’re all in this together.

I’ve started working on a project that involves an area of clinical informatics that I haven’t worked on in some time. To get up to speed with the vendor landscape, I’ve been visiting lots of websites to view white papers and customer case stories. Maybe my brain is just used to operating in an older way of working, but I find myself increasingly annoyed when companies have decided that the only way they’re going to share information on their websites is through videos. Some of us absorb more through reading actual words. Of course, others are more visual or auditory learners and might do better with that kind of content.

For me, it’s often a time issue. I can read much faster than most video presenters speak, which means that when there is only video content available, I tend to perceive the sites as not being a good use of my time. It left me wondering what happened to the good old written word and whether it’s just me or whether times have changed and I need to get used to my work taking 50% longer than planned.

A primary care colleague reached out to me today, venting that her organization has yet to configure the EHR to allow physicians to submit the G2211 billing code that went into effect on January 1. That’s an add-on code that allows physicians to submit charges for the time they spend building longitudinal relationships with patients and addressing patients’ issues over the long term. CMS describes the code as billable for “visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed healthcare services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition.”

The nature of the relationship between the patient and the physician is the factor that determines whether the code should be used. It’s worth around $16 when billed for Medicare patients, so it’s not designed to drive significant revenue, but rather to offset some of the valuable whole-person care that is provided by primary care physicians. Medicare’s documentation about the change says that the typical primary care physician who has Medicare beneficiaries in their patient panel will coordinate care with 229 physicians in 117 disparate practices. If it hasn’t yet been added to your EHR workflows, your clinicians are missing out.

The US continues to have supply and demand issues with stockpiles of personal protective equipment (PPE). A recent AP report explored the fact that states that had scarcity of supplies during the high points of the COVID pandemic are now dumping PPE at an alarming rate. Ohio has auctioned off nearly 400,000 protective gowns and has thrown away 7 million gowns along with countless masks, gloves, and other supplies. States are having to determine their go-forward strategies for supply stockpiles and preparation for potential disasters.

The amount of materials that is being shredded, recycled, or destroyed is simply staggering. Georges Benjamin, MD, executive director of the American Public Health Association, mentioned that our “bust-and-boom public health system” creates waste as well as lack of preparedness. Many states didn’t respond to the AP’s request for information, so it’s hard to know exactly how large the problem might be.

As a CMIO, I’ve worked on a number of projects around health literacy. I would bet that most people in healthcare IT don’t understand the level of understanding of the average patient. For written communications, we need to focus our writing at roughly the fifth-grade level to ensure that patients will be able to understand any instructions we provide. Organizations have also made significant efforts to provide documents for as many patient-preferred languages as possible.

I was excited to see this article that looked as the association among hospitalizations, emergency department visits, and health literacy interventions. Researchers concluded that patients who read patient education materials and summarize their understanding back to the care team are 32% less likely to be hospitalized and 14% less likely to visit the emergency department. Additionally, there was an association with overall declining health costs in patients who received the intervention. The study was performed using subjects that were part of an employee health plan, so it’s not clear if results are generalizable to all patients. Thanks to Healthwise for including this study in their blog, otherwise I would likely have missed it.

The Consumer Electronics Show is upon us, and Garmin is finally taking a giant leap forward in the realm of wearables by introducing a women’s heart rate monitor that clips onto a sports bra and doesn’t require a separate strap. For anyone who has had to deal with a heart rate monitor strap interfering with your bra, this is a welcome addition. The HRM-Fit strap retails for $150.

What are the best and worst things you’ve seen coming out of the Consumer Electronics Show? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/8/24

This weekend was all about playing cleanup. The new year brings a lot of things for the physician to-do list, one of which is starting my quarterly questions that are needed for me to maintain my specialty board certification.

The Maintenance of Certification (MOC) process is almost universally hated by physicians, to the point where some of them will take a high-stakes exam every 10 years rather than participate in the program. I was part of my specialty’s pilot program for MOC and much prefer the quarterly questions to an all-day exam, especially since I haven’t practiced full-spectrum primary care in quite a while. Unfortunately, my specialty still thinks we should be able to manage all the conditions we used to manage during our residency training programs, so I have no choice but to play along.

The quarterly MOC questions are open book, so that’s something, and usually if I don’t know the answer, I can find it using a combination of UpToDate, the online version of my specialty’s flagship journal, and the website of the US Preventive Services Task Force.

Arriving in the New Year also means paying an annual fee to the board, which I had forgotten about. Many of my colleagues who are in purely informatics roles have to pay these expenses out of pocket, which is burdensome. The boards assume that physicians are either self-employed and can take their board fees as a business expense, or that they are employed and receive reimbursement from their practice, hospital, or health system.

There’s a lot of chatter in the physician world right now about the value of MOC, with oncologists and cardiologists being among the most recent to launch challenges. Usually, physicians have to maintain particular board certifications approved by the American Board of Medical Specialties in order to be granted hospital privileges and to join insurance plans. However, there’s a movement towards supporting an alternate organization, the National Board of Physicians and Surgeons. Although it’s gaining traction, NBPAS isn’t accepted in my area, so I haven’t pursued it.

Some clinical informaticists see MOC as an opportunity where AI tools might help physicians trim the time-consuming process. Rather than having to search three or four websites, one could query a generative AI system to provide the information that is needed to answer the questions. Physicians could also perhaps ask a virtual assistant to search the rules and regulations for their specialty and create calendar appointments for all the deadlines that are required to maintain certification. For those of us who have multiple board certifications, that might help a lot, especially since each board has its own timeline and requirements that differ depending on where you are in your certification cycle. The questions I did this weekend didn’t have any disclaimer that you couldn’t count AI tools as some of the online resources used in answering the questions, but I’ll have to keep my eye out for such prohibitions in the future.

Also on my list for the weekend was setting up a new laptop that was sent by a client I recently started working with. This is the first time I’ve had Microsoft balk at my use of a password that doesn’t contain words. I’m not sure how someone would guess a 10-character password that contains two numbers, three lowercase letters, three uppercase letters, and two symbols or why Microsoft would have seen my particular combination of characters “too many times.” I certainly don’t use the same password on all of my accounts, so this just seemed like a weird error. I had to try three versions of what I wanted to use before it finally gave up and let me set my password.

I also caught up on some reading, which put me to sleep the first time I tried to get through it. ONC is scheduled to publish its “Health Data, Technology, and Interoperability: Certification Program Updates, Algorithm Transparency, and Information Sharing” final rule this week. The rule implements pieces of the 21st Century Cures Act through the creation of new requirements for health IT developers under the Health IT Certification Program. The rule includes provisions for developers to report metrics that give insight into how organizations are using certified IT products, updated criteria for decision support interventions, and updates to patient demographics and electronic case reporting. It also requires developers to move to the United States Core Data for Interoperability (USCDI) Version 3 standard no later than January 1, 2026. This will help organizations better share data that will promote health equity, reduce healthcare disparities, and improve the interoperability that is needed for public health efforts.

Of course, no ONC final rule would be complete without a mention of information blocking, and I can assure you that’s in there, at least in the current unpublished version that’s available on the Federal Register website. Its 804 pages of double-spaced delight isn’t much of a beach read, but it contains other hot topics, including a C-CDA Companion Guide update, a Synchronized Clocks Standard, information on a patient’s Right to Request a Restriction on Use or Disclosure, and more. The rule will become effective 30 days after it is published in the Federal Register.

The final cleanup activity of the weekend was catching up on a New Year’s Resolution on which I had already fallen behind. This year, I’m aiming to read two scholarly articles each week that cover an area of medicine or clinical informatics that isn’t part of my usual practice. One of my articles this week was “Effect of an Intensive Food-as-Medicine Program on Health and Health Care Use.” The article, which was published in JAMA Internal Medicine, covers a randomized clinical trial designed to see if a program for patients with diabetes that provides healthy groceries, dietician consultations, education, and health coaching would improve blood sugar control in compared to the usual care they would otherwise receive. The study had over 400 participants. Although the authors didn’t find an improvement in blood sugar control, they did find improved patient engagement in preventive health care interventions. They recommend that additional studies be performed to find optimal “food  as medicine” interventions to improve patient health.

Since this resolution was designed to stimulate my curiosity, I wandered around the internet a bit to learn more about food-based medical interventions. I was intrigued by The Goldring Center for Culinary Medicine at Tulane University. The Center has been around for more than a decade and was designed as a teaching kitchen to educate future physicians “to understand and apply nutrition principles in a practical way” and to better work with patients on diet and lifestyle modifications. The Center also provides cooking classes for the community. I was glad to see that they offer continuing education classes for practicing physicians since many of my medical classmates subsisted for anywhere from seven to 10 years on a diet of ramen, sandwiches, drug rep-provided lunches, leftover patient meals, and a stash of graham crackers and apple juice that was liberated from nursing unit stockrooms.

New Orleans is a great city. Anyone up for a HIStalk continuing education field trip? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/4/24

I didn’t ring in the new year in Auckland, but since I visited there earlier in the year, I could at least visualize more accurately what it must be like to celebrate in one of the first major cities that greeted 2024.

I spent the evening in my Midwest neighborhood, where the fireworks started at 6:35 p.m. courtesy of some folks who I suppose either wanted to get a head start or were celebrating with small children before they sent them off to bed. The random gunfire held off until midnight. at least, and fortunately was short lived. Maybe I’ll plan a trip to greet 2025 in a more spectacular locale.

I always like reading various year-end review articles and Google shared the top 10 health-related searches of 2023. The list was wide ranging and showed that even post-pandemic, infectious diseases are still top of mind for many:

1. How long is strep contagious
2. How contagious is strep
3. How to lower cholesterol
4. What helps with bloating
5. What causes low blood pressure
6. What causes warts
7. Why do I feel nauseous
8. What causes preeclampsia
9. How to stop snoring
10. How long does food poisoning last

I have to admit I was a little surprised by #8, which is a pregnancy-related complication. However, a quick Google search of my own revealed that the condition affects over 200,000 pregnant patients in the US each year and the rate of the condition in the US has increased 25% in the last two decades. It’s good to know that people are seeking additional education about the condition, which is a leading cause of maternal and infant morbidity and mortality.

I also got a chuckle out of #7, since it’s decidedly first-person in comparison with the other queries. I doubt Google knows whether the person asking the question recently consumed Flamin’ Hot Cheetos and a Mountain Dew or whether they just returned home from a wild night at the local dance club, so maybe a more refined search is in order.

I spent a few hours on New Years Day catching up on my inbox, which has been overrun the last couple of weeks. One message advertised an upcoming webinar for automated fax processing, which made me chuckle. I’ve had a situation for over a year where a particular pharmacy chain is sending refill requests to my practice fax line for patients (and providers) who have no affiliation with my clinical practice. I thought it had been resolved, but it started up again, leading me to believe that the pharmacy chain somehow downloaded an outdated prescriber database.

I sent a formal notification to their corporate entity, but it hasn’t been corrected yet and they haven’t even responded to my message. If you work for a pharmacy company, please make sure you have updated provider profiles, because this kind of thing keeps patients from receiving their refills in a timely manner.

Also on New Year’s Day, I spotted this ad for Amazon’s clinical care options. I appreciate the sentiment that they are trying to express, namely that they are available for various clinical situations, but nasal foreign body removal isn’t listed as in scope for their in-person offices and it’s definitely not a problem that can be resolved during a virtual visit.

I’ve fished plenty of items out of kids’ noses and ears in my career, and while it might be helpful to talk to a medical professional for advice on whether to go to an urgent care (older kids with certain foreign bodies) or whether to go to the emergency department (pointed objects, young children who might need sedation), waiting for a consultation might lead to a delay before a child gets appropriate care, which can make extraction more difficult due to swelling. Here’s to all the parents who have survived the trauma and drama of this happening and the process that is needed to reverse it.

The US Government Accountability Office has appointed five new members to serve on the Health Information Technology Advisory Committee (HITAC). The group advises the federal government on implementing healthcare IT and has been around since 2016. Four of the new appointees are physicians and one is a nurse. Their experience includes quality standards, innovation, health plans, applied clinical informatics, AI models, and having personally been a caregiver for someone with a serious health condition. Personally, I think the latter element is one of the most important. If we had more healthcare consumers making decisions about healthcare strategy, we might see a different health system than we have today. Each will serve a three-year term with the potential for reappointment.

I’m continually amazed by the number of physicians that don’t understand some of the basics of clinical informatics. This wasn’t such a big deal a decade ago, but now that nearly everyone is using EHRs, there is a minimum level of knowledge that one needs for survival. The first thing to understand is that most EHR installs have significant differences, even if they’re from the same vendor.

I lurk in some unofficial user forums, and people working at different hospitals seem baffled that there aren’t magical pixies that move their favorites and defaults from hospital A to hospital B even though “it’s all Epic.” They’re also confused about the governance of IT systems, that one hospital might tightly lock down their EHR against customizations where another is permissive, and that the EHR vendor isn’t responsible for hospitals that make bad decisions about EHR configuration.

I was glad to see a recent article in the Applied Clinical Informatics journal that calls for the support of informatics curricula in US-based residency training programs. Graduate medical education bodies are focusing on telehealth competencies, clinical quality, and documentation, but I’m not seeing education that helps physicians understand why their systems are the way they are and what they can do to help.

I’d be happy to go back to my medical school or residency program and deliver the same governance lecture that I delivered to countless healthcare executives and physician leaders during my time as a field consultant. I’ve found that helping people manage expectations can lead to happier end users, especially when users are educated on which pieces of the EHR can be customized or configured, which ones can’t, and who makes the decisions. One physician colleague who was recently griping about his EHR was shocked to learn that his practice partner sits on the EHR steering committee. The look on his face when I explained it to him was priceless.

Do your physicians and end users understand that your organization has made the majority of decisions around how your EHR is structured, or do they just assume the vendor is responsible for the things they don’t like? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/28/23

As we expected, coming out of the Thanksgiving holiday and moving towards Christmas, emergency department and hospital visits for respiratory viruses were on the rise. According to data from the Centers for Disease Control and Prevention, the most recent numbers show a 21% increase from the previous week, with influenza accounting for the majority of visits.

While seeing patients, I’m hearing a lot of stories about family drama when someone attends a gathering and they’re sick. I’m also hearing a fair number of complaints about people who are staying home when sick, depriving their relatives of the chance to see them. It’s rough for patients who can’t win either way, especially when all they want to do is take a nap and feel better. Kudos to those who stay home when sick and keep their germs to themselves.

Speaking of staying home, Uber is advertising its package service as an option to help with post-holiday gift returns. Customers selecting “Return a package” can send up to five packages to a single postal carrier for $5, with the driver sending a confirmation when the drop off is complete. Packages are limited to less than 30 pounds, need to fit in the trunk of a midsize car, and must not contain any prohibited items. I perused the list of banned items for entertainment value. As expected, you can’t send illegal items, weapons, money, or alcohol. Also making the list: recreational drugs, stolen goods, obscene materials, livestock, or animal parts.

The virtual water cooler is abuzz with a recent private equity-related article that was published in the Journal of the American Medical Association. The findings suggest poorer quality care and clinical outcomes at facilities that are owned by private equity firms. The researchers were associated with heavy-hitting organizations: Massachusetts General Hospital, Harvard Medical School, Beth Israel Deaconess Medical Center, and the University of Chicago. They looked at data on millions of hospitalizations at 300 facilities, focusing on years before and after private equity transitions. They found that private equity-acquired hospitals had higher rates of hospital-acquired conditions such as falls or central line-associated bloodstream infections. Surgical site infections also rose after acquisitions. The other interesting finding was the lower-risk demographic of patients at private equity-associated hospitals, which makes the other findings all the more striking.

As expected, more research is needed, but lots of physicians are jumping on the fact that staffing looks dramatically different at PE-owned hospitals compared to other community hospitals or even academic medical centers.

In other journal publication news, this year’s Christmas edition of the BMJ provides an “Analysis of Barbie medical and science career dolls” as a descriptive quantitative study. Among the highlights: although Barbie can be a doctor, she is usually shown caring for children and rarely meets occupational safety standards. Loose hair, heels, and exposed legs are all considered workplace hazards. Science-related Barbie dolls were also short on personal protective equipment such as gloves or full-coverage lab coats. Competitor dolls were also analyzed and had a more “clinically accurate” appearance. Of note, Dr. Ken was more compliant due to his full-length pants, flat shoes, and short hair.

The article goes into gory detail on a lot of different features, but is interesting to think about given the sheer number of Barbie dolls out there. Of note, my own childhood Barbie doll had scrubs, and although they came with a pair of white sneakers, she couldn’t wear them due to her heavily molded feet. My Ken doll was a hand-me-down and had one leg that popped out of the socket any time you tried to get him dressed, so in hindsight perhaps my own Barbie should have been an orthopedic surgeon rather than whatever specialty she was.

It was nice to take a bit of a holiday break, but my heart goes out to all the healthcare professionals who are working during the holidays. I’ve spent enough of them in the emergency department to know that it’s hard work, and the pressure just keeps increasing. One of my colleagues mentioned that the new ED mandate is “do more, do it faster, do it friendlier, with less resources, and you can never ever make one mistake.” Hospitals continue to use short staffing as an excuse for everything, and often the buck stops in the ED because they don’t turn patients away and the halls end up filling with patients who are boarding. They don’t yet have rooms elsewhere in the hospital, yet require care that is often different from what the emergency department is equipped to provide. It’s stressful for all involved, especially when there are empty beds in the hospital but not enough people to staff them.

I’m involved in an online physician support group where one of our members shared an editorial that was published this week in the Annals of Emergency Medicine. The title is certainly eye-catching: “My Suicide Blanket.” It begins with a vignette about a hospital giving out blankets to staff as part of a mental health improvement plan. It reminded me of the challenge coins and other tokens given to staff during the height of COVID and which served only to illustrate how disconnected administrators were from those who were actually delivering care on the front lines.

Emergency department physicians are often treated as if we are expendable, expected to operate under a mindset where we don’t dare call in sick because that means we’re not team players. We’re supposed to just take everything thrown at us even when we know we’re working so fast that we aren’t delivering good care. The author of the piece is a member of our group and mentioned that it had to be published anonymously due to fear of retaliation. Students have been seeing this for the last few years, and during the most recent residency program match, they ran away from the specialty of emergency medicine.

Many of your clinician colleagues are not OK. Check on them and let them know that resources are available. They can call or text 988 or visit the 988 Suicide and Crisis Lifeline for help at any time.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/21/23

I’ve spent the majority of my career helping people use healthcare technology as efficiently as possible. It gets under my skin when clinicians report wildly inefficient workflows and I always want to dig in to see if I can fix them.

The grating example this week occurred in an article featured in a communication from the American Medical Association. In the piece, the AMA’s vice president of professional satisfaction, Christine Sinsky, MD, claims that workflows for immunization ordering had gone from a verbal order to “21 clicks… to order a flu shot for one patient.”

Although I understand the sentiment, I’m wondering if this isn’t a bit of an exaggeration. There are now thousands of clinical informaticists out there who have dedicated their careers to stamping out what can only be considered a horrific workflow if it actually exists. I’m wondering if she’s not referring to the entire immunization documentation process, which is more than simply placing an order and had a significant number of steps in the paper world if practices were doing it properly.

I don’t think examples like this are helpful, especially if they are inaccurate or if people are comparing apples to oranges. If your workflow for ordering (and not administering) an immunization is really 21 clicks, I encourage you to reach out. Let’s name and shame organizations where this is happening.

The AMA was busy this week, also publishing an article about EHR usability and safety challenges. The article cites a 2018 report looking at EHR safety. I’ve seen some significant improvements in the base versions of EHRs in the last few years and I don’t think it’s necessarily fair to regurgitate data from a half decade ago.

I think also when we look at EHR safety and efficiency, it’s important to note that many clients are not using their vendors’ systems out of the box. I’ve watched client after client configure perfectly good EHRs into the stuff of user nightmares. This typically occurs when those responsible for installing and implementing the EHR don’t understand clinical workflow, don’t have adequate clinical governance, and/or don’t have adequate clinical and end user participation. Usually, these deficiencies are directly related to budget, timing, and politics, a sad combination that often sabotages projects before they start.

Unfortunately, some of the concerns do still exist a half decade later. Physicians and other clinicians are doing too much non-value-added data entry, they’re encountering too many alerts that don’t improve patient care, and they’re dealing with content, including drug databases, that isn’t updated with the appropriate frequency. Couple that with inadequate training and rising expectations for patient throughput and you have a recipe for unhappiness all around.

There are also rising expectations for care quality. When you looked at physicians in practice 25 years ago, they were tracking health maintenance screenings and chronic care management elements, but they weren’t necessarily being graded (or paid) based on their outcomes. Now, insurance contracts have added bonuses and penalties for performance, and regardless of EHR use, there is simply more expected of physicians and clinicians. It’s easy to blame the EHR and to wax nostalgic about the good old days of paper charts, but there are so many more complicated factors at play. I watched two more of my family medicine colleagues retire this month and miss them already.

From ShowMe: “Re: the go-live of the Missouri Prescription Drug Monitoring Program (PDMP) last week. I was able to log in through my existing credentials with the St. Louis County PDMP, although I did have to accept new state-level terms and conditions. On the previous system, I had requests for midlevel providers to become delegates under my license that had been pending since I left a previous employer in 2017. They were still there on the new system, but I was finally able to figure out how to decline them. As expected, there were two major inconveniences: the absence of information from surrounding states, and the loss of records of past searches. It will take time for the new system to build up a history on some patients and it still feels a little like two steps forward but three steps back.” Missouri is the last to deploy a statewide solution, and I wish all the clinicians the best as they navigate the transition.

From Internet of Things: “Re: the proliferation of web-connected devices. It’s cool until it’s not. Healthcare isn’t the only single-threaded industry in which connectivity issues can bring everything to a screeching halt. The local school district has lost all internet communication and phone lines due to a fiber-optic cable being cut somewhere, although they don’t know where yet. They have learned that literally everything is tied to the internet, including the bell to start and end classes and the automatic motion-detection light switches. For two days (so far), the kids have been sitting in the intermittent dark, with administrators using an air horn to announce the beginning/end and periods at school. It’s so loud I can hear one school’s horn blow every 42 minutes. They can’t assign, grade, or update any work and it’s finals week. Did I mention that even the photocopiers are internet-based, and they can’t print out worksheets or paper tests?” I come from a long line of teachers and I bet the ones who are having to teach in that environment are losing their minds. It’s already a rough time of year, with many students dealing with end-of-semester anxiety, too much holiday excitement, or increasing levels of family dysfunction. Here’s to those courageous souls that need to make it through just a couple of more days before break starts.

The holiday season is also a time when companies occasionally behave badly. One colleague reported that his hybrid employer took all in-town employees out for lunch, but completely ignored the remote team. I guess management has never heard of sending Uber Eats or DoorDash? Holiday gifts abound, often with company logos and questionable usefulness. Among the best I have received during my career: a Total Wine gift card, small picnic cooler, a $100 bill, and jumper cables. Among the worst: a Santa hat with a company logo, a vanity-published book written by the company founder, framed pictures of the CEO, a rock with an inspirational word carved into it, and nothing.

Does your employer give holiday gifts that put them in the hall of fame? Or are they more deserving of admission to the hall of shame? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/18/23

Mr. H posed a question last week about how to streamline training for PCPs and asked me to weigh in as well.

To really answer the question, we have to ask ourselves what we as a society actually expect primary care providers to do and what kinds of experience we expect them to have. The answers to those questions directly impact how we could best train people to share the primary care load.

To help mitigate my own bias as a board-certified family medicine physician with 20 years of experience, I looked to MedlinePlus (which is an official website of the US government) to define “primary care provider.”  According to the site, “A primary care provider (PCP) is a healthcare practitioner who sees people that have common medical problems. This person is most often a doctor. However, a PCP may be a physician assistant or nurse practitioner. Your PCP is often involved in your care for a long time. Therefore, it is important to choose someone with whom you will work well.”

Some lay people might read that and think “common medical problems” are things like cough and cold, urinary tract infections, rashes, sprains and strains, and the like. Although those are common, those kinds of acute problems are only a small part of what primary care providers actually see. In a traditional primary care practice, we’re also caring for lifelong medical problems like asthma, diabetes, high blood pressure, heart failure, stroke, chronic obstructive pulmonary disease / emphysema, kidney failure, vascular disease, connective tissue disorders, cancer, neurological diseases, and more. Additionally, we care for more complicated acute problems like pneumonia, bronchitis, kidney infections, unusual rashes and suspicious lesions, and clusters of symptoms that don’t have a clear cause.

The latter is where primary care physicians really shine, being able to look at a set of related or seemingly-unrelated symptoms and pulling it all together to create a plan to diagnose the patient. That kind of clinical skill is far beyond evaluating cold symptoms and running a COVID or flu test.

The other thing that happens in primary care, but was not mentioned in the MedlinePlus definition, is the delivery of preventive health services. This is the part where we talk to patients about recommendations, present the options, discuss the risks and benefits and which options might be best depending on the patients’ other medical factors, and ultimately order the services. For a patient who is reluctant to undergo a screening test, this might involve ongoing conversations over a period of months to arrive at the point where a patient accepts a test.

Other preventive services include counseling on smoking, drugs, safe sex, diet, exercise, nutrition, mental health, family dynamics, and what to expect as you age. Speaking of the aged, we also have conversations about advance care planning. On the other end of the spectrum, those of us who see pediatric patients do a lot o bnf counseling and anticipatory guidance, making sure parents know what to expect as their children grow and what might be normal or not normal. Some days, we give a lot of reassurance.

In family medicine, we’re also trained to perform office-based procedures ranging from skin biopsies and toenail removal to joint injections to flexible sigmoidoscopy to colposcopy and cervical / endometrial biopsies. In some areas of the country, we provide full-spectrum maternity care, including c-sections. Some of us are trained to perform colonoscopy, and a small subset of us who have done extra training can even perform appendectomies and other urgently-needed surgical procedures. Most of the family physicians working at that level are either part of a residency / fellowship training program or are practicing in a more rural area, but it’s something that the majority of readers are likely not aware of.

Internal medicine training is similar, but with less of a focus on procedures and no care for infants, children, or pregnancy. Pediatrics generally covers people under the age of 18, but includes a full spectrum of conditions and procedures. Geriatrics is often left out of the primary care list, but as our population ages, it is becoming increasingly important.

That broad definition of primary care falls to the wayside if you listen to many of the talking heads in the healthcare industry today. They feel that primary care can be delivered in a transactional fashion without continuity, and don’t fully understand that when a patient has a lot of different seemingly-minor problems, they can actually add up to something much more significant. These organizations are happy to hire people who aren’t even trained in primary care to deliver primary care services, as long as they’re willing to work for cheap. You don’t have to be board certified when patients are paying cash. (Generally, you do have to be board certified or at least board eligible if you’re being added to insurance panels.)

The definition also morphs a bit when primary care providers become employed by organizations that see them as little more than referral mills, sending patients to subspecialists who perform high-dollar procedures. One of my primary care colleagues who works for a hospital-affiliated group was recently scolded for not sending her diabetic patients to an endocrinologist. Guess what? Her patients have excellent glucose control, are on evidence-based regimens, and aren’t having side effects. That combination of factors means that referrals weren’t warranted. The organization tends to make more money on patients when they are referred to endocrinology, though, so they weren’t happy.

Another role of primary care providers, according to MedlinePlus, is to “assess the urgency of your medical problems and direct you to the best place for that care.” When we actually know you (which means you’re probably not getting your care from a transactional non-continuity entity) we can better assess your symptoms and determine if you can see us in the office on Monday, whether you can go to an urgent care tomorrow morning, or whether you need to go to the emergency department immediately. That’s not to say that a primary care provider who doesn’t know you can’t do that assessment, but from experience, that’s when I see the most patients sent to a higher level of care than they need, usually at a higher cost.

Many primary care providers also see patients in the hospital, although that’s becoming less common every day. Being able to manage hospitalized patients in an environment where the goal is to get the patient out of the hospital as quickly as possible becomes difficult when you’re also seeing patients in the office. That has led a large number of primary care providers to turn over the care of their hospitalized patients to “hospitalists” for inpatient management. Sometimes this results in better coordinated care, sometimes it results in more disjointed care, and I’ve seen the whole spectrum. In an ideal situation, the hospitalists have close relationships with the primary care providers and coordinate discharge and follow up, but there can be misses when the focus is on patient throughput.

Primary care physicians have a bachelor’s degree, four years of medical school for a MD or DO degree, and a minimum of three years of residency. They graduate training with around 20,000 clinical contact hours, which makes it much more likely that they will have seen rare diseases or unusual presentations of common diseases. Physician assistants have bachelor’s and master’s degrees and typically graduate their training with around 2,000 clinical contact hours. Nurse practitioners have a bachelor of nursing degree and typically graduate their training with around 500 clinical contact hours. Although in the past many nurse practitioners had extensive experience as a registered nurse prior to going to NP school, most of my colleagues who have recently entered the field have two or fewer years in practice before starting their NP program. Boiling those hours into years of post-bachelor’s training using data on the quickest paths around — physician=7, PA=2, NP=2.

Keeping that all in mind, we can turn back to the question. What is the shortest time we could train someone to work as a primary care provider? It all depends on what we want them to do. If we want them to be able to find the zebras hiding among the horses (which is how medical school professors like to describe rare diseases) we probably need people with more education. If we want people to follow algorithms and guidelines and crank out referrals and orders, we can use resources with less education.

I think there is room to streamline the path for physician trainees, or at least to allow them to focus on the areas where they might want to dig deeper. For example, I knew early on in my training that I would not be practicing in a rural area and would not be delivering maternity care. Still, I had to complete multiple months of required labor and delivery rotations that could have been better spent learning geriatrics or weight management. I also spent several months staffing the intensive care unit even though I knew that I would be moving to an area that doesn’t allow family physicians to have ICU privileges.

Mr. H asked whether med school should be more training than education given the endless access to literature and resources. I think med schools have evolved over the last decade. I have watched my alma mater make significant changes to its curriculum. For example, they’ve shifted clinical education so that it starts almost on Day One.

For people who are committed to a career path, it could be streamlined a bit, but sometimes physicians don’t find their calling until their third or fourth year of medical school. My own school penalized me for wanting me to do family medicine from the get-go, but that’s another story. As someone who chose a path to deliver comprehensive care, though, I can only think of one clinical rotation in medical school that didn’t contribute to my future specialty-specific knowledge, although it taught me an unquantifiable amount in the realm of delivering compassionate care.

Mr. H also asked how much of a mid-career PCP’s practice uses their training from decades before. I’d say that 20 years out, my family physician colleagues in traditional practice are using a fair amount of their original training, minus the obstetrics, general surgery, ICU, and some of the emergency medicine procedural skills. They’ve also learned a considerable amount as medicine has changed. For example, many of the drugs used to treat diabetes today didn’t exist when I was in medical school. For me in the emergency and urgent care space, on a routine basis, I use about 70% of my training, but when something comes in that falls into the other 30%, I’m glad I have it deep in the recesses of my brain.

Mr. H asked whether some things can be eliminated because they’ll become obsolete, and I think that’s tricky because it’s hard to predict what exactly will be obsolete. For example, we’re still treating strep throat the same way we did 20 years ago, but not diabetes.

As a seasoned attending physician who formerly precepted students and residents, I’ve seen what can happen when less-trained individuals see patients. During the training period, however, there’s the opportunity for supervisors to educate and correct these situations. When less-trained individuals are out in practice unsupervised, regardless of their degree, there’s no process for correction until the patient sees another provider or something bad happens. There is a growing body of literature that demonstrates that less-trained individuals order more referrals, which leads to more expensive care, not to mention delays in patient care and poor patient experience.

Because of that, and what I’ve seen in practice, I personally don’t believe that less training or less education is what we need. Instead, I think we need to be using the resources we have more effectively. How do we do that, you may ask?

First and foremost, unshackle the highest-trained providers (the physicians) from the work that others with less training can do. Free them from their inboxes and hire adequate staff to support them. Use highly trained support staff to manage messages and triage patients using protocols and standing orders. Put registered nurses back on the team, not just medical assistants or patient care technicians.

Second, embrace team-based care. Bring nurse practitioners and physician assistants into specific roles. For example, seeing complex diabetic patients monthly for ongoing education and fine-tuning of treatments while the physician sees them quarterly. That way, the patient can benefit from both levels of education. Encourage patients to build relationships with the team so that there’s a larger pool of people that know them and can watch for changes in their status.

Third, bring in ancillary disciplines for support – registered dieticians, clinical pharmacists, certified diabetic educators, psychologists, social workers, care coordinators, health coaches, patient navigators, and more. Those disciplines have different education than primary care providers and can help deliver more focused interventions so that others can work at an appropriate level commensurate with their training and education.

Finally, I’m going to go out on a limb and mention the rise in the number of for-profit schools as contributing to the problem. For some of them, the focus seems to be on cranking out graduates rather than producing well-educated, well-qualified graduates. As an example, the local medical schools and PA programs (which are affiliated with comprehensive universities) all provide students with lists of “approved” preceptors for rotations. They are vetted and provide documentation about their teaching style and what they’ll allow students to do. The for-profit NP program in the area (which is not affiliated with a comprehensive university) allows students to select their own preceptors, and the students have to call around and beg people to allow them to rotate. I get two or three calls a month. I can’t imagine there’s much quality control over what some of those preceptors may or may not be teaching and the process seems predatory given how much tuition the students are paying.

To make a long blog short, I think there are some ways we can streamline training programs in the US, but we still need some primary care providers to have longer, more comprehensive educational experiences. By using those with shorter training programs or those that have a narrower focus alongside those with broader training, along with other ancillary professionals, we can provide not only the best care for patients, but also the most cost-efficient care with the best outcomes. I would be remiss if I didn’t mention the biggest barrier to people becoming primary care physicians, which is that they are among the lowest-paid specialties.

What do you want in a primary care provider? Or do you just want to get your care from Amazon? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/14/23

From Patient Satisfaction: “Re: patients navigating coverage choices during open enrollment. You are right on target. The challenge of navigating the maze between coverage and patient care is overwhelming. I sympathize with physicians and staff that have to navigate this mess. I appreciate their efforts. I am fortunate to have a great PCP and a network of specialists who care for me. I have been impressed by the coordination of care I have received in my area, even though all the practitioners are not with the same health system. They are all on Epic and share my medical information, which may account for this.” Having your records on a common EHR platform certainly makes some kinds of sharing easier. The most reliable sharing seems to be clustered around the data elements that were required as part of federal incentive programs and now have become table stakes: medications, allergies, and problem list.

Things become murkier when you’re trying to share laboratory data even among systems using a common vendor. Some require mapping of specific lab tests among all trading partners, which can be laborious. Even mapping the top 100 labs can be challenging when you’re dealing with different hospitals using different analyzers. Reference ranges and normal / abnormal flags have to be dealt with, and I’ve seen plenty of organizations just throw up their hands and avoid the problem by doing minimal mapping. Sometimes a thyroid test isn’t just a thyroid test, after all.

For years, I’ve been a keen follower of footwear fashion, but a reader recently clued me in to advances in surgical wear. Surgeons at Mayo Clinic have partnered with Cardinal Health to create the first commercially available surgical gown  with pockets. It boasts two instrument pockets and one holster, suitable for different users, “right, left-handed; any gender of clinician; standing or sitting procedures; etc.”

Although I like the sales talking points around reducing handoffs and drops, or avoiding breaches to the sterile field, I’m less enamored of the gown’s ability to give “an extra hand to understaffed ORs” since that feels like a way for administrators to justify continued understaffing. I reached out to a couple of colleagues. The first said “heck yeah, it’s amazing,” but it sounds like he hasn’t experienced it yet. The second colleague, a 20-year veteran scrub nurse, was a bit more skeptical. She felt it may create issues with lack of standardization in how different surgeons put equipment in their pockets, creating potential confusion for surgical assistants and scrub staff that could ultimately impact patient outcomes. In a salute to the litigious folks out there, Cardinal Health warns that “sharp, hot, heavy, or long instruments should not be placed in the pockets or holster.”

CMS recently released data on National Health Expenditures for the 2022 fiscal year. Here are some of the highlights:

• Healthcare spending grew by 4.1% to reach $4.5 trillion.
• The percentage of insured persons in the US reached 92%.
• The share of Gross Domestic Product devoted to healthcare is 17.3%.
• Hospital care is responsible for 30% of spending, followed by physician / clinical services at 20%, and retail prescription drugs at 9%.
• Private health insurance pays 29% of the bills, followed by Medicare at 21% and Medicaid at 18%. Patients paid out-of-pocket for 11% of care delivered.

It’s important to keep in mind that although the percentage of insured persons has reached a historic high, that figure doesn’t say anything about the comprehensiveness of their insurance coverage, whether it’s affordable, or whether it’s delivering high-quality care.

The Association of Health Care Journalists has released a tip sheet educating reporters on how to spot and report on deepfakes, following concerns about cybercriminals trying to impersonate health system executives. Informatics guru Dean Sittig, PhD and professor of biomedical informatics at the University of Texas Health Science Center at Houston contributed to the document. Potential scenarios include using the technique to get employees to engage in activities that would allow criminals to gain access to technology, creating media that impacts an institution’s reputation, or creating media for use in blackmail efforts. The article also includes guidance from the Department of Homeland Security on how to spot faked images and videos and things to listen for in faked audio recordings.

From Renee’s Friend: “Re: lawsuit award. As a nurse, I’m always interested in stories about whistleblowers that address quality issues. This one about a Kaiser nurse who was awarded $41.49 million has me scratching my head a bit – check out the part about the isolette.” Apparently the nurse claimed retaliation and wrongful termination following her quality and safety complaints. However, the article notes that “In their court papers, Kaiser attorneys maintained that the 30-year employee admitted that in 2019 she took off her shoes and socks and placed her bare feet on an isolette, a medical device that holds sick or premature newborn babies. The defense attorneys included a photo of Gatchalian doing so in their court papers.” This seems truly bizarre and I can only imagine the events leading up to its occurrence. If anyone has more details, do share.

Axios reports on a recent survey that found patients are concerned about how their physicians may be using AI. The article noes that four out of five patients are concerned with the use of AI in making diagnoses or determining treatment plans, with the majority voicing concerns that they don’t know where the information feeding the AI tools is coming from or whether it should be trusted. Half are concerned about the creation of false information, while eight in 10 were concerned about AI using information from internet searches. That number fell to 63% when patients were told the tool was from a reputable healthcare source.

Even as a clinical informaticist who understands how various organizations are creating their AI-powered solutions, I am concerned about the frequency with which they engage clinical resources during the development process and the level of scrutiny present when engineering teams are determined whether a solution is ready for deployment.

An article published last week in the Journal of the American Medical Informatics Association looked at another angle to this issue – ethical perspectives on the development of algorithms used in healthcare. The authors identified areas where greater attention to ethics may be needed, along with technical challenges that influence clinical usefulness, and how solutions support the key ethical concepts of beneficence and justice. We are indeed living in interesting times.

What do you think about the role of ethicists in the development of AI solutions? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/11/23

I’ve been doing some locum tenens work in a traditional family medicine practice. I can attest that the negative feelings that primary care physicians have towards performing uncompensated work are real.

I was brought in to provide coverage for a physician who is on family leave. I was impressed that the practice would go through the work effort to bring in a locum tenens physician. Many practices just expect the rest of the staff in the practice to absorb the excess work, which often causes resentment when there are partners who take more frequent family leave and others who feel that physicians should “power through.”

That was an interesting dynamic that played out during my interview process with the practice. The partners who were making comments about why they didn’t think my assistance was needed were generally older and/or male, and those who voiced support for having a locum were generally younger and/or female. However, there were some exceptions to the rule.

I hadn’t been told what kind of family leave the physician I’d be filling in for was taking, but was surprised at how willing some of the partners were to share another physician’s private information. One told me, “I worked every day during MY chemo, so I’m not sure why she thinks she needs to be out for her chemo.” On the surface, it’s an unprofessional comment, but it also clued me in to the potential for burnout in this practice since burnout is often associated with lack of empathy.

Another physician told me how glad he was that there would be locum coverage because he was tired of covering his partners because “so many of them have been popping out babies.” He mentioned that he didn’t ever feel the need to take paternity leave and his kids turned out OK. It was good to be clued in about the fact that I would be taking a trip to the cultural 1970s in this wayback machine of a practice, but I agreed to take the job anyway.

Although I have deep experience with the EHR the practice uses, I went through all the onboarding steps, which was good because I got to know the practice’s in-house trainers and super-users well. Fortunately, the practice’s use of technology didn’t mirror their attitudes, and I was impressed by how much delegation and automation they had in place for patients who had medical needs in between their office visits – things like refills, questions about lab tests, etc. Most of those were handled by appropriately trained staff members using standing orders and clinical protocols, which were also built into the EHR for efficiency. I’d give them an A-minus grade for overall efficiency compared to other practices I’ve seen, so I was surprised to hear some of the physicians complaining bitterly about their inboxes.

After getting my feet under me for a bit, I was able to explore what was really going on with patient messages since I was getting a lot of them. It’s been a while since I’ve been in an ambulatory practice during the typical open enrollment period for health insurance, and it turns out that questions about insurance plans, medications, coverage, and the like were making up a high volume of patient questions. Not only were employed patients sending in questions, but plenty of retirees had questions, too, thanks to some recent marketing campaigns on TV that tout the benefits of Medicare Advantage plans. It sounded like many patients were facing dramatic premium hikes and were trying to figure out how to get what they needed in the most economical way possible, but like most patients in the US, they lacked the context to be able to formulate the right questions.

For example, one question was, “Is Cigna better than BCBS for my medicines?” Since this question wasn’t addressed by any of the existing triage protocols, it came to the physician to address. No physician, care coordinator, or health navigator can answer the question with the facts provided. What kind of Cigna or Blue Cross Blue Shield plan are we talking about, HMO, PPO, or something else? Is it a commercial Cigna plan, or one that’s for a self-insured employer that just uses the Cigna network? Are there carve-outs for religious exemptions for employers in this predominantly red state? Is the patient using mail order or retail coverage? Are they stable on their medications or do they have new conditions that are being optimized? Patients were asking their primary care physicians because they felt they had nowhere else to turn to try to figure out what to do for their families.

One of my colleagues mentioned that he saw an article “where someone fed the plan data into AI and then asked it to make comparisons,” but noted that it would be nearly impossible unless you had all the plan details for the various options. Another mentioned that he just tells patients to call their employers and see if they have someone who can help. One noted that he had done that in the past, but found that employers were telling patients to call the office since they didn’t have any idea what the patient’s medicines were to determine the level of coverage. All of this together just goes to illustrate some of the key failings of our healthcare non-system in the US.

The idea that patients should be seen as consumers is part of the problem. Historically, consumer education in the US relies around people being able to make comparisons around price, looking at products with features that they generally understand. It’s one thing to compare the per-ounce price of two brands of pasta sauce, but things get more complicated when you’re trying to compare major appliances like washers. It’s another thing entirely to compare interest rates and mortgage terms to figure out which loan is the best option for a new home purchase. Looking at even more complex consumer comparisons, such as the purchase of an electric versus gas-powered vehicle, it’s different for people to assess because that decision also injects somewhat less-tangible values and feelings about renewable energy, tax policy, and more.

Now, take it to the highest level. Trying to perform comparisons of health insurance coverage is more like graduate-level consumer education. Given the levels of health literacy in the US, it’s no wonder that patients often have little understanding of their coverage.

Recent efforts to make price transparency data available to the public aren’t helpful for the majority of patients. A lot of healthcare is unplanned, and those are the costs that typically push people over the edge. Data from 2022 shows that nearly 40% of people in the US couldn’t cover an unexpected $400 expense. When someone’s child gets bounced off the trampoline and breaks their arm, parents aren’t going to head into the house and price-shop the internet to find the best deals on x-rays and orthopedic consultations. If they’re savvy, they’ll call the number on the back of their insurance card, make sure the emergency visit is authorized, and go to the facility they’re directed to. But a good number of patients are just going to hop in the car and go to the nearest hospital.

At the other end of the spectrum, when you’re diagnosed with a life-changing condition like cancer, what patient has any idea of all the healthcare charges they’re about to get hit with? How are you supposed to shop that around?

For patients with longstanding primary care relationships  — which are becoming fewer in this transactional healthcare landscape that is riddled with third parties trying to pick off the easiest and most profitable patients — these questions roll downhill to the primary care physicians, who are barely better equipped to answer them than the patients themselves. I took the issue to the office manager, who hadn’t previously been made aware of the volume of inquiries the practice was receiving. I’m glad I brought it up because it turns out that the practice’s affiliated health system has volunteers within their patient advocacy department who are tasked with helping answer those questions.

The practice was able to quickly throw together a protocol, including the creation of some quick phrases in the EHR to respond to patient questions and get them headed in the right direction. For those skeptical about having a locum in the practice, I guess I provided a little value-add that day. Now that open enrollment is largely over, those new workflows will be dormant for a while, but it’s nice to know that they’ll be ready for next year. 

As I thought through the whole process, it made me think about the use of AI to make this easier. All of the data needed to make true meaty comparisons lives in the EHR and its corresponding practice management or revenue cycle management system. You have all the medication data, including patient compliance and stability of the treatment regimen. You know what pharmacy the patient uses. You have the data on the different insurance plans such as contracts that at least give an idea about allowable charges and expected adjustments. You also have the data on other physicians the patient sees and their past history.

Certainly some smart people could figure out a way to pull that together along with the data from the insurance plans’ Summary Plan Descriptions, the employer and employee costs, and cost data from the local market. I’d pay money for something like that to help me make the hard decisions and I’m betting I’m not the only one.

What’s the solution to the chaotic problem of choosing your insurance coverage for the year? Is AI the answer? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/7/23

Researchers at Brigham and Women’s Hospital, Massachusetts Institute of Technology, Celero Systems, and West Virginia University have created a new ingestible device that can monitor vital signs such as respiratory rate and heart rate. The so-called Vitals Monitoring Pill uses an accelerometer to pick up small movements in the digestive system that occur each time the patient’s heart beats or they take a breath.

The device was initially validated in an animal model, then used for humans as part of a sleep study trial. Although the study was small with only 10 patients, researchers found that the data the device collected was comparable to that collected using standardized monitoring equipment. The study was also limited by the fact that participants were either sleeping or resting in a bed and the authors note there is the need to evaluate it in a more natural environment.

Researchers plan to focus on modifications that could keep the device in the digestive system for up to a week and to develop systems that could release medication in response to certain readings. They propose to be able to use it to detect opioid overdoses and treat them without external intervention.

From ShowMe: “Re: the state of Missouri. The last one in the nation to get on board with a prescription drug monitoring program (PDMP). For several years, in the absence of a state solution, the St. Louis County PDMP has been the de facto solution and other counties participated. Missouri is finally rolling out their solution next week, but users have been warned that they’ll have less functionality with the new solution. Way to go, technology.” I reviewed the materials forwarded by ShowMe and it looks like providers will lose the interstate sharing options they previously had through St. Louis County’s PDMP. Instead, they’ll have to separately register for access to neighboring states and use those individual state PDMPs to perform queries. Illinois requires that registrants of their PDMP have an Illinois controlled substance license, which many Missouri physicians may not have, so drug-seeking patients may be able to exploit the data gap. Additionally, not all counties have agreed to transfer their historical data from the St. Louis County solution to the state solution, so gaps will exist there as well. Physicians have been asked to “please keep this in mind when making clinical decisions. As a result, co-prescribing of naloxone with opioid prescriptions is recommended.” Technology is supposed to support clinicians rather than cause new issues, but I guess it’s to be expected when a state is dead last at doing the right thing. Missouri was one of the last states to bring up an immunization registry, if I recall correctly.

From Jimmy the Greek: “Re: return to office. My organization’s leadership has asked us to ‘practice’ working in the office. Having spent more than half of my career in an office, the idea that I need to practice coming to the office before I do it for real is insulting.” Jimmy’s screenshots made my head spin. Although I appreciate the company’s sentiment, there are ways to offer the same information without being patronizing. Despite this being a team of IT professionals, they were encouraged to come to the office for a “dry run” to test the wi-fi, headsets, and desks as well as to experience the parking arrangements and practice booking a conference room and eating in the company cafeteria. Additionally, employees were told to test their commute to evaluate travel time and traffic considerations, but gave no mention of the fact that hundreds of employees returning to the office are going to totally change the traffic patterns around the facility. As someone who has been a people manager in both remote and in-person situations, I’d like to think that managers know their people well enough to know who has worked in an office setting before and who might be at risk for issues or might require extra support. At a minimum, the organization could have offered a free meal to help entice employees back.

The Joint Commission has unveiled a new certification which will become available starting January 1. The Responsible Use of Health Data certification will evaluate hospitals across key areas including deidentification, data controls, data use, algorithm validation, patient transparency regarding deidentified data, and oversight structure for use of deidentified data. It will be interesting to see how organizations prepare their employees for this certification and whether clinicians will discover that there is so much more to using health data than they realize. I recently was in a spirited discussion with a clinician who had been ignoring a patient’s request for an amendment to their medical record. When the chair of the compliance committee and I informed the clinician that this was a violation under HIPAA, she said we were “full of crap, because no patient information was shared.” It had never occurred to her that HIPAA covers much more than information sharing, because the organization’s training had a narrow focus. A follow up survey to other clinicians revealed that 90% of them didn’t know patients had a right to request an amendment and 12% thought it was acceptable to just ignore patient portal messages. It looks like this organization has some work to do, not only in education, but also in fostering professionalism.

NorthShore-Edward-Elmhurst Health has rebranded itself as Endeavor Health as a follow up to the $5.3 billion merger that was responsible for its creation. The transition effort will include new names for its hospitals as well as updated employee uniforms, websites, and of course a social media campaign. Statements from leadership were around the “inspirational and aspirational” nature of the name, but when I hear it, I only think of the similarly named PBS program. I wonder how the cost of a health system rebrand compares with filming a gritty period drama, but suspect the latter has a better return on investment.

After considerable good-natured cajoling by younger colleagues, this blog marks my first attempt at trying to stop using two spaces after a period. As someone who is in my fourth decade of touch typing and who learned on the venerable IBM Selectric, I can attest that it’s hard to learn new tricks. Objectively, the process change added frustration and reduced my typing speed significantly, but I found the mental overhead to be the worst. I think I’ll go back to the old ways that will die with me, along with the use of handwritten thank you notes, formal invitations, and knowing how to set a table to accommodate a five-course meal.

One space or two? Is it worth it to try to eliminate the extraneous keystroke? Leave a comment or email me.

Email Dr. Jayne.