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EPtalk by Dr. Jayne 3/7/19

March 7, 2019 Dr. Jayne 2 Comments

My sci-fi nerd flag was flying high when I heard that the Amazon, Berkshire Hathaway, and JPMorgan Chase venture will be called Haven. That was also the name of a planet featured in “Star Trek: The Next Generation” and one where the Enterprise crew was supposed to have some well-earned rest and relaxation. I’ve perused the website and appreciate the way they’ve spelled out their mission clearly and in a way that most people can understand. It looks like most of the open positions are in their Boston and New York offices. It will be interesting to see what kind of people gravitate there.

Researchers are seeking to use artificial intelligence to help design better vaccines against the influenza virus. Flu is a virus that mutates rapidly. Researchers from two pharmaceutical companies are taking biochemical data from samples of exposed patients and running them through an algorithm in an attempt to understand how an effective immune response forms. Other teams are using machine learning to predict the spread of influenza using training data sets from physician offices, hospitals, and social media. The Centers for Disease Control maps flu trends, but being able to truly forecast flu activity would be an asset. I hope they hurry up and get it right. I’ve avoided flu for most of my medical career, but it hit me this week and with a vengeance.

In Mr. H’s annual reader survey, there were some responses that indicated a desire to see more focus on less-traditional areas of healthcare IT, including telehealth. Since I’ve been doing some of my own explorations in the telehealth realm, I’ll share my observations and findings.

One of the first things I’m finding is that it’s important to understand what you mean when you start talking about telehealth. Is this provider-to-provider, institution-to-institution, or direct-to-consumer? The differences involved in the various approaches are vast.

In talking with physicians, there is good acceptance of the provider to provider offerings, which can help serve rural areas or places that don’t have the specialists needed to care for patients with certain conditions. This typically involves a patient coming in to see their provider, then joining with a subspecialist or other clinician via video call. The provider who is actually with the patient can assist with physical exam findings and vital signs. It doesn’t have to be a physician, but can also be a nurse or other trained member of the care team.

This approach can be huge as far as saving time and money for patients to travel to see subspecialists, understanding that some patients just wouldn’t go because of the burden. I’m seeing this more as academic medical centers partner with outlying organizations and it seems to really be taking flight in the pediatric subspecialist world.

There is also good acceptance of institution to institution telehealth, such as remote ICU monitoring or telestroke management services. This can allow specialists to weigh in on the care of patients at institutions that might not have the level of expertise needed to care for certain conditions. It can also just serve as an extra set of eyes for an already-skilled facility, making sure that nothing is missed in the care of critically ill patients. There are typically deep linkages between the organizations from both contractual and philosophical perspectives, so the level of trust is high.

Telehealth services that are delivered directly to the consumer have variable uptake. Some healthcare organizations have already built robust telehealth programs, allowing their providers to work directly with patients who may have challenges traveling to the office. Devices can be used to report patient-generated data in order to provide better care, such as daily weights for heart failure patients or blood glucose readings for diabetic patients.

Other organizations may be using telehealth strictly for acute visits, allowing physicians to extend their hours, access, and productivity without having staff in the office for an extended session. They may be using a telehealth platform within their EHR or licensing with one of the nationally-known telehealth companies to get this done.

Then there are the independent telehealth organizations that may contract with employers or payers, or may market directly to patients as consumers.

I think providers are skeptical of the independent telehealth organizations. There was recently a raging editorial from one of the leaders of the American Academy of Family Physicians on the topic. However, there’s no question that these services are filling a gap in services that aren’t being provided by brick and mortar clinics or traditional primary care practices. Although there are some direct-to-consumer organizations that seem fairly profit motivated, others have significant interest in measuring clinical quality and patient outcomes along with patient satisfaction and efficiency metrics, just like an in-person practice would. These organizations are doing work to explore how they can fill gaps in care while maintaining antibiotic stewardship and clinical quality. They’re also working to ensure that the loop is closed with reports to primary care physicians so that there is continuity of care.

The challenge for these organizations is the lack of data looking at telehealth care of various conditions. There simply isn’t a body of research (yet) that looks at the effectiveness of a telehealth history and examination vs. an in-person examination. We know that physicians have treated certain conditions over the phone for decades, yet there are challenges when it is a brand-new patient-physician relationship rather than an existing one. Smart organizations are gathering data on their outcomes and their approaches and using it to drive future care pathways.

I think we’re going to see a continued boom in telehealth including expansion into the primary care and chronic care space. There will also be plenty of room for specialized telehealth organizations to flourish. Patients are voting with their pocketbooks on convenience and access and I hope traditional organizations are making note.

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The Epic campus has made it into Atlas Obscura,one of my favorite sites for internet time-wasting. I had heard about many of the features, but not the medieval drawbridge, which caught my attention. I’ve never been, but I hear it is something to behold.

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Curbside Consult with Dr. Jayne 3/4/19

March 4, 2019 Dr. Jayne 1 Comment

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Due to bad weather, I was gifted a fairly quiet and unremarkable urgent care shift today. I definitely appreciated the time to allow my brain to play catch-up. Word of advice: if you get blackout drunk at a Mardi Gras party and wind up with a visibly deformed leg, I hope you have sober friends who can take you to the emergency department immediately. Waiting until the next day and then going to urgent care for your nine-way fracture isn’t going to be as helpful.

I’m working on a couple of projects, one involving creation of some new educational resources for an organization that is pursuing EHR optimization. It’s often difficult to figure out the best way to train people, and successful organizations will use multiple methods to ensure that everyone is receiving information in the way that best suits them. Those organizations also use frequent retraining to ensure the information is retained.

Out of all the organizations I’ve worked with over the years, only two had individuals with advanced training in adult education involved in the creation and upkeep of the training process. Too often, training is done “like we did it last time” and doesn’t take advantage of different types of media and experiences.

Some people are visual learners who are going to respond best to well-delivered presentations and written materials, often taking notes on the content. These folks may do well with classroom presentations as long as they’re organized and concise and have dynamic presenters that don’t bore the audience to death. Others are auditory learners who may also do well with a classroom format. Still others are kinesthetic learners – they need to touch, feel, and do to absorb workflows they are trying to learn. They do best in a lab setting. There are also variations on the various learning styles, including whether people learn better individually or in a group setting.

Too often leaders make assumptions about how their people should learn,  limiting the options that are offered and potentially to negatively impacting a subset of their users. Savvy organizations poll their users and see what kinds of training materials they would like to have.

LOINC recently surveyed their core users and the breakdown was interesting. Of nearly 500 users:

  • 48 percent preferred a published guide available as a PDF
  • 25 percent wanted written documentation as a web page
  • 6 percent preferred slide presentations
  • 17 percent wanted video presentations with audio
  • 3 percent wanted in-person training

It would be useful for leaders to survey their users to see what kind of training is preferred.

Leadership should also be aware of the corporate culture and how different types of training will be received in the field. For example, one large health system I worked for decided that they didn’t want to expend the resources to bring everyone together for training. They decided to train via web meeting with people at their desks. Participants were not aware that the training team had attentiveness tools, including being able to see whether the window in which the presentation was occurring was the primary focus on the desktop.

Within 15 minutes of the start of the webinar, hardly anyone still had the session in primary focus, and of those who did, they were most likely multi-tasking based on the lag in their responses to interactive polling questions. Others never even signed in to the webinar because they were sidetracked in the office with the urgent issues that occur on a minute-by-minute basis. Had they been allowed to leave the office and attend classroom training, those interruptions and distractions would have been minimized. Needless to say, the training was a flop, and for our next upgrade, we returned to classroom-based training.

One of the things that bugs me the most is training sessions that lack of materials for the participants. Back in the days after the demise of the Kodak slide carousel and following the rise of PowerPoint, lecturers often handed out copies of their slides for attendees to take notes on. As we became more environmentally conscious, people stopped handing out copies, but this left students frantically scribbling and trying to capture concepts and ideas. Some presenters balk at handing out the slides before a lecture for fear that it will make the audience inattentive. This completely ignores the subset of learners that benefit from seeing an overview of material before they’re confronted with a deep dive.

For this new project, I’m working on the scripting that will be used to retrain physicians, including a compilation of the clinical scenarios that are the most relevant to each physician who will attend an in-person session. They will be experiencing a classroom portion followed by a lab, followed by time for individual questions and interaction with the trainers. All of the sessions will be recorded and we’re distributing the materials, both before the class and after. The slides that are sent before the class will allow people to bring a printed copy if they want to, and those distributed after the class will contain notes and annotations from questions and discussion held during the session. Not everyone wants a big shelf full of binders and manuals, but the reality is that some people still like hard copies.

The other project I’m working on is more creative in nature, a communication and marketing plan for a practice that is planning to launch virtual visits. They have decided to try to do them in-house using their EHR, which doesn’t have great telehealth functionality, but at least they’re willing to dip their toes in the water to see whether patients are interested in it. We’re putting together communications to make sure everyone in the office is aware of the project and the plan to launch it as well as the questions they will need to be able to answer when patients ask.

Figuring out the best way to market it to the patient population is also a challenge. The majority of them are tech-savvy, but will need some education on why they will be billed for a virtual visit that in the past would have been handled as an unreimbursed phone call. It’s been fun to come up with the flyers illustrating the difference as well as doing some role-play with the leadership to make sure they can articulate all the goals and objectives before we roll the materials out to the front-line staff. I’m enjoying working with people who are willing to lead by example and to roll up their sleeves instead of just delegating something this major to someone down the line.

A nice creative project helps get my brain working again after this long awful winter. Even though snow is still on the ground, I’m starting to feel like spring might finally be around the corner.

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EPtalk by Dr. Jayne 2/28/19

February 28, 2019 Dr. Jayne No Comments

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I’ve been rationing my fun socks post-HIMSS. Today was the day to show off these polka dot doozies from the amazing CoverMyMeds sock machine. I have to give them props for the best swag-dispensing system on the show floor. If you were willing to hit Twitter and follow some basic instructions, you got a great pair of socks.

I checked in on the company’s statistics. They have helped complete 128 million medication prior authorizations. More than 700,000 providers have used it and they are connected to 96 percent of pharmacies. The service remains free for providers and partners, with health plans, PBMs, and drug companies footing the bill. I don’t run across many prior authorizations for medications in the urgent care space, but if I was back in traditional practice, I think it would be a must-have.

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I needed my great socks to boost my mood since I’ve been having adventures in collaborative software this week following an organization rollout of Microsoft Teams. It seems like nothing lasts for more than a year or two here and we’ve been through an entire progression of applications, from Windows Live Messenger to Skype to Slack to Yammer and now to Teams. At one point we also had HipChat in the mix, which created confusion since people were expected to collaborate on multiple platforms depending on who we were working with.

Although use of the actual Teams platform has been seamless, I’ve been struggling because since we went live I can’t use my OneDrive documents offline and no one can explain why it’s not working. I discovered this not-so-little issue when I was on a flight with no Wi-Fi service and couldn’t even edit documents, despite them being stored “on” my laptop within OneDrive. There’s a ticket open on my behalf with Microsoft, but it’s already been a couple of days and I’m not hopeful about a resolution. If anyone has seen this and has any ideas, let me know.

I was pleased to see that the HIMSS Electronic Health Record Association (EHRA) is working to make it easier for physicians to effectively use data to avoid opioid misuse. The US has a patchwork of Prescription Drug Monitoring Program (PDMP) systems by state (except for Missouri, which still can’t seem to get its act together). The systems function differently depending on state laws, which can be challenging for providers practicing on state borders. It’s also challenging for EHR developers who have to try to figure out how to create solutions that work across the country.

EHRA has put together a compendium of state-specific policies and standards, including what data is being collected and who can access it. EHRA’s Opioid Crisis Task Force has also created an “ideal minimum data set” detailing the information needed to best support clinicians who are making decisions around opioid prescriptions. The ultimate goal is to be able to create a standard for PDMP data that would be consumable by EHRs and useful to clinicians. EHRA notes that they’d like to work with ONC and other stakeholders in this effort. I agree it would give the effort some teeth since it’s often hard to herd the states in a common direction.

CMS is holding a listening session on March 5 covering the Interoperability and Patient Access Proposed Rule. Registration is open for the session, which will include opening comments by CMS Administrator Seema Verma followed by an overview of the proposed rule. Participants will also be able to submit questions and get clarifications that are needed prior to submitting formal comments to CMS.

Many physicians have concerns about the impact of patient satisfaction scores on their overall performance including how they play into compensation and insurance rating issues. An article published this week gives credence to some of those concerns. The investigators set out to specifically investigate whether Asian physicians received lower patient satisfaction scores compared to non-Hispanic white physicians. Researchers surveyed nearly 150,000 patients and found that those who self-identified as Asian were less likely than other patients to give their physicians the highest ratings for patient satisfaction. Overall, Asian physicians had lower patient satisfaction scores due to the higher proportion of Asian patients treated by those physicians.

There were other subtle differences in the data depending on the characteristics of the patient and physician populations. The authors encourage organizations that use patient satisfaction scores to drive provider compensation to look at the possible need to adjust their numbers based on patient race and ethnicity.

As physicians try to be more responsive to the cultural preferences and practices of patients, this type of research is going to be more important and brings up many questions. What defines a particular race or ethnicity? What if you are Asian but were raised by a Midwestern Caucasian family with no connection to your birth culture? What if you are Caucasian but grew up deeply immersed in the Latino community? How do you grade a physician based on true cultural competency vs. their ancestry or genetics?

The study looked at data gathered from 2010 to 2014 from a community health clinic in northern California. What would the data look like if it were gathered from a practice in another part of the country or with a different socioeconomic makeup? What about a more recent timeframe given the speed of change regarding cultural practices?

These are important factors to consider, but they aid in exposing how difficult it is to measure patient satisfaction and the various factors that might go into it. How do you control for compassion and communication when looking at clinician behavior? I’ve heard some interesting physician comments on the study, but would be curious to hear what others in the healthcare community think and also what people think as patients.

I’m waiting for the HIMSS session recordings to come out so I can finish “attending” sessions and claiming continuing medical education (CME) credits. It seemed like many of the sessions I wanted to attend were at the same time, so I’ve got some catching up to do. Despite the availability of on-demand recordings, we’re still limited to only claiming credit for one session per real-world time slot. In the age of electronic media, it would make more sense to allow participants to claim the credits that best meet their professional development needs rather than limiting them by their inability to be two places at once (which used to be reality before recordings).

I’d be fine with still capping the overall number of hours if granting too many hours is part of the concern, but I think this is one of those situations where we’ve simply added technology to an old-school process without revisiting how it might best serve the end users. For the hours to count for the CME needed for Clinical Informatics you have to also complete questions on the learning objectives so it’s not like a bunch of us are trying to game the system.

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Curbside Consult with Dr. Jayne 2/25/19

February 25, 2019 Dr. Jayne 2 Comments

I spent the weekend with one of my healthcare IT mentors. He’s been around the industry for several decades and I’ve been the fortunate recipient of some of his knowledge as he’s shared it with me over the years. He taught me much of what I know about building relationships with clients and constituents, along with how to cut through the noise that some in the industry constantly generate.

Over time I’ve been his customer, later his co-worker, and even did a brief stint as CMIO at an organization he led. Most of all, I’m grateful for his friendship as I’ve moved through this wild and crazy industry. He’s helped me weigh the pros and cons of various opportunities and reminded me to be true to myself, because the industry and the people in it can change with not even a moment’s notice.

Following the whirlwind of HIMSS, it was good to be able to sit by the pool and do nothing. When the most major item on your agenda is determining which movie you’re going to watch after dinner, life is good. (Note to readers: “A Quiet Place” is not so quiet of a film.)

It was nice to have a glimpse of retired life, although I can tell he misses the industry at least a little bit. He spent the majority of his career on the vendor side. We played the “who did you see at HIMSS” game and it was a trip down memory lane talking about everyone we’ve known or worked with over the last 15 or so years. Very few of our mutual friends are in the same places in the industry, with many having made the rounds among multiple EHR vendors over time. Certain executives seem to bring their entourages with them as they move, which leads to an exodus when they ultimately leave. It seems like some people just follow each other around the industry.

The people we’ve worked with have ranged far and wide, landing full-time gigs at academic medical centers, health systems, and with cross-industry vendors such as Salesforce or AWS. Some work in lobbying or the healthcare policy arena. Others have left the healthcare IT world altogether – one raises pygmy goats and another owns a hot yoga studio.

It’s always fun to hear about their exploits and to wonder where various people landed in later phases of their careers while pondering one’s own future. I’ve been a bit restless the last several months. Running your own business is challenging and making sure that the people who work on your behalf are meeting client expectations can be exhausting even with a small group of people.

I’ve explored a couple of opportunities to return to life with a Big Health System, along with one to move into the vendor space. None of them were particularly conducive to staying in practice, which ultimately led me to cross them off the list. I’ve had a couple of periods during my career where I didn’t see patients and I did miss patient car,e although I didn’t miss dealing with insurance companies or landlords.

In reviewing my recent foray into job hunting, I was frankly surprised by the inability of the provider organizations to come up with a clinical situation that would work. Often the emergency department or urgent care work has been contracted out to a staffing company that is reluctant to take on a part time physician.

One offered to add me part time to an existing internal medicine group. Trying to work as a primary care physician but only be in the office half a day a week is very challenging. I did it when I first moved into the CMIO trenches and there was much patient dissatisfaction with the arrangement, as patients were used to having advanced access scheduling with me as their physician. Not to mention that my partner constantly grumbled about having to cover for me even though he was being compensated for the extra work.

I can’t imagine trying to be a new physician to a practice but only be in the office half a day a week unless you were just seeing acute or overflow visits, and none of the organizations I talked to were offering that kind of arrangement. I don’t think that seeing patients is essential to being a good clinical informaticist or physician leader, but I do enjoy it and think it provides valuable context for being able to serve the organization.

The vendor role was reluctant to let me stay in practice at all, for fear that I wouldn’t devote my full efforts to the job. I think that was short sighted and they shouldn’t care what I do on my weekends. It turns out they have a “no moonlighting” policy for all employees, which was a bit of a red flag anyway. I don’t think employers should try to dictate what people do in their off hours unless it reflects badly on the company or interferes with the employee’s ability to complete their responsibilities successfully. It seems like many people have a “side hustle” these days, probably due to the uncertain aspects of the healthcare IT economy.

I’ve been looking into some telemedicine opportunities because they seem to be flexible and might be a bit more easily worked around a full-time informatics role. However, it’s not anything I have ever done, so it’s hard to gauge whether it would be a good fit. My friends who have done telehealth either really liked it or didn’t. I’m used to being adaptable, so we’ll have to see how things unfold.

I’ve got a major volunteer commitment this summer that I need to schedule around, so I don’t want to upset the proverbial apple cart too much unless an amazing opportunity comes along. A wise man once advised me to always keep my mind open to new opportunities and his advice has been spot on so far. Until the universe drops something spectacular in my lap, however, I’m perfectly content to sit by the pool, contemplate a nice glass of wine, and be grateful for the life I’m living.

If you could re-engineer your career, what would you do differently? Leave a comment or email me.

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EPtalk by Dr. Jayne 2/21/19

February 21, 2019 Dr. Jayne 9 Comments

We’re officially post-HIMSS, because the emails have started arriving thanking me for my interest in various vendors’ products after I stopped by their booths at the show. Folks have had time to decompress and begin sorting through various business cards that were traded and notes that were made about follow up. 

I have my own stack of cards to go through, following up on new connections and seeing what opportunities might arise from the conference. As summer approaches, I tend to start putting together my strategic plan for the upcoming year. I’ve had some tempting offers to go back into the hospital trenches as well as some interest from the vendor side, so this might be a year full of change.

Normally I don’t spend a lot of time reading things from Healthcare IT News, but their interview with Judy Faulkner caught my eye. Part of the conversation was around physician burnout and relative happiness (or unhappiness) with EHRs. She brought up some good points that many of us in the trenches already know, but that large organizations seem to tune out at times. One of those points is that although EHR use can be associated with physician burnout, it’s not necessarily causal. There are burned out physicians that are happy with their EHRs, and EHR-haters that aren’t burned out. Other factors influence burnout including administrative burden, leadership issues, patient load, and work-life balance issues.

She also notes that clients need to stay current with their EHRs, installing the latest versions so they can benefit from usability enhancements that followed the post-Meaningful Use programming era. I’ve found that to be true with nearly all the vendors I’ve worked with, not just Epic. Once they cleared the certification hurdles, vendors often went back to customer enhancement request lists and started making good on old promises.

Another point she made was around training. Physicians that tend to do better with EHR adoption are likely to have had better training. That doesn’t always mean more hours of training, but it could mean more focused training or role-specific training, using the physicians’ time wisely and training them on the tasks they are most likely to perform in their work.

She calls for physician subspecialists to train their peers. That’s great in theory, but it’s not very easy to find physicians who want to dedicate themselves to learning how to train other physicians how to use the EHR. I’ve worked to mentor multiple CMIOs in this regard and not everyone has the aptitude or personality to be a trainer even if they want to do it, even when the hospital is willing to compensate them appropriately. In too many cases the compensation, isn’t remotely adequate, so it becomes a non-issue.

Faulkner does mention the idea of EHR personalization as a positive factor towards EHR happiness. She notes that it’s a challenge to convince health systems to do that for their physicians. My take on it is that it’s not just an Epic issue, but happens with most vendors and most health systems. It can also vary based on the degree of autonomy held by physicians outside the EHR.

One hospital I work with keeps its employed physicians on what many would consider a short leash. They’re fanatical about quality and reducing unnecessary variation, so physicians are expected to use order sets and standardized workflows. They’re incented on following the rules. Generally, people comply or they leave. The users tend to be satisfied with the EHR because they know what to expect and they know the rules of the game they’re playing.

At other organizations where there may be lots of competition for attending physicians’ patient volumes, I’ve seen hospitals bend over backwards to customize the EHR on an individual physician basis for fear that someone will take their surgical business elsewhere. This can lead to redundancy and confusion in order sets and workflows and costs more to maintain, but the organization feels it’s worth it. There’s definitely a need for vendors to make their systems easier to personalize and to allow user-level configuration rather than having to have IT teams involved in making small adjustments.

She goes on to note some data from KLAS that looks at EHR happiness and whether the health system is “agile,” meaning “If a physician wants a change made and talks to an IT person, how many committees does it have to go through? And if the answer is zero, that’s good.”

I understand the sentiment, but for those who haven’t waded into the muck that is EHR or IT governance, it’s an oversimplification. I’ve done hundreds of hours of work for hospitals and health systems “undoing” various changes that were made without any level of approval (and often without any documentation). Oversight isn’t a bad thing, but has to be crafted carefully to support the needs of the user and the goals of the organization. There should be a decision matrix that shows what kind of changes need what kinds of approval, and from whom. Simple things that don’t have downstream ramifications should happen quickly, where more complex issues that might have far-reaching consequences might need multi-level oversight.

Assuming the interview is a relatively straight transcription and didn’t go through much editing, it shows the level of understanding and insight that Judy Faulkner has into some of the issues her clients are facing. I’ve interacted with C-levels at many vendors and some of them don’t seem to have as much understanding of the challenges their clients are facing and how it impacts the end users. Many of them are good at using sound bites, but when it comes to getting into the details, they become quiet.

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I’m approaching a milestone reunion for my medical school class, and one can’t help but think about how much it cost to get here. Some of my classmates are still paying off their loans. A recent planning committee get-together led to some conversation about free tuition being offered at some medical schools. The brand new Kaiser Permanente School of Medicine in California has announced that it will waive tuition for all years for the school’s first five classes of students.

This led to quite a bit of discussion on the fact that Kaiser Permanente is opening its own medical school, unaffiliated with any university. Depending on how much influence Kaiser Permanente has on the students and what facilities they rotate through, there may be significant difference from the educational opportunities received at other schools. The first class will be relatively small (48 students) and the school names three academic pillars: foundational science, clinical science, and health systems science (which they describe as focusing on care delivery including population health, quality improvement, and social inequality). Students will participate in longitudinal clerkships starting in year one, hosted in Kaiser Permanente hospitals and clinics along with community health centers. It will certainly be interesting to see how this plays out.

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I was in the office yesterday treating lots of folks with influenza. At one point, all nine of our exam rooms were occupied by people receiving IV fluids. The flu is hitting people hard. I had a great team working with me. However, at one point, I noticed that probably all of them were young enough to be my children.

This thought came back to me later in the day, when one of them was using the EHR to print a label for a blood draw and asked aloud, “What did we do before we had Dymo printers?” They looked at me like I was from Mars when I started to tell them about the Addressograph machine, with which we used to print headers on patient chart pages and various labels. One of my jobs as a Candy Striper on the mother-baby unit was to stamp new chart pages for all of the patients on the floor. It’s funny the things you forget as technology moves on, but I think I can still smell the ink when I think hard enough.

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

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Curbside Consult with Dr. Jayne 2/18/19

February 18, 2019 Dr. Jayne 2 Comments

I’m still recovering from HIMSS. What started as a slightly runny nose on Thursday has turned into a full-blown head cold with plenty of sneezing. At least it’s not influenza, however, so I’m grateful.

Any time you get that many people together shaking hands in flu season, it’s always a risk, but hopefully vaccination and lots of hand sanitizer has worked to keep the bad pathogens away. Unfortunately I’m spending the weekend in the clinic, making up for time out of office, and there isn’t much room for rest and recovery.

I mentioned the Arcadia-sponsored lunch I attended that featured John Halamka. I have been thinking about some of the things I learned during that presentation.

He talked about several countries and some of the challenges they are facing with healthcare. There was a lot to process. First, he talked about his experiences with China’s healthcare system and its approach to primary care, or lack thereof. The concept of coordinated care is just starting to take hold as China works to develop its primary care workforce. Until then, patients might self-select to a subspecialist physician based on what they think might be happening to cause their symptoms. He gave the example of someone waking with a headache and choosing to queue to see an academic neurosurgeon rather than seeing a primary care physician first. He is involved in a pilot project looking at care coordination that has one million patients in the cohort. That’s quite a bit larger than the pilot projects we’re used to in the US.

Next, he talked about healthcare in India, where a workforce of 600,000 physicians care for approximately 1.4 billion people. (Google shows the number at a bit closer to 800,000, but either way it’s a relatively small number for the care that needs to be delivered). Halamka has traveled to India multiple times and shared photos of his experience looking at x-rays that patients are carrying around with them as part of their personal medical record. There are significant healthcare disparities by region and the informatics community is starting to look at using clinical decision support to address issues where certain diseases such as tuberculosis might be more common in certain regions of the country.

He shared a story about a post-partum patient with abdominal pain and polled the audience (there were a handful of doctors in the crowd) about their thoughts. Nearly everyone thought about post-partum infection or complications like a retained placenta, but the real answer was abdominal tuberculosis, which isn’t even on the radar for most of us in the US, but is apparently fairly common in some parts of India. It really makes one think about how different healthcare experiences can be around the world.

The third country he talked about was Norway, where patients are expected to contribute their personal health information to the overall dataset of public health records. There’s not an “opt out” per se, which results in much more information being able for research and for investigation of health practices. I did some additional digging on this and found that although the Norwegian national Summary Care Record is in place for all citizens, the tool isn’t used as routinely in practice as it might be. Halamka also touched on the drinking habits in Scotland, which are among the largest per capita across the globe.

He also discussed interoperability in Australia, which is chiefly by PDF. This means there is no drug-drug or drug-interaction checking, no clinical decision support, and no common medication lists. There are, however, probably a great deal of duplicate data entry and wasted resources. He touched on Japan with its aging population and low birth date, where fewer clinicians are tasked with delivering care to a growing population, often with significant quality variation. Apparently in Japan it’s also illegal to host electronic health records on cloud-based services, which is going to need to change for optimal use of digital health resources.

Halamka paused from his round the world tour to address the role of artificial intelligence in healthcare, particularly the need to make sure that training sets used to build AI technologies aren’t full of biased information based on historical challenges such as delivering care to patients whose primary language is something other than English. We also need to take care with the use case for AI in healthcare — he used the lack of progress with Watson as an example. He doubted that the big EHR companies would really be doing much innovation, going on to say that the real innovation will be in a cloud of apps around those legacy systems and that the “24 year olds in the garage are the real innovators.”

He noted some of the challenges with interoperability in the US, namely with data sharing for adolescent patients, which must be controlled by policies and age ranges to meet the changing needs of children who are transitioning through adolescence and into the adult world. He mused on Apple’s partnership with Aetna, where patients will be given Apple watches as tools for health monitoring. It will be challenging for providers to figure out how best to use patient-generated data and for systems to figure out what data is important enough to act on.

He used his own example of a rapid heart beat as a test case. When it happens, it usually goes away in a minute or two. How will the system know not to act on it vs. to act on someone who is having a new onset of rapid heart rate or a more dangerous type? It’s one thing to have data, but another thing entirely to transform that data into information, knowledge, and wisdom.

There were good questions from the audience and Halamka went on to explain how he sees his role as “care traffic controller” for three generations of people in his family. I hadn’t heard that phrase before and I have to say I like it and will be stealing it for future conversations. Overall it was a solid session and I am even more curious about how other countries are handling various healthcare delivery crises and whether we’re really as bad off as we think we are. I’m going to have the opportunity to practice medicine with people from around the world this summer and I hope it will be a great learning experience.

What’s the best session you saw at HIMSS? Leave a comment or email me.

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EPtalk by Dr. Jayne 2/7/19

February 7, 2019 Dr. Jayne No Comments

Physicians are always up in arms about quality reporting, having been burned by payer, federal, and institutional quality programs. The American Academy of Family Physicians released a position paper recently that hopes to help influence the development and use of quality measures in physician payment initiatives. The Academy plans to use the principles outlined in the paper in its discussions with payers, health plans, and healthcare IT developers.

The first principle involves differentiating between quality measures and performance measures, with a goal of using the former for internal clinical improvement while reserving the latter for comparative data and resource allocation efforts. AAFP supports the use of performance measures, not to drive penalties, but to show where investment should be made to improve access and equity in healthcare.

The second principle addresses integration of quality measures into an overall methodology, allowing for “a safe space to allow honest assessment of care without fear of punishment and without pressure to increase revenue or produce bonus payments.”

The third principle outlines the need for a single set of universal performance measures that “focus on outcomes that matter most to patients and that have the greatest overall impact on better health of the population, better healthcare, and lower costs.” A secondary goal is limiting the measures that are included in value-based payment programs since “giving in to the temptation to measure everything that can be measured drives up cost, adds to administrative burden, contributes to professional dissatisfaction and burnout, encourages siloed care, and undermines professional autonomy.” It goes on to say the standard set of measures should be used across all payers, programs, and populations.

Principle Four addresses the application of performance measures at the system level, with risk adjustment as needed for demographics, case severity, and social determinants of health.

Principle Five addresses primary care features such as access, coordination, patient and family engagement, and care management.

The sixth principle calls for health IT redesign, encourage automated data collection and quality measurement while eliminating the need for self-reporting. I’m not thrilled that AAFP left this one at the bottom of the list as it is so critical to the success of primary care moving forward.

I’m working with a couple of vendors that are taking existing EHR data and using it in novel ways at the point of care, focusing on making life easy for clinicians and improving outcomes for patients. It’s been refreshing to see their enthusiasm, but the rubber will meet the road as they begin integrating with EHRs since their products essentially replace clunky or non-existent EHR features that clinicians need and want. The future of healthcare IT is bright and there are many challenges to come, a good thing since unless I win the PowerBall, I’ll be here for a while.

My curiosity was piqued by a pre-HIMSS email for Edgility, a vendor that claims to be “bringing situational awareness to healthcare.” It’s always interesting when a phrase can be used in multiple contexts, and seeing “situational awareness” my mind went directly to my most recent self-defense class. If you’ve ever spent time with military or law enforcement people, you’ll know what I mean about situational awareness. You will have had to sit where you don’t want to sit so that someone else can have their back to the wall.

For those of you who might not be preppers, here’s a quick summary of how others think of the phrase. It’s amazing how the 10 tips provided in the article directly apply to what we do in healthcare IT: learn to predict events; identify elements around you; trust your feelings; limit situational overload; avoid complacency; be aware of time; begin to evaluate and understand situations; actively prevent fatigue; continually assess the situation; and monitor performance of others. Even the ad for the bug-out bag applies, knowing how hospital staffers coped with working during recent natural disasters.

One of the sessions that caught my eye for HIMSS is one covering a Centers for Disease Control project that is digitizing infectious disease guidelines to work within EHRs. The team’s goal is to create digital algorithms and guidelines that could be easily consumed by various EHR platforms, shortening the time that it takes to implement that kind of decision support within the EHR. In our global environment, there’s a need to stay vigilant about emerging diseases. My dermatologist’s office still has a sign up advising patients to let staff know if they’ve traveled from West Africa, even through it’s been years since Ebola was in the US.

It’s also important to be able to use guidelines for diseases that we see more than we should, such as the current measles outbreak. If this topic floats your boat, you can join me on Tuesday the 12th at 3 p.m. in room W311E.

Neurodiagnostics vendor Oculogica, Inc. recently received FDA approval for its EyeBOX concussion detection tool. It can be used on patients from five to 67 years old and employs eye-tracking technology to identify patients with suspected concussion. I regularly see concussions in clinic and not just from football any more. Some of the worst I’ve seen have been from water polo and field hockey. The EyeBOX solution doesn’t require documentation of a testing baseline for athletes and isn’t easily gamed by someone who is eager to return to play, unlike some of the alternatives.

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I’m engaged in a health exchange project that happens to include a client using the Greenway Health EHR, so you can bet there was plenty of buzz today about the payment the company will be making to settle recent False Claims Act allegations. One of the key allegations was Greenway’s modification of the software that is used in the certification testing so that it appeared that Prime Suite had certain capabilities. News flash, folks — it’s not just Greenway. I suspect there are plenty of other vendors out there who cooked their software a bit to either pass certification more easily. I’ve seen functionality that was included for testing that was later implemented in a materially different way for the rollout to actual clients.

The only way to truly protect consumers is to require testing on off-the-shelf products by independent testers, not a dream-team of vendor employees who know how to grease their way through the defects. This is similar to what we saw with Volkswagen sneakily modifying test builds for their diesel vehicles. I’ve already heard other vendors bad-mouthing Greenway and all I’ll say is that people in glass houses shouldn’t throw stones.

I’ll be headed to sunny Orlando soon, so this will be my last post until HIMSS starts on Monday. Watch this space for all the news, rumors, party updates, and great shoes.

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Curbside Consult with Dr. Jayne 2/4/19

February 4, 2019 Dr. Jayne 1 Comment

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

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

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

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

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

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

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

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

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

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

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

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

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EPtalk by Dr. Jayne 1/31/19

January 31, 2019 Dr. Jayne 2 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 1/28/19

January 28, 2019 Dr. Jayne 1 Comment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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EPtalk by Dr. Jayne 1/24/19

January 24, 2019 Dr. Jayne No Comments

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

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

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

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 1/21/19

January 21, 2019 Dr. Jayne 2 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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EPtalk by Dr. Jayne 1/17/19

January 17, 2019 Dr. Jayne No Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 1/14/19

January 14, 2019 Dr. Jayne 2 Comments

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

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

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

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

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

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

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

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EPtalk by Dr. Jayne 1/10/19

January 10, 2019 Dr. Jayne 2 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 1/7/19

January 7, 2019 Dr. Jayne No Comments

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

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

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

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

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

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

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

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

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

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

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EPtalk by Dr. Jayne 1/3/19

January 3, 2019 Dr. Jayne 1 Comment

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

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

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

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

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

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

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

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

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

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

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

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

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

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