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Curbside Consult with Dr. Jayne 2/8/21

February 8, 2021 Dr. Jayne 3 Comments

It’s been a pretty crazy week in the clinical trenches, with COVID cases ticking up in my area. I’m approaching my one-year COVIDversary, memorializing one year since the day I saw my first COVID case, which happened to be one of the first five in my city.

I laugh a little thinking about it, since of course it presented itself at the urgent care as so many other health conditions do. It wasn’t some diagnostic mystery at a tertiary medical center, or an academic puzzle for someone like House. It was a household contact of someone suspected to be infected, who presented to our office saying she had a fever and couldn’t smell dirty diapers. My physician assistant and I spent the next several weeks wondering if we were going to die. Little did we know that the day would come when we would be seeing 15 to 20 known positive patients a day, with essentially the same level of employer-provided personal protective equipment we had prior to the pandemic (although many of us are supplying our own N95s).

Urgent care centers are healthcare’s front door for many patients who might not have a primary physician or who can’t see theirs during hours that are convenient. Even before COVID, our practice was seeing significant growth, having expanded from five locations to more than 20 in the five years I had worked there.

In November, I was having heated phone calls with our governor’s office about their vaccine plan that left non-hospital-owned urgent cares out in the cold. They were incredulous that urgent care offices treat COVID patients. “When did that start?” they asked. That would be March 14, when COVID-19 first crossed our state lines. The staffer seriously thought that all COVID patients were being seen in the emergency department, which doesn’t give me great confidence in our state understanding how healthcare is delivered to its residents. They also didn’t fully grasp that my practice performs almost 10% of the state’s COVID testing and diagnoses sometimes 500 new COVID cases a day. Seeing more than half a million patients a year, damn straight we’re on the front lines, so how about sending us some vaccine?

As I reflect back on the last year, it’s been a wild ride. At the beginning of COVID, we had to temporarily close several of our locations due to low volumes. I was furloughed without pay, something I never expected to happen as a physician. Once we started offering testing, though, it was off to the races, with volumes going crazy. I’ve mentioned before that in my clinical world I’m just a worker bee, an hourly physician with no leadership responsibility. However, due to my experience and as a consultant, I’m constantly analyzing the actions of my employers against what I might do or recommend that my clients do in a similar situation.

Some of the things they’ve done have been good. Retention bonuses for our clinical support staff helped boost morale and prevent turnover, particularly when patient volumes were high. However, they never did anything to bolster physician morale. When we brought it up, we were told that we should be glad to have jobs since one of the local health systems had completed a significant physician layoff. That never makes one feel good.

Neither does learning that your employer accepted millions of dollars in Paycheck Protection Program funds despite a clinical rebound that had us seeing more patients than we have ever seen in organization’s existence. It’s particularly special when you read about the PPP amount on the front page of the local paper right after seeing an email from your boss that everyone needs to tighten their belts because of the finances. They weren’t following any communications playbook that I would recommend as a consultant, that’s for sure.

The “acting poor” strategy also didn’t play very well when they announced that we were opening additional locations even though we couldn’t fully staff the existing ones. As a part-timer with other sources of income, I had the luxury of being able to push any negative reaction to the back of my mind, but I watched some of my full-time colleagues begin to look for employment elsewhere. Burnout is real and 12-hour shifts are rough, especially when they routinely stretch to 13 or 14 because you’re never allowed to say no to patients who are streaming in the door. I watched several of my favorite physician assistants leave for jobs with eight-hour shifts at local hospitals and have to say I was a bit envious.

I suspected something major might be up several months ago when they hired a new member of the C-suite, but didn’t announce his presence to the physicians. I met him walking through my patient care area after he had been on the job for a couple of weeks. I was underwhelmed by his demeanor and the fact that he was oblivious to my full patient board and the 40+ patients on the parking lot wait list and wanted to stand there and chat. I was even more underwhelmed a week later when his announcement email finally arrived, not from the CEO or COO, but from himself. At that point, I decided to start looking for other clinical opportunities, even though I knew that part-time physician spots basically don’t exist in my community and I’m only in this one because I’ve been here so long.

Toward the end of an already busy clinical week, we received an invitation to an all-hands meeting a couple of hours from when the email was sent. That’s never a good sign. Most of our staff meetings are at 6 a.m. so people can get to their shifts on time. During this quickie Zoom call, we learned that our previously physician-owned practice had gone the way of so many before us in being acquired.

I can’t say I’m surprised knowing the personalities involved, but it explains so much about how they’ve been managing the finances and some of the other decisions that have been made over the last several months. I’m sure it was all targeted towards making the balance sheet look as healthy as possible.

I’ve seen many versions of this movie before and I’ve never seen an ending that works out well for all parties. Inevitably, the investors want their money back and then some, and that money has to come from somewhere. I’m at a point in my career where the plot has to be pretty compelling for me to stay until the end and I’m not sure this fits the bill. I’ve done some research on the investors and I’m not impressed by their healthcare experience. Having participated in due diligence exercises with other organizations looking for outside funding, what I could find on them left me with quite a few questions and not as many answers as I would like.

Most people don’t realize that when physicians leave a clinical position, it’s not like quitting other jobs. It’s not unusual for physicians to be required to give a 90- or 120-day notice so that patients aren’t left in the lurch. Sometimes non-continuity practices like mine will accept less notice, but that’s not the case with my employer, who actually lengthened the notice period for some recent hires. There are some other things that were announced in addition to the investors, and frankly I’m not sure I want to be around when those proverbial bombs begin to drop.

I’ve been thinking about leaving for a while, and this might just be the push I need. When the handwriting on the wall wasn’t done with Sharpie but rather with red spray paint, it’s likely time to dust off the resignation letter. It’s an unsettling feeling since I’ve only resigned from two long-term jobs in my career, but I trust my gut, even in the middle of a global pandemic and without another clinical gig on the horizon. Time for my next leap into the unknown.

What’s your best job quitting story? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/4/21

February 4, 2021 Dr. Jayne 2 Comments

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I’m not sure what to make of the recent communications from HIMSS regarding HIMSS21. They are eager to confirm that the event will proceed and to tell us the next milestone where they plan to tell us more about it, but I personally would rather have information at hand than the promise of information down the road. It’s clear that the exhibit hall will be much reduced and the sessions will be a mix of in-person and digital, but beyond that, I’m not sure what we know. The reality is that HIMSS is about making money and they’re going to structure their communications in the way that they think will be most profitable.

What I do know is that August in Las Vegas is deathly hot, and the things that many of us have been doing to avoid COVID — such as having social events outside — may or may not be tenable there at that time of year. The average high for the week of August 9-13 is 103 F, with a low of 80 F. Even in a “dry heat,” it’s not my favorite way to travel back and forth from the hotel to the conference center. I’d like to stay at one of the connected conference hotels, but the charges are prohibitively high for those of us who are paying our own way for the privilege of attending a conference where we have no idea what to expect.

We also have no idea what vaccination status will look like as we move towards August, since vaccination administration is still rather messy across the US. Based on anecdotal reports, many of the would-be HIMSS attendees from US health systems may be vaccinated, since many of those health systems seem to have had plenty of vaccine for non-patient-facing workers under the premise that everyone supports the patient journey. My friends who are part of independent practices and federally qualified health centers are still struggling to find vaccine, and the process has become more challenging now that states have prioritized the elderly.

I honestly don’t have a bead on what vaccination processes look like elsewhere in the world except for the UK and Australia, where friends keep me posted on what they are experiencing. They have employed different strategies than the US or each other, so it remains to be seen who will ultimately be judged by history as having the best approach. Certain countries and alliances have bought up enough vaccine supply to more than vaccinate their own populations, and it’s not yet clear what will happen to any surplus in the end. The goal is of course to vaccinate people quickly, but there are still plenty of barriers worldwide.

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Being a clinical informaticist in the midst of a global pandemic has its challenges, since many of us are armchair quarterbacking the charts and graphs we see and trying to determine whether they’re accurately illustrating the facts or are in danger of looking like someone changed the data with a Sharpie. A neighboring state just got caught cooking the books on their COVID positivity numbers — they decided to exclude test results that have been performed by any other methodology than PCR. Many of the large urgent cares are using rapid molecular testing like the Abbott ID Now devices in use at the White House, and those numbers are going unrepresented. Also not included in the totals are other rapid tests, such as antigen tests. We use both of the latter in my practice probably 80% of the time, only sending PCRs when required, so failing to include all the data seems like a no-no.

The state health director tried to explain it away by saying that there’s enough “saturation of PCR tests in the market to be representative,” and although I understand what he’s trying to say, it just seems like it would be better to use all the data, especially since the state requires practices to report it. Why would you want to not use data that you have? Those are the kinds of decisions that lead people to question the truthfulness of public health officials and that give rise to conspiracy theories. There have been enough irregularities with data and reporting throughout this pandemic that future academics can teach full semester classes on what went wrong.

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February 3 marked National Women Physicians Day, which occurs on that date to honor the birthday of Elizabeth Blackwell, who in 1849 became the first woman to achieve a medical degree in the United States. I spent the day caring for patients, some of whom were particularly cavalier about spreading COVID to their friends and family members, which is always frustrating. I didn’t even realize it was today until I got home and was curled up with my laptop, surfing the internet while waiting for my face to stop hurting from wearing an N95 mask for 12 hours. It typically takes about three hours for the mask marks to go away and a couple more for the headache to improve if I don’t take ibuprofen or drink a martini. I’m surely in a place I never expected to be when I started my medical career.

I was proud to be part of the first majority female class at my medical school, and to be part of an all-woman residency class well known for shaking things up in the world of graduate medical education. As the first physician in my family, I didn’t really appreciate what that meant until the day I took my mother to visit the gross anatomy lab. It was there I learned, as we stood there holding a human heart, that she might have liked to have been a physician, but when she was in college women were steered towards career paths in teaching and nursing. I was surprised that she hadn’t mentioned it while I was pre-med and applying to medical school, but maybe there was something in the genes that kept me going even when training got rough.

Here’s to all the women physicians that came before us, breaking barriers, putting up with enormous amounts of harassment, and paving the way for us to be where we are today. Your courage and dedication will never be forgotten.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/1/21

February 1, 2021 Dr. Jayne 2 Comments

I mentioned in last week’s EPtalk my ongoing healthcare adventures with Big Health System. As a patient, the organization unfortunately continues to provide plenty of material for HIStalk.

It’s an interesting setup there, with the academic medical center and the non-academic hospitals not fully aligned. That leads to somewhat of a “let’s do it separately together” approach to not only the EHR, but operational and workflow elements, too.

The academic side of the house continued to have their act together. I had specifically requested that my skin biopsy be sent to the flagship hospital’s pathology department after hearing about a friend’s disastrous experience at one of the community hospitals. They didn’t disappoint. Pathology was turned around in less than 48 hours and I received a phone call from the dermatology office bright and early on Saturday morning. When I went to look at the report via the patient portal, not only was it there, but also present was a full copy of my visit note and not just the post-visit summary.

The community hospital where I was scheduled for my MRI continued to underwhelm. I showed up at 6:45 a.m. as requested. There was a backup of people waiting to enter the hospital at the COVID screening checkpoint. Based on the predominance of running shoes and scrub pants peeking out from long winter coats, I assumed that many of them were employees arriving for a 7 a.m. shift change.

It would have been useful for the facility to have separate lines for employees and patients to get people more quickly to where they needed to go. No one was standing six feet apart, but everyone was masked, so I guess that’s something. After finally making my way into the building. I noted that at least the line at the coffee kiosk was well spaced, so that was good.

I quickly found my way to the “imaging pavilion,” the name of which made me laugh since it looks like just another hallway branching off in the bowels of the mammoth complex. I’m sure the naming had something to do with fundraising, but a decade after its addition, it just seems silly. The hospital has grown up around it, and once you’re in that part, you still have to snake around to get to the particular area where your study will occur.

Despite my compliance with the pre-registration team’s phone call, they had no record that my file had been updated. I had to answer all the questions again, this time while yelling through Plexiglas to someone who acted like they couldn’t hear me despite the fact that my patient-facing work has made me very good at speaking clearly while wearing a mask. I had to sit for a full 15 minutes, which was annoying since I was the first patient of the day and had arrived at the time they specified. There was no explanation of the delay, and I was somewhat tortured by the overly-loud TV blaring a local morning show.

When I finally made it back to the MRI suite, I noted that they had turned the two curtained changing areas into a single larger one, presumably for distancing. They had rearranged a credenza and chair in the changing area, but unfortunately had not rearranged the herd of dust bunnies and leftover hair on the floor, which kind of grossed me out. I know that hospitals are running on razor-thin margins, but skimping on housekeeping services isn’t the answer.

As I finished changing, they brought in a second patient. That person was using the changing area while I was in the adjacent IV chair, so they got to listen to all kinds of personal questions that I was asked. Starting my IV was challenging, resulting in multiple attempts in which the second patient was the audience for the latter two.

I’ve had this study done numerous times and have never had someone right behind me like that. As a patient, it was unnerving. I don’t expect total privacy, but I do expect that they pace appropriately so that staff doesn’t feel rushed while they’re trying to complete satisfactory IV access.

I was greeted in the MRI room by the team member who was going to do my actual study. Turns out I recently cared for her daughter at the urgent care, so we had a bonding moment. Since this particular MRI study is face-down, they don’t make patients wear masks. We had a laugh when I handed my mask to her at the last minute — the MRI magnet was attracting the metal nose piece, and I felt for a brief second like I was in some weightless space movie as it floated upwards.

The rest of the procedure was uneventful, and I slept through it as planned. Any day the IV works right and you don’t get an arm full of contrast material is a good one. I headed home to await my results.

I usually get a call from the nurse coordinator who manages my program, but this time I got a call from the physician because they’re changing my follow-up protocol. She explained the situation and the next steps and promised to send the information through MyChart. The results arrived more than 24 hours later with this header:  

Result Letter: Not Sent
Error: The exam failed to generate a default result letter. Please review the exam information and select the correct result letter or contact your helpdesk for assistance.

Just what every patient wants to read, right? I don’t know if the issue was on the part of the radiologist or the physician who called me, but either way it’s a poor user experience and one that patients should not have to deal with. Fortunately, I’m a physician informaticist who understands what this means, but for other patients, it might have generated anxiety and phone calls.

I wonder if the institution explains to physicians how to prevent this, or what things need to look like on their side to make sure the patient gets the right letter. I have the notes I took during my phone call, but that’s it as far as commentary on the results. I also wonder what kind of user acceptance testing is done from the patient perspective, if any. I know of too many hospitals and health systems that never test the patient-side views.

I would be interested to hear how other organizations manage testing for scenarios like this, and whether they’re doing any post-visit quality checks to ensure it’s not a common occurrence. Have you seen this at your institution? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/28/21

January 28, 2021 Dr. Jayne 3 Comments

In response to my recent piece about hospital price transparency, Jenn clued me in about Turquoise Health and their pricing website. It’s still in beta and doesn’t have data for my area yet, but comparisons for a neighboring state were pretty easy to understand. It looks like they’re still building their insurance rate database, but their cash-pay display was clear.

A reader also sent some thoughts about the whole transparency situation. He notes that based on some vendor-side experiences, a large number of hospitals seem to be deliberately dragging their feet and don’t want to be the first in their market to show what’s behind the curtain. Either that, or they’re not able to meet all the requirements since many of them assumed that the rule would be killed or further delayed. He notes, “Many will presumably quietly delay until HHS starts embarrassing some folks with bad PR and the compliance / penalty process.”

He goes further to note that the online tool I mentioned in my piece isn’t compliant, since “the Rule requires that a consumer be able to access the pricing info for all contracted payers WITHOUT providing any identifying information or agreeing to anything.” He agrees that third-party aggregators (presumably like Turquoise Health above) will take the machine-readable files and create the equivalent of “Travelocity for Hospital Prices.” I think that’s going to be the best approach that will benefit consumers from an experience perspective, but agree with him that the behind-the-scenes benefit will be when plans and networks and benefits brokers can see the information and use it to drive pricing negotiations.

My reader predicts that price transparency will ultimately lead to hospital closures, as hospitals will no longer be able to “cross-subsidize underfunded services with high commercial rates.” I always love hearing from readers and understanding what’s going on in different parts of the country and this was a great discussion. Rather than watching hospitals close, I’m hoping that health systems will take this as a wakeup call and begin to help lobby for better public health infrastructure and more public funding for early prevention, screening, and treatments so that we can push back against the chronic diseases that are driving healthcare expenditures.

Unfortunately, that approach will erode the profits of hospitals and payers, and some people feel it smacks of “socialism” and we’ll see politics and economics forcing public health into the back seat again and again despite the fact that strong public health measures make good economic sense long-term. The resignations of public health officials across the country due to their COVID-fighting stances has been disheartening. I hope we’ve seen as much of that as we’re going to see for a while. I’ve enjoyed seeing Dr. Anthony Fauci smile again this week, though, so I’ll stay hopeful.

I had another round of healthcare adventures with Big Health System this week. The first was for a physician appointment with their academic faculty dermatology practice. I received my appointment reminder in Epic and completed the online check-in process, which was seamless. I was surprised that they’re not doing any virtual waiting room strategies and that I had to physically come to the office to check in and sit in the waiting room, which is very different than what my practice does. At least the wait was brief and I was impressed by the documentation of the cleaning protocol that was posted on the exam room door. Since this was a dermatology practice, they also had signage explaining how they do a full skin exam in the time of COVID and to keep my mask on — the physician would tell me when to take my mask off and reminded me not to talk when my mask was off.

The second encounter was an unsatisfactory pre-registration phone call prior to an upcoming MRI. Apparently, my data in the system journeyed through a portal to another time and reverted to values from 2018. I just had another radiology study at the same facility less than five months ago, when I updated everything on a lovely paper form that I assume would have been uploaded. Somehow today they had my employer from 2018 listed and the wrong emergency contact. Having been in the CMIO trenches there, I asked what system the registration agent was working from, since they still use another system for some financials and Epic for clinical. She said she was working in both systems, but the data in question was not in Epic. Apparently, they  don’t have a bidirectional interface, or no one updated the information provided back in August, or both, so I got to do it all over again over the phone with someone who wasn’t that interested in my responses and wasn’t really paying attention.

She also went through the same COVID screening questions I had just answered an hour earlier, and I asked her to verify that I was flagged in Epic as an emergency doc since this was an issue during some previous visits. She actually admitted that she really didn’t look at the screen because she’s just so used to asking the same questions over and over. When I clarified that yes, I’m regularly exposed to COVID in my work, she replied, “So, you currently have COVID?” and I had to explain again. Here’s hoping she was actually doing what she said she was doing and updating their revenue cycle platform rather than just going through the motions, because I don’t want to have to update everything again at my radiology visit at the crack of dawn on Friday. These were the kinds of issues I enjoyed fixing when I worked there – making the patient experience seamless. I wonder if anyone there even knows it’s messed up, and if they do, whether they really care.

I’m not exactly looking forward to having my molecules magnetically spun, but it is what it is when you’re playing the early cancer detection game. Usually I schedule the test first thing in the morning when I’m tired so I can sleep through it, which the technicians find hilarious since “no one ever sleeps through an MRI due to the noise.” Maybe they just don’t scan enough sleep-deprived urgent care docs to have a good sample size. I figure the first appointment of the day is also good for COVID-prevention purposes.

What’s your strategy for being a patient in the time of COVID? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/25/21

January 25, 2021 Dr. Jayne 3 Comments

Many of my healthcare IT colleagues are deeply involved in their organizations’ COVID vaccine administration efforts. They’re involved in creating pre-registration and wait list systems, running analytics to determine who should be invited to receive a vaccine next, managing outreach efforts, then scheduling those patients. It’s a massive effort that, like many IT projects, can be subject to external disruptions.

One of our local health systems just went through a massive cancellation of vaccination appointments after they received fewer doses from the state than they anticipated. The sheer volume of appointments that had to be canceled and rescheduled created havoc. As their API-driven chatbot was reaching out to patients to offer them new appointments, it was creating temporary locks on the appointment slots that were being offered, which is standard when you’re doing scheduling outreach. However, the magnified consequence of trying to reschedule thousands of patients at once prevented the call center from being able to reschedule anyone else, including patient-facing healthcare providers who were needing to also reschedule after missing vaccine appointments while awaiting negative COVID tests.

The answer to the latter problem became decidedly low-tech, with the system standing up a temporary walk-in vaccine clinic to accommodate the healthcare providers with its remaining available doses. A Google Doc was used to keep track of the employees who were approved to come to the clinic and what time they planned to come, so that the vaccination team could coordinate with the call center to ensure that the correct number of doses were available real time. Since they weren’t running the public-facing vaccine clinic, they had a surplus of workers who could handle the manual scheduling, but the fact that the situation arose at all shows how much difficulty the US is having with the last mile of vaccine distribution.

With recent stories about vaccine spoilage due to temperature issues, those running the vaccination operations could learn from their IT colleagues. A Veterans Affairs hospital in Boston recently had a freezer failure from multiple contributing causes. First, a pipe burst leading to a water leak in the building, which led to the arrival of a cleaning crew who had to move a freezer to get to some standing water. The power cord for the freezer apparently wasn’t properly secured to the freezer, causing it to disconnect. Then the freezer’s alarm system didn’t function properly, which coupled with the lack of daily monitoring, led to the loss of 1,900 doses of vaccine.

The VA is still investigating why the alarm failed, but proper daily human monitoring could have saved the vaccines since the freezer was unplugged for several days before being discovered. Any small-practice primary care physician who has had to maintain thousands of dollars of vaccine inventory knows that even though you have thermometers with alarms, you still need to have someone check the logs daily and document the ranges. It’s shocking that a larger organization that is responsible for such a precious commodity didn’t have the right processes in place. However, based on some of the IT failures I’ve seen over the last several years, I’m not surprised.

Many healthcare organizations have complex automated backup systems and sophisticated disaster recovery systems that promise a rapid fail-over to sustain clinical operations. However, they may not test them often enough, and some organizations don’t test them at all. We’ve all heard horror stories of clients who went to restore from a backup, only to find that the backup contained no data or was corrupted in some way.

We’ve also encountered the unforeseen. Early in my career, a car that was involved in a police chase crashed into our hospital’s data center, which led to a small fire, which led to discharge of the fire suppression system and a complete shutdown of the building. There was a failure of the network switches that should have rerouted everyone to the disaster recovery site as well, which led to a multi-hour outage since no one could get in there to see if they could switch things manually since the building was now a crime scene. I’m sure “what if the building becomes a crime scene” was never in the minds of those who designed the downtime policies and systems, but you can bet it’s on the checklist for my consulting clients.

Organizations may also be missing physical safeguards that are needed for their systems to be effective, like the VA hospital’s freezer was missing a couple of screws that could have prevented the vaccine loss. I worked with a client not too long ago that thought they were creating nightly backups of their system. They were using removable hard drives as the media. An employee would come in every morning and disconnect the drive, place it in a manila envelope with the date, then pull the oldest backup drive and connect it to the system. They failed to lock the door to the data room consistently, however, resulting in the disappearance of the box full of envelopes and drives.

As I tell these stories, I feel a bit like a Monday-morning quarterback. However, except for the crime scene part, the preventive maneuvers for these situations are already well documented. HIPAA requires a Security Risk Assessment where covered entities must look at physical, administrative, and technical safeguards for protected health information. Participation in federal and state vaccine programs requires signing agreements on vaccine storage and accountability. Although there were technical failures in the situations above, the human error component is strong as well.

This story out of Boston isn’t the only vaccine loss story out there. Much larger losses were recently documented in Maine and Michigan. The COVID vaccine is such a scarce commodity. If I were in charge of an organization that was a vaccinator, you can bet that I would have daily touch points with the leaders involved to ensure accountability and that systems were in place to approach zero waste. Every dose that doesn’t go to someone who wants it is a tragedy in the making.

My parents and elderly relatives are scheduled for vaccines over the next two weeks. I’m crossing my fingers that they don’t get caught in one of these situations. Based on the horrors I see in my clinical role, I’ll be holding my breath to some degree until everyone in my family is fully vaccinated.

How does your organization approach disaster recovery planning? Do you have plans in place if you need to execute a massive rescheduling operation if vaccines are lost or delayed? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/21/21

January 21, 2021 Dr. Jayne 1 Comment

I took time out this week to listen to the tolling of the funeral bell at the Washington National Cathedral. The bell tolled 400 times, once for every 1,000 COVID deaths in the United States. The 12-ton bell creates a deep and somber tone, intended to help mourn but also celebrate the lives of the lost. The recording was accompanied by video of the paper doves that form the Les Colombes installation by artist Michael Pendry, which is located in the Cathedral’s nave. It’s likely that we’ll see another 150,000 deaths by summer unless something changes significantly.

To the relief of many, Inauguration Day passed without any serious incidents, with the new US president getting straight to the business of trying to manage the COVID pandemic. I’m interested to see if the tone at the Centers for Medicare & Medicaid Services changes, since nearly every email that I’ve received over the last several years had a headline or opening paragraph celebrating the administration’s accomplishments. I suspect the new leadership may be a little more humble, and hopefully they’re getting the right kinds of leaders in place to help steer the massive bureaucracy to a more functional and productive place.

Many healthcare organizations are holding their collective breath to see if there will be major changes to policy or additional federal funds targeted towards vaccine administration. From people I’ve spoken to who have boots on the ground across the country, administration continues to be chaotic. We’ve finally been able to get my family members scheduled — they range in age from 75 to 95 — but it remains to be seen whether there will be vaccines shipped and available for their scheduled appointments.

Speaking of vaccinations, two Michigan marijuana dispensaries are offering free joints to customers who are vaccinated for COVID-19. The Detroit Free Press reports on the “Pot for Shots” campaign and its attempt at “blunting the curve.” The participating locations are Greenhouse in Walled Lake and UBaked Cannabis of Burton. You have to love a business name that clearly defines the brand.

Back to the realm of healthcare IT, I had a chance to catch up with a friend this week. We were bouncing ideas around as far as what sectors of the market might actually be heating up. Although most of my friends on the vendor side say that none of their prospects or clients is in a buying mood, there are indications that there will be money to be made. Intel Chairman Omar Ishrak is building a $1 billion war chest for a special purpose acquisition company IPO to target health technology deals. Prior to Intel, he was at Medtronic, so he’s not a stranger to the marketplace. Goldman Sachs Group Inc. is putting together the IPO. It seems that lately we’ve been hearing a lot about SPACs and I suspect this will be one to watch.

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I enjoyed reading the recent blog penned by my long-term crush Farzad Mostashari. Aledade’s premise is that primary care is the foundation of an effective health system, and that it must be strengthened if we are to deliver better patient care and lower healthcare costs. Since 2014, the company has expanded to 27 states.

The blog notes that shared savings payments have been a way for primary care practices to stay afloat while fee-for-service payments have dropped due to decreased volumes during the pandemic. Aledade hopes to grow that savings from $50 million last year, doubling it this year and tripling it for the next. Investors are taking note, resulting in a $100 million funding increase that will drive an ambitious agenda that includes a 50-state growth strategy, expanded remote patient monitoring, predictive analytics, continuation of telehealth, and upgrades to Aledade’s software. It’s exciting to watch a truly mission-driven company do well, and I wish them continued success.

The Office for Civil Rights of the US Department of Health & Human Services will not be imposing penalties for potential HIPAA violations when healthcare organizations use online or web-based scheduling applications as long as they are “used in good faith and only for the limited purpose of scheduling individual appointments for COVID-19 vaccinations during the COVID-19 nationwide public health emergency.” That’s good, because my employer was one of the potential violators. In order to try to rapidly schedule employees for the 300 doses of vaccine that we received (which had to be given within 36 hours of receipt, since it had already been thawing at another health system) they used the Calendly platform. The so-called “enforcement action” does not include appointment scheduling systems that connect directly to the EHR, but encourages healthcare providers and their business associates to continue to guard the security of protected health information.

HIMSS announces a new recognition program, the HIMSS Changemaker in Health Awards. The award recognizes “inspiring senior healthcare executives who rigorously challenge the status quo in their journey to build a brighter health future.” Recipients will be determined by peer voting and will receive a “symbol of recognition” as well as coverage in HIMSS publications and seminars. They also must agree to contribute to HIMSS content including articles, podcast interviews, and participation in webinars. I was surprised to see that candidates can nominate themselves. If you know someone who is making change, or think you’re hitting it out of the park yourself, nominations are open through February 16.

In COVID news, the internet is full of cures and treatments that haven’t necessarily been proven. I’m interested in further research on this one, which purports that chemical compounds found in dark chocolate may interfere with COVID virus replication. Researchers at North Carolina State University are continuing to investigate, although they note that no human trials have been conducted yet. I’ve already got at least one reason to want to visit the Carolinas, so I’m happy to volunteer as a research subject.

If you’ve been holding off on travel due to COVID, what’s the first place you’d like to visit? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/18/21

January 18, 2021 Dr. Jayne 1 Comment

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It’s finally time for price transparency, with hospitals now being required to disclose their contracted prices on their websites. I decided to see how difficult it would be to find out the potential pricing for my local hospital, and also to compare it to recent Explanation of Benefit (EOB) documents from a couple of friends and family members.

I first went to the hospital website. Of course there wasn’t any kind of notice about the availability of the new data, so had to guess where it might be filed. Clicking on “Billing and Financial Assistance” took me to a health system website, and after scrolling two full screens, I found an “Understanding Your Costs” header. Under that, I could select either a customized cost estimate or the “General Estimate Tool – Shoppable Services.” A description under that link noted: “Under 2020 pricing transparency guidelines from the federal government, this tool allows you to view your costs for the most frequently used hospital services.” I knew I was at the right place.

From there, I had to again select my hospital and agree to Terms and Conditions for the tool. Next, I had to select my insurance. My my plan was unfortunately not listed on the pick list, so the system instructed me to call to speak to a financial specialist. I backtracked and just selected Cigna since I have a general working knowledge of how their plans work.

I was next asked to select whether I was choosing an inpatient or outpatient procedure. Although the system defined these strictly as “staying overnight in the hospital” versus “not planning to stay overnight,” as a physician I know there are nuances to this. When I had my emergency gall bladder surgery, I spent the night on an inpatient unit, but my visit was billed as outpatient since I was admitted less than 23 hours. Patients aren’t going to know or understand this, nor should they be expected to do so.

After that, I was asked to choose a popular procedure. I’m not sure I would have chosen the word “popular” when building this user interface. Medical procedures are rarely popular, and perhaps “common” would be a better word.

Bouncing back and forth between the inpatient and outpatient lists, I quickly determined that the system wouldn’t let me match combinations that went with the EOB documents I had. These involved my outpatient gallbladder removal, an outpatient hysterectomy, and an outpatient hip replacement (for which this particular facility is renowned). Instead, I went with the colonoscopy, although my EOB was from an ambulatory surgery center rather than the hospital. From there, I had to input my insurance benefits, including deductible, how much I’ve met for the year, my out of pocket maximum, and whether I had met it. I also needed to know my co-pay and co-insurance for the procedure. Most patients aren’t going to have this at their fingertips.

The system told me I’d be responsible for $20 for my colonoscopy, which I know isn’t remotely accurate. I played around with the “my insurance benefits” screen and could make the numbers go up and down depending on what I put as a deductible. At no point did it tell me what the contracted charge was for the procedure, only an estimate of my patient responsibility. I went back and plugged in “uninsured” for my coverage and was able to get an estimate of costs for a diagnostic colonoscopy with biopsy, which ranged from $1,286 to $3,744, with a median of $1,575. There was no explanation whether the numbers being provided reflected only the facility fee or whether they included any other fees, such as pathology. Again, I wouldn’t expect patients to know that there are going to be multiple fees from multiple sources, so they are still likely in for some sticker shock.

Other things I learned: the system thinks a cardiac catheterization costs $141,636, which is grossly inaccurate. Based on the codes and descriptions displayed, I think they confused it with a cardiac valve replacement. Patients wouldn’t know that. The only chest x-ray on the list was a one-view, which isn’t typically done for outpatients. The hospital charge for that one view was four times what my urgent care charges for both the technical and professional components. The markup for a CT scan of the abdomen and pelvis was also four times higher. I guess those big fancy marble lobbies have to be paid for one way or another. The facility fee for a hospital outpatient clinic visit was $169 and that doesn’t even include seeing the physician. An emergency department visit ranges from $2,190 to $7,573, with a median of $3,310. That definitely underscores the benefit to patients who see us at the urgent care versus going to the hospital for urgent issues.

I ran through the various procedures at a couple of the other hospitals in the health system and found that even an as uninsured patient, I could receive some procedures for dramatically less by driving 20 miles, assuming the data was accurate. The $1,800 CT scan became $900 at the hospital that is in a somewhat economically depressed part of town. However, the mysterious cardiac cath/valve procedure jumped to $171,625 at that facility. The procedure jumped to $209,451 at the system’s flagship academic medical center hospital.

Although the push for price transparency was certainly a hot topic when it was initially proposed, it quickly became a battle between the patient advocacy factions and the hospital lobbyists. From my N=1 analysis, I’m not sure patients are any better off using the tool than using other available data or even a simple Google search. The data provided was too vague to be used for real decision making.

If I was really price shopping a major surgical procedure, I would want to call and talk with the system’s staff to see if they could put together a better estimate. One would also need to research all the ancillary costs, such as laboratory, anesthesia, in-procedure radiology, pathology, etc. Don’t get me wrong, this is a step in the right direction, but we just need to realize it’s a baby step.

Have you looked at price transparency for your institution or neighboring hospitals? What did you think? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/14/21

January 14, 2021 Dr. Jayne 2 Comments

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I’ve been knee-deep in the Consumer Electronics Show the last couple of days. It’s a treasure trove of things you expected to see (smart home accessories, high-tech vacuum cleaners) and some you didn’t (high-tech sex accessories). Still, I’ve seen some cool things, and although some are not 100% healthcare related, they appear to have the potential to deliver solid benefits.

  • Abbott predictably showcased its Navica mobile app, which pairs with its BinaxNow COVID-19 antigen testing cards. Its FreeStyle Libre 2 continuous glucose monitoring system may not have received top billing, but could be a game-changer for diabetes patients age 4 and up.
  • Ampere offers the Shower Power hydropower Bluetooth shower speaker. It recharges via the water flow and is made of recycled ocean plastic. It’s pricey at $100, but the idea of having your own mini-generator to keep tunes playing is kind of cool.
  • Butterfly showed off its handheld ultrasound units that integrate with smartphones for a portable and accessible experience. This would be great for organizations that don’t want to spend the money on traditional ultrasound machines or that need to be able to deploy on the go. I was disappointed to see that some features are only available for IOS devices since Android clearly dominates the world market.
  • PenguinSmart offers individualized online speech and language therapy support for pediatric patients. It claims to be the first remote / teletherapy solution to serve developmentally delayed patients who have speech and language needs.
  • Samsung offers an AI-powered JetBot 90 robotic vacuum which “identifies messes” and avoids them. Anyone who has ever experienced a pet-related “poopocalypse” with their Roomba knows what a nightmare this can be. Pricing is expected to be upwards of $900, but depending on how bad you’re scarred from past events, it might be worth it.
  • Steri-Write is a UV-C sterilization unit that cleans and dispenses ink pens for patients or the public. An article on the device was published in the American Journal of Infection Control in 2020 and the device itself is pretty slick. It’s got a slot on the top for the pen to enter the machine, then it travels on serpentine belts while exposed to UV light. A hands-free dispenser finishes the process. Since our office has the front desk team sanitizing pens with wipes and constantly managing them throughout the office, it would save time and resources.
  • Welldoc offers app-driven solutions for management of multiple chronic conditions, including diabetes, hypertension, heart failure, prediabetes, and behavioral health diagnoses. It reportedly can integrate data sets from payers, employers, and providers, but information on the actual solution was light unless you wanted to talk to a rep.

Other offerings include an AI-powered toothbrush (Philips Sonicare) that adjusts intensity based on user-applied pressure and has its own app to track effectiveness. There was also Heatbox: The Self-Heating Lunchbox, but honestly I’d rather have a self-chilling martini shaker that I could stick in the side pocket of my backpack for those particularly challenging days. Med:na from Medipresso is a DNA-driven solution that matches consumers with tea capsules based on their profiles. Not sure about the evidence-based background on that, but I bet someone will buy it. One thing I might consider buying is the Sniffy Personal Dog Trainer App, which is desperately needed by my neighbor since I get to hear her annoying dog barking outside my office window on a daily basis.

Procter & Gamble also featured a smart toothbrush, the Oral B iO. Its companion app provides feedback on brushing and offers tips for improving technique. I always love hearing German engineers discuss things like magnetic drive in the context of a “surprisingly enjoyable brushing experience.” Its AI brushing algorithms were trained with thousands of brushing sessions in the company’s labs.

I wanted to look at wearables and Garmin didn’t really have anything that caught my eye from a running and walking standpoint. Omron showcased its HeartGuide wearable blood pressure monitor that links with its HeartAdvisor app for BP, activity, and sleep monitoring. It also presented its VitalSight remote patient monitoring solution. MySize Inc. won the buzzword bingo challenge with its sensor-based measurement technology that allows for shoppers to have a contactless fit and style experience. They won by using “AI, Big Data, and Machine Learning” in a single sentence.

CES generated about 10x the email I usually receive prior to a HIMSS conference, and it shows no signs of letting up. I flipped through all the promotional emails I received, but if I couldn’t figure out what you were presenting, I didn’t do any further investigation.

The ones that were the easiest to figure out were those with COVID in the pitch. Their offerings were often straightforward, such as thermal scanners and social distancing accessories. Several vendors offered smart masks with various fans, filters, and monitors. Others weren’t COVID related but were clearly identified, such as Nexvoo’s ergonomic office chair with health monitor app. I’ll stick with my Ikea chair (which honestly is the best office chair I’ve ever had) for now.

If I had some advice to offer to the marketing teams that create the email, it would be to at least tell the reader something about the offering. For example, a company I’m already familiar with touted its “AI Powered Platform for Pandemic Response,” but the tagline didn’t really tell me anything, and it was frustrating to try to dig through press releases to see what the new or updated solution really offers. For example, Rise Gardens hit it out of the park with a single sentence describing their modular, WiFi-connected and app-guided indoor hydroponic garden for home use. I knew in less than a second that I wanted to check it out. Font and readability are also important in emails – if your font is unreadably small, everything you have to say is unfortunately a no-go.

Home bathrooms were a hot topic at both Kohler and Toto – touch-free commodes and faucets for the home were featured as a COVID-related solution. Bidet functionality was also prominent, especially with greater awareness of their existence following the Great TP Shortage of 2020. They’re also handy for postpartum and postoperative patients, but a good number of people might not have experienced either of those situations.

I have to admit I was captivated by Kohler’s Stillness Bath, which it describes as “an immersive bathing experience that uses light, water, steam, and aroma to transport you away from the everyday” and to simulate Japanese forest bathing. I’m definitely starting a list of things to purchase if I ever win the lottery.

The CES digital venue continues to remain open through the weekend, so I’ll still be hard at work plugging away through all the emails and the vendors I flagged to visit. Did anyone else attend? What did you think? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/11/21

January 11, 2021 Dr. Jayne 1 Comment

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My weekend took a decidedly positive turn after I was able to get my second dose of COVID vaccine. The side effects were a little more noticeable compared to the first dose, with a brief temperature elevation and headache. Tylenol and a nap vanquished them both, although I felt a little more tired than usual, but it’s unclear if that was from finally being able to let go of the anxiety of whether I’d be able to get a second dose or not.

It is unreal that frontline physicians who are actively caring for COVID patients would have to worry about getting a vaccine, but that’s the reality in many states across the US. I’m active in several nationwide physician forums and the majority of states are having difficulty vaccinating all frontline healthcare workers, while others are already vaccinating the general population based on age and comorbid conditions. We certainly live in interesting times. Artwork credit: physician Cindy Hsu.

I received the Pfizer vaccine and should reach target immunity two weeks after the second dose. I still don’t get to change any of my habits since the vaccine is only proven to reduce the risk of severe disease and/or death – we don’t have strong data on reduction of transmission at this point, although those studies are ongoing. There’s still the risk of being infected with COVID. I’m just less likely to die, which is a good feeling to have when you’re exposed to 20 or more COVID-positive patients a day.

My area continues to be in a surge that is being fueled by mass defiance of the county’s “safer at home” order, which means I still get to deal with heartbreaking situations at the office as people infect their grandparents and other loved ones when we are so close to getting vaccines for them.

A non-medical friend wasn’t aware of the lack of transmissibility data and asked me how long I planned to continue strict masking. After explaining the limits of the vaccine, I mentioned that I’ll most likely be masking forever. It’s not due to a concern about disease or contagion, but the fact that I’ve lost all ability to control my facial expressions simply due to the volume of ridiculous statements I have to hear on a daily basis. Plenty of patients still believe that the vaccine contains microchips or has the capability to modify human DNA, science be damned. As a physician, the most effective treatment I have right now is education, and although I’m happy to deliver it, I miss the days when I could solve problems with a flip of my electronic prescription pad.

The best side effect of the vaccine was the fact that I received it at a facility where I hadn’t previously been a patient, which exposed me to their version of Epic’s MyChart platform. Compared to the version being used by Big Medical Center where I usually receive care, it was amazing. Clean lines, no clutter, no distracting colors, and a much cleaner view of upcoming and past appointments. The medication list was easier to read without distracting color as well. Knowing that Big Medical Center is typically reluctant to take upgrades or to stay current with general release versions of software, I can only assume my new access is to a later and greater version.

I also haven’t been overwhelmed with announcements and updates from the new platform, so perhaps their communication plan or governance is a little tighter as well. It will be interesting how these contrasts play out now that I have access to both systems. I’m also curious to see how long it will take my previous employer to upgrade to the latest and greatest.

I spent a good chunk of time preparing my plan for the Consumer Electronics Show. I’ve never been in person, but have seen a lot of media reports and the in-person version sounds pretty overwhelming. The online schedule is a full one, but I suspect that like HIMSS, most of the interesting finds are found by checking out the exhibitors, which is a bit of an interesting process for most of the virtual conferences I’ve attended. I’ve been poking around the website and haven’t found anything that looks like a virtual exhibit hall yet, although there are lists of exhibitors and I’ve been getting plenty of emails from them. We’ll have to see if new features go live once the show officially starts tomorrow.

I’ve already identified quite a few digital health, wellness, smart home, and lifestyle vendors that I want to check out. I’m involved in some efforts to promote aging in place for older patients, so I hope there are innovative solutions that won’t cost an arm and a leg but will give patients and families greater peace of mind. Based on the lockdowns of the past year, so many people are afraid of moving to retirement communities or assisted living facilities even when they could benefit from expanded services. Hopefully, organizations have moved to fill that need. Kohler is scheduled to debut some smart home kitchen and bath accessories, but I’ll also be looking for design inspiration to finally complete what is possibly the world’s longest bathroom remodeling project.

Of course, there are also cool things that are not directly related to healthcare, but may provide interesting innovations in a secondary capacity, such as the unveiling of the world’s first autonomous racecar at the Indianapolis Motor Speedway. There are over 500 university students competing to win a $1.5 million prize in what’s billed as “the world’s first high-speed, head-to-head autonomous race.” The engineering types in my household are particularly excited to hear what that’s all about.

Some of my show sessions start as early as 6:30 a.m. local time, so I’d better get my rest this week if I’m going to keep up. Unlike the typical Las Vegas show, though, I’ll be able to readily access snacks from my own refrigerator and won’t have to wait in an eternally long line for a bad cup of convention hall coffee. I’ve stocked in extra martini supplies so I can pretend like I’m actually at a trade show.

If you’re attending CES, let’s have a virtual cocktail together. You can find me on Twitter: @JayneHIStalkMD

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/7/21

January 7, 2021 Dr. Jayne No Comments

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ONC announced dates for the 2021 annual meeting, scheduled for the end of March. You can subscribe to updates to make sure you’re in the know.

I have to say I miss big meetings and getting to connect with interesting people. I’ve done several virtual conferences and they just don’t provide the level of randomness that we were used to in person. I was going to attend the Consumer Electronics Show in person for the first time in 2021 and that didn’t turn out so well. The event is scheduled to run virtually January 11-14 and I’ve been approved to attend as a member of the media. If anyone can hit a virtual conference out of the park, it should be CES.

I’m looking forward to seeing what companies have come up with as far as expanding the utility of wearables in patients’ personal health journeys. Wearable devices seem to have plateaued the last few years, so it’s going to take something novel to get people re-engaged.

I also want to see what companies are doing to make tech more accessible. Although we may be used to the majority of people around us having a smartphone in their pocket or purse, there are plenty of people in the world that don’t have that access. I’m also looking forward to seeing first hand some of the wild and crazy things that will debut at CES, and following them over time to see if they take off or not.

Speaking of conferences, HIMSS is planning a meeting for August, but I wonder what it’s going to look like in reality. A recent article described the downstream impact of the February 2020 Biogen conference. Its 100 confirmed cases were identified as causing 50,000 cases in the US alone within the first two months following the super spreader event, nearly half of which were in Massachusetts. By November 1, the virus strain from the conference was linked genetically to over 330,000 cases in 29 states plus Sweden and Australia. Even for those of us that will (hopefully) be fully vaccinated by the time HIMSS rolls around, it’s important to remember that the vaccine has not yet been shown to prevent COVID infection — it just dramatically reduces the risk of severe disease and death.

Mr. H has already reported on the wind-down of Haven, which hoped to lower healthcare costs and improve outcomes. One of the key reasons cited for its inability to disrupt healthcare is that each company continued to deliver its own projects separately, which reduced the need for the joint venture. The inability of large organizations to work together is being seen everywhere in the US, particularly with vaccine distribution. Physician colleagues are reporting from across the US that hospitals that have been entrusted with vaccine distribution are refusing to vaccinate frontline healthcare workers if they’re not employed by that particular institution. This is often in violation of state vaccinator contracts and agreements, but no one wants to enforce it. Until we understand that we can be stronger together than we can be separately, we will all continue to struggle.

My state isn’t the only one struggling: New Jersey’s vaccine registration site launched this week but immediately experienced issues attributed to high volumes. It may not be perfect, but I at least give the state credit for trying to create a list and communicate with people, which is much more than many other states have done. My home county finally received vaccine and has no way to manage a list of Tier 1a providers who are trying to get vaccinated – the only way to get through is to wade through a maze of phone prompts and hope you reach someone who can add your name to a paper list.

JAMA Surgery published a piece this week looking at “the Empowerment/Enslavement Paradox” among surgeons and their personal communication devices. The authors note that “the same tools that empower people can also eliminate personal freedoms by increasing work pressure and blurring the boundary between work and personal life.” There are certainly benefits of being able to be continuously connected particularly with smartphones, such as being able to act quickly to care for patients and to be able to have the world’s medical literature literally at your fingertips. Unfortunately, technology can also function as an electronic leash, continuously tethering physicians to their work. I’ve experienced both extremes and it takes a tremendous amount of discipline to keep tech from taking over at times. It will be interesting to see if improvements in technology will help resolve this paradox.

Like many of us, I tend to multitask, and I have to admit I was surfing the internet while listening to the US Senate speeches as our Congress reconvened following Wednesday’s unbelievable events. In hindsight, I probably would have benefitted from drinking a strong martini and making sure to take a sip every time a particular Senator used the word “hooligans” or “temple of democracy.” During my surfing, I enjoyed learning about a set of lava lamps that are used to drive internet encryption. The lamps are located at the Cloudflare company headquarters in San Francisco. Cameras capture the changes in the patterns and transfer them to a computer that translates it into encryption keys. The randomness inherent to lava lamps reduces the chance that hackers would be able to break the key. The Cloudflare site offers a great primer on random numbers, cryptography, and entropy. At its London office, Cloudflare uses a slightly less-groovy method of random data generation, using a double-pendulum system, which seems a bit more classically British. The Singapore office uses radioactive decay from a uranium pellet as its source.

Given the events of the day, I could use some quality time staring at a wall of lava lamps since I’m not traveling to see a nice waterfall or sunrise anytime soon. There’s also always that stout martini. Who’s with me?

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/4/21

January 4, 2021 Dr. Jayne 1 Comment

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The new year is upon us, and other than hearing quite a few more fireworks and gunshots at the appointed hour, my celebration wasn’t terribly different from years past.

As someone who has worked big-city emergency departments on New Year’s Eve, it seems like a holiday that is ripe for trouble if you decide to go out, so I kept with tradition by celebrating at home. During the day, I binge-watched “Bridgerton” on Netflix, sparing anyone else from a tour through 19th century London. As the evening unfolded, it was time for “The Mandalorian” with the rest of the household. I feel like I’m finally caught up with the rest of the sci fi-loving community now, and can move into 2021 with a full appreciation of Baby Yoda.

I took January 1 off, then returned to the clinical trenches for a full day of adventure. Our region is going through a prolonged peak for COVID cases, and we’re perpetually running our locations with a skeleton crew in part due to illness. More than 50% of our physicians, NPs, and PAs have been infected with COVID, so I count myself fortunate to have avoided it and am thankful to the folks who have been helping me source additional PPE beyond what my employer has been able to provide.

Another segment of our staff has left the healthcare labor market entirely, deciding that perhaps dealing with COVID isn’t part of their ongoing career paths. We have a lot of staff that are from dual healthcare worker households, and if the cost of childcare is a factor, it makes a lot of economic as well as health-related sense.

Our state is still woefully behind in vaccinating healthcare workers. Our organization received a limited number of doses that were shared from a local hospital. The state still doesn’t understand that urgent cares are also on the front lines of the COVID fight.

It was great to see people starting to receive vaccine and beginning to feel a little bit of hope that we may be truly rounding the corner on our battle against COVID-19. Many of the individuals who have had COVID recently deferred vaccines so that those who have not yet been infected could go to the front of the line. We still need several hundred doses to finish the first round of vaccines, plus enough to perform Round Two. I never thought that a group as big as ours, which performs over half a million patient visits a year, would be overlooked. Hopefully, we’ll get more doses soon because we still have plenty of unprotected Tier 1a healthcare workers among our ranks.

Judging from some national Facebook groups I belong to, the vaccine distribution plans in many other states are poor as well, but I would rank us in the bottom 10% for having our act together. I learned today that our state department of health violated CDC prioritization guidelines and vaccinated its non-clinical office workers, even those who can work from home. I also learned that the department has no plans to hold hospitals accountable for going outside the guidelines, which many are. With that kind of leadership, it’s no wonder that they’re not able to meet the needs of the actual patient-facing healthcare workers.

The other adventure of returning to work in 2021 was the debut of the new CMS Evaluation & Management coding guidelines. As a consultant, I did some behind the scenes work for a couple of medical groups creating educational curricula for their physicians and teaching classes to help them get ready. We’ve been working on it for several months and most of the physicians felt confident going into the new year. As a physician, my practice waited until the eleventh hour to reveal their plan and it was pretty underwhelming. They’re so worried about the coding that they’re going to let Certified Professional Coders assign the codes.

They sent us a two-page document on December 29 letting us know of a few new EHR screens we needed to be aware of. They also sent instructions about documenting free-text information to bolster our “medical decision making” discussion in an area of the chart where we don’t usually put it. Because many of us write that information in patient-facing language in the patient plan for “cover yourself” purposes, we now have to put it in two places, which seems like a pain.

I asked for clarification and was told it was for consistency for the coders to know where to look. I’d think it’s cheaper to tell the coders to look in two places rather than have the providers do double work, but I’m just a worker bee in this scenario. Given the labor cost of the coders and the sparseness of some of my colleagues’ documentation, I give this approach no more than 90 days before they decide to retool it.

Even though the new coding rules are supposed to simplify documentation for the History and Physical portion of the note, my practice didn’t change expectations for those areas, still asking us to document Review of Systems and Exam elements that are beyond what is needed for the kind of problem-focused visits that occur at an urgent care. They make sense for some of our more complex patients, where we may be co-managing chronic conditions because the patients can’t get in to see their regular care teams, but I refuse to do them when the visits are straightforward. You can bet I didn’t document a multi-point Review of Systems on the guy who came in with the 6 cm scalp laceration after having fallen into a door while tripping on his son’s skateboard.

I’m curious what other organizations have been doing to prepare their physicians for the transition, and how well they’re handling it. It will be interesting to see if groups are seeing revenue dips due to lack of documentation or whether they actually see a little bump because they’re not being nitpicked on data elements that physicians may feel aren’t meaningful. Many physicians may also choose to code their visits based on time, which may result in an increase in code levels.

It will be at least 30 days before we can see trends, and possibly longer depending on patient volumes. Traditionally January is a slow time of the year for patient visits because no one has met their deductibles. We’ll have to see if 2021 holds true for this and how long that depression lasts. Of course, it will be confounded by the pandemic, so it may be hard to tell.

How did your organization handle the rollout of new E&M coding rules, and how is it going? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/28/20

December 28, 2020 Dr. Jayne 1 Comment

I’m in the middle of a blissful stretch of days away from in-person patient care. The days are still full, though, as I try to wrap up a bunch of year-end projects for clients.

I also spent several hours finishing up some Maintenance of Certification and Continuing Education requirements so that I can remain board certified moving forward. Several of the major boards have given people relief from completing their usual requirements this year, which is much appreciated since those of us still seeing patients have been a little busy dealing with the pandemic.

The last couple of weeks have also brought some unexpected changes that have shaken things up in my consulting practice. I’m having to completely re-engineer my plans for 2021 as I seem to suddenly have a lot of open time on my calendar. I can always backfill the time with telehealth visits, but I am really starting to miss being part of the large-scale health IT projects that I worked on when I was in more of a traditional CMIO role. My remaining clients could certainly benefit from full-time clinical informatics attention, but no one has the budget to make it a reality.

There are so many non-COVID initiatives that healthcare organizations could be working on right now. Even with the uncertainties of COVID, there are plenty of diseases that need prevention or early detection. Colorectal cancer is one of those, and JAMA highlighted it this week in a piece about in-home screening tests. Even pre-COVID, colonoscopy as a means of cancer screening presented a lot of barriers – cost, transportation issues, and the dreaded (but not really that bad) prep. At-home kits, while not quite the same level as the gold standard colonoscopy, can help close those gaps in care.

While health plans and other organizations are sending kits to patients who are due for screening, there are plenty of people of screening age who aren’t plugged in with a primary care physician who are falling through a second gap since they’re not an anyone’s database to be detected as needing the test. Some of these are patients who use urgent care centers as their primary source of care, since they either don’t have a primary care physician or don’t think they need one. Given the shortage of primary care physicians in my community, no one is reaching out to these individuals to try to bring them to care. The average wait for a new appointment for a patient who actually wants to see a primary physician is close to three months.

The JAMA piece also highlighted some interesting food for thought facts. One is that colonoscopies and stool tests haven’t been compared in a randomized trial. There is one ongoing to compare the two, with 50,000 veterans randomized to receive either a single colonoscopy versus annual home testing for 10 years. The endpoint is deaths related to colon cancer, and results are due in 2028. Another element that requires thought is the fact that discussing the pros and cons of different colorectal cancer screening tests takes more physician time than actually performing a colonoscopy. Guess which service pays better for the physician? It definitely helps us understand yet another reason why patients are pushed towards colonoscopy as a first-choice test.

I do respect the attitude taken by UnitedHealth, which has an educational campaign that includes an online video. Their main message is that the best test is the one you will actually get done. It sounds simple, but unfortunately there’s a lot of over-thinking in healthcare and sometimes providers miss the obvious due to competing priorities, lack of time, lack of understanding, or all of the above. UnitedHealth is also doing outreach direct to its Medicare members, which will hopefully spur some important conversations between patients and their care teams.

Kaiser Permanente Northern California is another organization that has gone direct to patient, in this case, mailing test kits directly to patients who are eligible for screening. They were able to more than double their rate of screening among members. The piece notes that sending kits isn’t enough, though. There needs to be a wraparound campaign to support patients — including text, email, and phone reminders — to ensure completion. Education is key – people are still squeamish about handling a stool sample at home and mailing it back. We need to figure out how to normalize this experience, even if it takes celebrities showing off their stool kits in an effort to encourage average people to complete screening.

Technology can certainly play a role in this, whether it’s chatbot systems to remind patients to do their tests, apps that gamify medical screenings, or database analysis to determine which patients are most likely to do the test with minimal intervention versus those who need a human nudge. The National Cancer Institute projects a potential excess of 4,500 colon cancer deaths in the coming decade due to pandemic-related delays in diagnosis and treatment. Hopefully, we can harness technology to think outside the primary care box and engage these patients in multiple ways. Otherwise, we’ll see patients presenting with more advanced cancers down the road, which will lead to increased treatment costs as well as disability and death.

Unfortunately, many healthcare organizations are just trying to get by one day at a time as we approach what will perhaps be the highest peak of COVID cases and deaths during the month of January. By necessity, they’re taking the short view and aren’t thinking about consequences we won’t see for five or 10 years. However, even as uncertain as things are today, I want to challenge them that they can’t afford to not think about the longer term. Not to mention that with all the darkness and despair that surrounds healthcare on a daily basis right now, it would be nice to have some wins to celebrate with health outcomes where we can actually make a difference for our loved ones and our communities. COVID is going to be with us for the foreseeable future, but colorectal cancer and other life-altering diseases will continue to impact patients long after COVID is under control.

Is your organization doing preventive outreach initiatives or focusing on non-COVID health conditions? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/21/20

December 21, 2020 Dr. Jayne 1 Comment

A recent article on telemedicine, privacy, and information security caught my eye this week. It appeared in the Journal of the American Medical Informatics Association. Although it’s not a write-up of a blockbuster study, it brings up some important points that we need to address as we move forward with new ways of delivering healthcare.

Even with vaccines on the horizon, there will still be a need to deliver care with reduced contact for the foreseeable future. Health systems and providers have made major leaps forward. One of my CMIO colleagues notes that it took her system less than 60 days to roll out an implementation that they had planned to take more than 18 months. It’s amazing what can be done when resources are focused on a single project since most of us are used to trying to manage dozens of projects that move forward an inch at a time. The reality, however, is that many projects were likely sidelined in favor of the one, and I bet the re-prioritizations were interesting when projects were reassessed through the lens of a global pandemic.

For organizations that didn’t already have a plan to roll out telehealth, many went with whatever solution they could take live quickly, especially with government waivers allowing non-healthcare solutions such as FaceTime, Facebook Messenger, and more. Zoom has been heavily used, but the phenomenon of “Zoom-bombing,” along with encryption concerns and the inefficiencies of a freestanding system, have led provider organizations to look for more robust solutions that integrate with EHRs and scheduling systems.

Broadband continues to be a barrier in several areas, and even in areas with good coverage, there can still be outages. I experienced this first hand this week as my internet was down for nearly five days as AT&T came up with different troubleshooting strategies and failed solutions before it finally was resolved yesterday. If I had been trying to practice telehealth this week instead of in-person care, it would have been a nightmare. When I was finally able to schedule a rep to come and assess the situation in person, I had an in-person shift and was only able to get back online by having my favorite retirees come house-sit.

The article also had good discussion of privacy and security concerns, including the ransomware attacks that continue to plague health systems. They cited recent research which showed that employee workload has a major impact on the rate at which employees are likely to click on phishing links. Increased use of broadcast email announcements was noted as a risk for increasing workload.

One of the organizations that I work with sends entirely too many broadcast emails and doesn’t pay much attention to crafting crisp subject lines that allow employees to prioritize their reading. They also overdo the “high priority” flag and haven’t figured out to focus the audience for different emails to send a more effective message. Maybe when I finish their informatics consulting engagement I can convince them that they need more routine management consulting-type services.

There’s a technical component to privacy and security that gets most of the focus, but especially when many of us are in work-at-home situations, there needs to be more focus on the need for physical safeguards. From the number of calls I’ve been on during the last few months where small children and significant others have come walking into the middle of the call, I’m guessing there is a shortage of locks on home office and bedroom doors. Some of the calls where this happened have involved discussions of protected health information, including quality review of patient visits, so having people potentially present who have no right to the information is a concern. Perhaps a corporate policy to require that headphones be used when discussing PHI would be an easy fix as well.

One of my clients tackled the issue of people working at home by setting the idle time lockout for all their laptops at 90 seconds, which is pretty short if you’re doing work that involves flipping through written documents and taking notes on your laptop, or if you’re using multiple computers to perform different tasks while working on a project. It also discourages sitting there thoughtfully reading an email before replying, which is a skill that the world could probably use more of. I was going to try a USB “mouse jiggler” to get some relief, but enough people complained that they relaxed it a bit. For someone working in an otherwise empty house, it’s still a little short for my taste, but at least I could stop entering my password dozens of times each day.

Thinking about how technology should evolve to keep up with telehealth led me to consider other ways in which telehealth may want to evolve. Many organizations encourage their telehealth providers to wear their white coats while on camera as a sign of professionalism. I always feel a little weird doing this, since for me the white coat is a tool that I absolutely don’t need while at home seeing patients on my laptop. In medical school, my white coat was stuffed full of everything I could possibly need for patient care – depending on which service you were on, it could contain an otoscope, ophthalmoscope, reflex hammer, stethoscope (although that was normally around students’ necks since our pockets were so full), penlight, multiple ink pens, patient notecards, reference books, and more.

As physicians progress in their training, the contents of the coat are reduced and more specialized. Right now, my in-person coat typically contains a stethoscope (there’s no way that thing is ever going around my neck again in a post-COVID era), single pen, lip balm, and a pocket full of gloves since we had to take them out of the exam rooms because patients were stealing them. I don’t need any of those things to practice telehealth, and it just seems contrived to be sitting in front of a bookcase in my house wearing a white coat. I’m pretty sure patients who are calling in for my urgent care services don’t care what I’m wearing as long as I seem competent and do what I can to help them.

I can’t wait to look back on this post a year from now and see where telehealth has taken us. Will we have evolved to a place where patients have home monitoring and assessment devices and physicians are able to really diagnose and treat like they would in person? Or will we still be using creative exam strategies to get the information we need? Will there be a physician-enabled camera filter that can take the bags from under my eyes and remove the semi-permanent mask marks from my face? Only time will tell.

How do you think telehealth will evolve for the future? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/17/20

December 17, 2020 Dr. Jayne 1 Comment

I was excited to see joint press releases this morning from Abbott and EMed regarding FDA Emergency Use Authorization for their at-home COVID antigen test solution. The test is the Abbott BinaxNOW test, which is being used in schools and physician offices. According to the release, they plan to deliver 30 million tests in Q1 2021, with another 90 million in Q2. It’s the lowest priced at-home test and involves performing the test in front of a live EMed supervisor via video. After testing, Abbott’s Navica app will deliver a digital testing certificate, which may be used by employers or venues as evidence of a recent negative antigen test. The solution is approved for age 15 and up and a prescription is required.

Even though antigen testing isn’t the same as the gold standard PCR test samples collected in physician offices, it would certainly help keep people at home rather than being out and about. At our practice, we’re using a technology solution to manage a virtual waiting room so that people stay in their cars or return home to wait, rather than crowd a waiting room.

One unintended consequence is people running errands while they “wait” for their visit. It’s difficult to get the public to understand that if they have had a concerning exposure for COVID or are having symptoms, they shouldn’t be exposing other people through errand running. We’re also still struggling to get patients to keep masks on during their visits despite signage and education. I’d say one of every four rooms I walk in has a person with their mask down, often talking on the phone, which has the risk of spreading droplets and aerosolized particles. If anyone has better solutions to these problems, I’m open to suggestions.

Our practice went live with a new patient education vendor this week and it’s been a blessing and a curse. I really like the new content which has both regular and easy-to-read versions and it’s much more practical than our previous vendor. On the downside, there was a glitch in mapping the content to the existing order sets, so providers are having to manually add the patient education documents to each patient plan. They’re trying to get it fixed, but it’s frustrating. I haven’t had a scribe in many shifts because so many of our staff members are out sick right now, so it all falls to the providers to fix.

We also had a radiology system outage today, which happened as I had several CT scans in the process of being read. Fortunately, the images had already been sent to the radiologists and I was just waiting on readings, rather than having my scans stuck upstream in the process. Because patients are still having difficulty getting in to see their primary care physicians and their other usual caregivers, they are winding up in urgent care. One of the scans in question revealed a tumor which is likely cancer, based on the presence of metastatic-appearing lesions. The patient had waited three hours to be seen because there were so many COVID-related patients in front of her, and I put the entire office on pause while I sat with her to discuss the diagnosis. It was a humbling experience and I was surprised at how well she coped with the news, but I’m sure it would have been better coming from her trusted family physician rather than me.

COVID vaccinations have begun in earnest across the US. In most areas, vaccine has been allocated to major health systems and hospitals. Our area began vaccinating Monday, and it became quickly apparent that despite our city having a Regional Pandemic Coalition, that once the vaccines started, arriving everyone was doing their own thing. One health system is vaccinating strictly by age, oldest first. Another is vaccinating by service line, trying to prioritize ICU and emergency department workers. A third is vaccinating seemingly at random, with several of my friends in their 30s who have no chronic health conditions or risk factors and who don’t even see COVID patients being vaccinated on the first day. I understand allocating vaccines to the organizations that have capacity to get shots in arms, but it’s not going to help the overall cause as much as it could if the scarce vaccines aren’t going in the arms of the people for whom they would provide the greatest benefit.

My practice still has no idea when we will receive vaccine, despite diagnosing 500 COVID patients every day. Since we’re not part of a hospital or health system, we were overlooked in the initial allocation. I don’t think those making the decisions understand how much pressure that urgent care centers have taken off of the hospitals as we serve on the front line. My group sees close to 2,000 patients a day, 365 days a year. We’re constantly having staffing shortages due to people being out with COVID. It’s a shame that the players couldn’t figure out a way to work together and are just looking out for their own without much consideration of the regional healthcare ecosystem.

I knew it was going to be this way, but to be honest, I underestimated the emotional impact that seeing friends and colleagues getting vaccinated would take on me. Reaching out to a national physician forum for support, it turns out that urgent cares have been overlooked in many states. We’ve seen large-format newspaper headlines that “Hope Is On The Way,” but some of us feel pretty hopeless and helpless. I had to stay away from social media this week because after a 13-hour urgent care shift, I just couldn’t process the joyous pictures of people with bandages on their arms without feeling anger and despair.

This is what having no national strategy gets us, a patchwork arrangement where some high-risk workers are still shouldering a disproportionate amount of the risk burden. Some states are doing better than others, but my state can’t even figure out how to put page numbers on its 100+ page vaccination plan, so I’m not confident about their organizational ability.

What grade would you give your state for vaccine allocation? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/14/20

December 14, 2020 Dr. Jayne 18 Comments

I’ve written a couple of times recently about some healthcare misadventures. The first story involved a delay in care due to COVID-related office shutdowns and the subsequent fallout when a close friend of mine ended up with an abnormal cervical cancer screening test. A couple of weeks later, I mentioned a glitchy pathology results interface that failed to send out results in a timely fashion, leading to delays in notifying patients of their results and subsequent delays in follow up for abnormal findings. I had the physician’s perspective for that one, feeling my colleague’s angst as she had to notify her patients of their delayed results. I also felt her frustration at her healthcare IT team’s poor management of the situation and the potential impact on the patients whose results were delayed.

I had hoped to not encounter any further stories like these in 2020, because heaven knows we’ve had enough stress, challenges, and outright disasters this year. Unfortunately for my friend the patient, her story has continued, and not in a good way. Although we’ve been talking about it on a daily basis in text messages, emails, and screenshots of her MyChart account, she has given me permission to write about the episode as a cohesive story.

Although I’m glad that I’ve been able to provide support and help her navigate the system, the reality of this is that none of it should have happened, and there should have been better systems in place to protect the patient.

Following the initial abnormal test, she went through an office-based biopsy procedure and waited more than two weeks for her results. The delay which was attributed to a continuing backlog in the hospital’s pathology department following some COVID-related furloughs. Although her surgeon expected some degree of abnormality, the result revealed a significantly worse problem that required further surgery and additional biopsies.

The scheduling process was frustrating due to ongoing games of phone tag and the perceived need for real-time communication rather than using email or text to schedule. My friend voiced her frustration: “I don’t know why they can’t just text me the open times. I’ve given them permission and it’s not like they’re talking about anything medical. It’s about as confidential as scheduling to rotate my tires.” Throughout this, her sense of humor has stayed largely intact, but reading statements like that gave me a hollow feeling in my gut as I had a ringside seat to watch the brokenness of the US healthcare system play out.

Instead of sending pre-procedure instructions and patient education via MyChart, the office sent them via postal mail. They were delayed by issues with the postal service that were likely related to the run-up to the US general election. When they finally turned up two days before the procedure, she was glad to confirm what she had already read via Google, but was still baffled at why the health system can send her bill through MyChart but not other items: “I mean seriously, they send me a bill in MyChart two days after the visit before insurance has even paid, but they can’t send me the important stuff like patient ed?” I agreed with her assessment, but didn’t know how much this statement would come into play later.

Finally, procedure day rolled around. Although I was able to drive her, due to COVID, she had to go by herself with no support person. Many in healthcare overlook the impact this has on our patients. She was definitely a little off when she got back in the car, and apparently she’d had an atypical reaction to one of the medications and was having some lingering effects from that. Although I understood as a physician why the rules are the way they are, as a friend, it didn’t seem to be the best thing for the patient to let her leave the facility the way she did. I went through a similar solo experience at my recent colonoscopy and they at least called my driver to pick me up at the door and made sure I got into the vehicle in one piece.

Her surgeon told her that pathology was still backed up and to expect a two-week turnaround for the results. She describes those two weeks as “eternal” from the patient side and joked that they should have tracking on the pathology specimens like online shopping: “Imagine it! You could get an email that said we’ve received your order, then we’ve received your biopsy jars, and it could just go through the whole process. We’ve prepared your slides! You’re next under the microscope! We’re writing your results! We’ve sent your results to your doctor!” It would be funny if it wasn’t so true that patients have more understanding of the flow of goods through Amazon then they do with regards to critical tests affecting their health. Putting on my vendor / consulting hat, I’d love the opportunity to write those messages, if anyone is interested.

She also lamented the fact that during those two weeks, she received numerous messages in MyChart about “complete nonsense that has no bearing on whether I have cancer or not.” Apparently, there were two more billing messages, along with several broadcast messages regarding COVID screening and the availability of telehealth visits at the university medical center. She had a good point: “Why can’t they set this up with a different notification if it’s something important versus something generic? All the emails just say there’s a new message in the chart. It could still be HIPAA friendly – ‘you have a new message in your patient chart’ means it’s about you, and ‘you have a general message from Big Health System’ means your heart can stop racing.”

We joked about taking it further to modify the notification sound on your phone, to a gentle “whoosh” for regular messages, an alert siren for the big stuff, and a cash register noise for the billing messages. We also thought about the ability to snooze general messages for 30 days just like we can snooze annoying Facebook friends.

Almost two weeks to the day, she received a text from her doc: “Path back, margins clear, all good, will send in MyChart” which she forwarded to me, followed by a copy of her doctor’s note and the report. I saw something odd on my first reading of the report, and after re-reading it half a dozen times, I knew I had to call her. It wasn’t in fact all clear, but there was a mismatch between the summary portion of the report and the actual microscopic description of the slides. The translated version is “all the cancer is gone, but cancer is present.” She messaged her doc, who agreed to call the pathology lab to have the slides and report reviewed.

Cue more waiting time, as the lab was vague on how long it would take for a repeat reading. As a good friend, and without naming any names, I reached out to a pathologist who works in the same health system to ask about the process. She was shocked that the report went out, since there was supposed to be a human review of all reports to make sure nothing like that was released. She also told me that re-reads are supposed to be done the same day.

Three days had passed and finally it took another phone call from the surgeon to get things moving. According to my friend, “that lab is in shambles due to COVID cases and quarantines.” She also noted that errors have been on the rise across her system since they replaced the human transcriptionists with voice recognition software, which is why they instituted human review. Although I sympathized with the quarantine and technology issues, I was still shocked at what a mess was going on within the healthcare organizations that we rely on.

After the surgeon’s second phone call, an amended report showed up at 11 p.m. Fortunately, my friend’s doctor was still up working her inbox when it hit, and my friend was still up as well. I was up too, and she texted it over. We chatted the next morning, and although the amended report was reassuring, she still didn’t know if she should trust the lab “since after all, this is just my life, right? They can’t even proofread?”

It’s a good point, and I encouraged her to ask for the samples to be sent to an outside pathologist for a second read, which she did. The overread took another two weeks. Personally, I think the first lab should absorb the cost of the overread since it was their error that triggered it, but I’m sure she’ll be getting a bill. At least though she has peace of mind that the reading is accurate.

Although she has received a reprieve for the next several months, there is still more testing to come. Even if all is good, she will be looking at ongoing followup for a few years. I hope that by the time she goes through this again that the systems have recovered to the point where she doesn’t have to endure anything near what she went through last time.

Many of the factors influencing these outcomes can be laid at the feet of the relentless cost-cutting that is everywhere in healthcare. As a clinical informaticist, this story is going to haunt me for a long time, because some of the work we’ve been collectively involved in is designed to prevent incidents like this debacle. Although we push hard to try to make things more patient-centric, money always gets in the way, not to mention the impact of a global pandemic. There are lessons to be learned here:

  • Patient self-scheduling can be an OK thing as long as there are guardrails around it, even for procedures. I’ve helped clients do it, and they’ve not only survived, but thrived.
  • It is unclear why a practice would send paper patient instructions to a patient with an active MyChart account, especially during a time of elevated concern about the US Postal Service.
  • COVID is going to be with us a long time, and we need to think out of the box on how to get patients the support they need when they’re engaging with healthcare institutions. Asking them to go it alone isn’t the answer, even if they appear young and healthy.
  • Hospitals are penny-wise and pound-foolish, and that’s not likely to change.
  • Amazon does a better job communicating about the status of a laundry detergent purchase than hospitals do regarding life and death matters.
  • Voice recognition software may be cheaper than human transcriptionists, but cost isn’t everything.
  • No matter what the technology is, human error still occurs, and multiple people missed the mismatch in the report including her surgeon. Not everyone has a friend who is a doctor to provide an additional line of defense.
  • Communication is EVERYTHING.

No matter where you are in this industry, please think about this story and think about how it impacts you professionally and also personally. If this patient were your mother, your sister, your daughter, or anyone you care about, is this how you would want it to play out? Regardless of who we work for, our ultimate customer is the patient, and doing what’s right by them should always be in front of us.

How does your organization tackle some of these missed opportunities? Leave a message or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/10/20

December 10, 2020 Dr. Jayne No Comments

As COVID-19 ravages large swaths of the US, CMS continues to push a strategy to enhance hospital capacity that is somewhat slow to start. It allows ambulatory surgery centers to provide inpatient care when needed. However, the problem is that most clinical staff at ambulatory surgery centers aren’t used to ongoing management of very sick patients. Just because there are more beds doesn’t mean there are more people to staff them. Our area has a surplus of beds but limited staff, which makes for some interesting spinning of hospital capacity rates.

The strategy also allows certain patients who would normally be admitted to the hospital to be cared for in their homes. Although many academic centers are gearing up programs to make this a reality with high-quality coordinated care following the CMS guidelines, some organizations are forcing greater at-home care by just discharging patients as early as possible even though they may not meet conventional discharge criteria. It will be interesting to see how this impacts readmission rates down the road. Analytics gurus, start your engines.

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With all the clinical shifts I worked in November, I missed out on a telehealth-related bill introduced in Congress that would penalize states that aren’t part of the Interstate Medical Licensure Compact. I’m fully supportive of anything that makes it easier for us to practice across state lines. I live fairly close to a state border and can have a telehealth visit with some patients while they are at work in my state, but it becomes illegal if they start their visit from their home across the river. HR 8723 would give states three years to join the Compact or risk not receiving funding from the Bureau of Health Workforce, which rolls up under the Department of Health and Human Services. State licensing boards would also be blocked from some federal grants if they don’t have a “public awareness campaign to encourage specialty physicians to practice telemedicine.”

The Interstate Medical Licensure Compact was launched in 2017 by the Federation of State Medical Boards and now has its own governing board. Its goal is to create a more streamlined process for physicians to gain licensure in other states. Currently 25 states plus Guam are live with five more states scattered throughout the process.

When I started practicing telehealth, my mentor encouraged me to apply for multiple state licenses. I quickly found the process to be arduous and expensive just for the applications, with some states requiring bizarre documentation such as high school transcripts that are largely irrelevant to the competency of a physician who has been in practice longer than some high schoolers have been alive. Once the licenses are approved, there is then annual maintenance of those licenses, and the risk/benefit equation quickly tipped to the former.

I’m deep in the final stages of a product launch this week, and this is the first one I’ve done in a totally remote environment. I’m used to working in a command center with everyone under one roof for rapid troubleshooting and hotfixes, which just isn’t realistic given the current pandemic conditions. Nearly all the resources are working from home, which has created some interesting situations, including a toddler attending one of our final checkpoint calls. The organization is doing a great job trying to foster togetherness and support the team during this high-stress situation, including sending gift cards for take-out and delivery meals.

Although I miss the feeling of togetherness and the satisfaction of working as a team, it’s just one more element of the new normal that many of us will be working in for the foreseeable future. I’m also glad for some time away from patient care so that I can refresh and recharge. Of all the go-lives I’ve supported, no one has ever tried to get me to look at a Ziploc bag full of their stool sample, which happened to me three times during my last few days of patient care.

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Nearly 100% of the chatter in the virtual physician lounge this week surrounds whether the Pfizer COVID vaccine will be approved on Thursday and how quickly organizations can start administering it. The lack of a national vaccine strategy has created vast disparities across states with regards to how it will be administered to frontline healthcare workers. Over the last couple of weeks, our area’s major health systems have announced their plans for employee vaccination and public health organizations have started to talk about their plans for vaccinating high-risk patient populations. However, it didn’t seem like there was any plan for vaccinating frontline healthcare workers at non-hospital entities.

After getting an unsatisfactory update from my employer, I felt like I was on my own and connected with a group of independent physicians who are in the same situation. They’ve been making phone calls to various county and state agencies along with hospitals and health systems for weeks, and each entity seems to point fingers at someone else who “should have been responsible” for including us in the planning. Just talking to the physicians in the group, our respective organizations deliver over 500,000 patient visits each year and represent close to 3,000 COVID tests each day. It doesn’t begin to reflect the amount of care delivered by independent physicians across our city, let alone the state.

My contribution to the effort has been reaching out to state and local professional societies and elected officials. Although many of the individuals we have collectively contacted are sympathetic, none of them are willing or able to take the burden from us and carry it forward. This has been such a long, hard slog and the emotional impact of knowing that physicians who don’t even care for known COVID positive patients will be vaccinated but we won’t, just because of who we work for, is enough to push us over the edge.

The best comment of the day came from the physician advocacy rep at my state professional academy: “It is truly unfortunate that something so important is so difficult to achieve.” It’s not like we haven’t had months to plan this, or in the worst-case scenario, could have just copied from the “smart kid” state next to us that seems to have a fully formed plan.

How is your state or community handling vaccines for non-hospital frontline healthcare workers? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/7/20

December 7, 2020 Dr. Jayne 2 Comments

My adventures as “just another physician” continued this weekend as our urgent care suffered a crippling EHR downtime.

My location had all of its staffed rooms full, several patients checking in, and a waiting room queue of nearly 20 patients when the EHR began to sputter. At first, it was only certain parts of the system that weren’t working properly, but they were some of the most critical – assessment and plan and medication orders. This of course created havoc in the discharge process. Because the EHR was merely sputtering, we were hopeful that it was a momentary glitch, so we kept trying to execute our workflows.

Eventually the EHR started spitting back truly unwelcome error messages, such as “server disconnect” that progressed to the hated “no servers available.” The dysfunction then spread to the practice management side of the house, with check-in and check-out grinding to a halt. For the staff members who had kept kept their systems up rather than trying to reboot, they at least had access to the tracking board to see what patients were physically in the exam rooms. For those of us who had tried to “turn it off and back on again,” the system was dead in the water and we were unable to access Citrix. (My staff often wonders how or why I even know anything about Citrix, and I must say I owe it all to one engineer who decided to take a young clinical informaticist under his wing.)

As expected, the IT emergency phone line was jammed, leading staff to call other locations to see if the outage was just our problem or everyone’s. We were all in the same unfortunate position, but when asked about instituting downtime procedures, the IT team told us to hold because they were already contacting the vendor. This led to wasted time and frustrated patients as we were trying to discharge patients so that we would have open exam rooms to use for those milling at the check-in desk in a non-distanced fashion.

I asked for a paper prescription pad to expedite discharges, but there was some confusion about where it lived and whether it was in the regular narcotics cabinet, the back stock narcotics cabinet, or the administrative office. One clinical tech started phoning prescriptions to the pharmacies and documenting them on Post-it notes while we waited for our site leadership to get their act together.

We were 15 minutes into this veritable goat rodeo with no update from our leadership when I directed the team to go ahead and pull out the downtime binders so we could start moving patients forward again rather than spinning our wheels over what we should be doing next. It took nearly 10 minutes to pull the binders, and then staff had to read the instructions to try to figure out what to do. There was some disagreement from our site leader about whether we should start the process, which added yet another delay.

Fortunately one of my clinical techs took the initiative to run from room to room and collect names and dates of birth for each patient, which we wrote on Post-it notes that were then attached to two old-school clipboards propped up at the physician work station. The list of physically present patients didn’t fully match the list of patients on the remaining tracking board screens, so we decided to make the clipboards the source of truth. Everyone updated the Post-its with as many facts as they could remember about the patients, and we queried our laboratory devices to provide duplicate results for anyone who had testing recently performed.

That provided enough facts to cobble together the information needed to discharge several patients, although we still had some confusion at the check-out desk as far as collecting payments. I was just happy to have exam rooms in which to install the remaining patients that hadn’t gone back out to their cars to wait, as they had been treated to a bit of a show as staff ran around trying to figure out what to do.

Nearly 30 minutes into the event, which felt like an eternity, we still didn’t have an update from leadership. Having come from a big health system where we lived and died by the strength of our downtime plan, I found that surreal. All the other IT systems were up, so there was no reason they couldn’t be sending email or text updates to each site or to the physicians since they already have groups set up for bulk notifications.

I continued to see patients, Post-it by Post-it, until the clipboards began to clear. Eventually, the system came back up, but not in its entirety. Restoration came in the reverse order of it going down, with medications, assessment, and plan lagging behind. The only way we knew the system was improving was by constant trial and error as opposed to an “all clear” notice from the practice.

Since our downtime policy requires manual entry of all data into the system rather than entry of critical or longitudinal data and scanning of the paper downtime forms for non-critical data, the staff immediately became even more stressed, wondering how they would catch up with a continuing flow of patients coming in the door. All told, it took us almost two hours to fully recover and get everything caught back up.

I don’t know whether this was a vendor failure, a hosting failure, an infrastructure failure, or what. but it’s clear that if there was a fail-over system for downtime, it didn’t work correctly. It’s also clear that we don’t practice our downtime protocols enough, or educate on them enough during training. Of the eight staff working at my site, only two of us have ever been through a downtime, and the others were generally unfamiliar with what needed to happen. Since I don’t play any role in the organization other than as a physician, I’m going to keep my thoughts to myself, but make sure my IT clients are better prepared than what I just worked through.

Experiences like these should be rare, and although they cannot be prevented, they can certainly be mitigated in a way that was better than what happened to us. It’s a good reminder of how critical it is to continue good IT practices, even in a pandemic. The patient experience was certainly less than optimal during the episode, and I hope there wasn’t any compromise in care.

When is the last time your organization practiced its downtime routine? Has anyone tested their backups lately? Leave a comment or email me.

Email Dr. Jayne.

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