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Curbside Consult with Dr. Jayne 1/11/21

January 11, 2021 Dr. Jayne 1 Comment

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

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

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

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

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

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

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

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

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

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

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

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

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EPtalk by Dr. Jayne 1/7/21

January 7, 2021 Dr. Jayne No Comments

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

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 1/4/21

January 4, 2021 Dr. Jayne 1 Comment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 12/28/20

December 28, 2020 Dr. Jayne 1 Comment

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

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

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 12/21/20

December 21, 2020 Dr. Jayne 1 Comment

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

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

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

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

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

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

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

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

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

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

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

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

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EPtalk by Dr. Jayne 12/17/20

December 17, 2020 Dr. Jayne 1 Comment

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

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 12/14/20

December 14, 2020 Dr. Jayne 18 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/10/20

December 10, 2020 Dr. Jayne No Comments

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/7/20

December 7, 2020 Dr. Jayne 2 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/3/20

December 3, 2020 Dr. Jayne 2 Comments

I’ve received quite a bit of feedback and comments on my recent Curbside Consult that addressed ongoing usability issues in EHRs. Some of the comments came with questions, so I thought I’d answer them here because the answers raise other interesting items for discussion.

The first question was around why my organization controls access to the vendor’s documentation and/or why I cannot access it because I’m a physician informaticist.

In my clinical practice, I am not a physician informaticist. I’m a frontline ER/urgent care provider, just like the other 100-odd providers who are employed by my organization. I play the role that the majority of physicians and healthcare providers in the US also play – we are simply gears in the machine. It has been made abundantly clear that our collective role is to see patients, follow organizational directives, and not ask a lot of questions. This is not unique to my organization, but also applies to many emergency physicians around the country, a good portion of whom are employed by third-party companies and not the hospitals or facilities they serve.

Back in the days before COVID, I made a couple of suggestions about the EHR – implementation of features that I know must exist because they were required for 2015 CCHIT Certification and this is a Certified EHR – and was told that it was not my concern and that leadership needed to focus on operations and not chasing down issues with the EHR. They apparently don’t see the links between happy users and productivity or good workflows and patient safety. Like many other mid-sized organizations, they do not see value in paying a physician good money to perform non-clinical work. Our EHR is maintained by a paramedic who is “into computers” with occasional input from the chief medical officer. I see this mindset all across the US, including at a major academic institution where I was on faculty.

Many institutions still do not see value in clinical informatics. This lack of understanding is the primary reason I became a consultant. Don’t think you need a CMIO? Fine, hire me for an engagement and I’ll convince you why you need one more than ever. To those who work at hospitals and health systems that place value in clinical informatics leadership, be thankful. It isn’t like that everywhere. Culturally, my organization would rather curl up and die than bring in a consultant that might tell them they’re not perfect, because they think they are the best and most tremendous care delivery organization on the planet and say it regularly in pep talk emails to the staff. Hyperbole is alive and well there, as is penny pinching.

Another question addressed why I won’t name an EHR when I talk about its flaws.

As a consultant who has seen the good, bad, ugly, and downright horrific, I am reluctant to throw a vendor under the proverbial bus for the sins of its clients. I used to do subcontract consulting work for a major EHR vendor. They would send me out independently to troubled clients. My only responsibility was to figure out what the issues were and craft recommendations that would help get the clients to a happier and more productive place.

Invariably, shadowing one or two patient visits would reveal a poorly-configured EHR that didn’t take advantage of the vendor’s latest features. Some clients were so far behind on upgrades they were no longer able to receive support, but they were unprepared to even consider an upgrade for various reasons. Operational and leadership pathologies contributed to never being able to optimize the EHR. I’d love to be able to get a demo-grade copy of our EHR to know how good or bad it isn’t, but until I know it’s the EHR’s fault and not that of my myopic leadership, I’m not going to blame the vendor. If I had unfettered access to a general release copy of the EHR that I knew had not been butchered or gutted by a client, I would be more than happy to name and shame.

I enjoyed David Butler’s comment about “God came in and created Intelligent Medical Objects.” IMO is one of my favorite add-ons for EHRs that don’t already have it. My current EHR as implemented does not leverage IMO. There is some kind of mapping among ICD-10 and SNOMED and ICD-9 (which we still have to use for certain work comp cases), but it’s mediocre at best.

I also enjoyed the comment from AnInteropGuy talking about systems that still ask if someone has had overseas travel, since that’s currently a somewhat moot point. I recently had to take a family member for dental care and assisted them in filling out their COVID pre-screening. Question #1 was, “Have you recently traveled to China or traveled on a cruise ship?” I kid you not. Those questions are so March 2020 and indicate a vendor who can’t be bothered to stay current or a client who refuses to upgrade.

Thanks to all who commented or reached out by email to either Mr. H or me. I enjoy hearing from readers and being able to understand where you’re coming from.

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Many of my physician colleagues are taking all kinds of unproven supplements — including aspirin, melatonin, zinc, and vitamin D — in an effort to either stave off COVID or reduce its severity should they become infected. To be honest, healthcare providers in my area are dropping like flies. I strongly suspect lack of appropriate PPE. Some nurses have been wearing the same N-95 masks since February because their hospitals say their role doesn’t demand anything more than a surgical mask even for COVID-positive patients, and even the best-provisioned of us may get one new mask a week despite the fact that the new CDC recommendation says masks should be discarded after five “donning” cycles, which equals one day if you eat lunch and hydrate a couple of times during your shift.

A few of my more fringe colleagues are also taking prescription drugs like ivermectin (which will also keep them free of heartworms and cat scabies) because there are a couple of papers that say it might be a good idea. I’m personally on board with a new study that links consumption of chili peppers to better midlife survival.

The research was presented at the virtual American Heart Association 2020 Scientific Sessions. It concludes that higher intake of any type of chili pepper was associated with fewer deaths from all causes (including cardiovascular disease and cancer) during a seven- to 19-year follow-up in middle-aged adults. As any good student of the middle school science fair can attest, correlation does not equal causation, but at this point as a physician looking down the barrel of a rampant and seemingly unstoppable pandemic that many in the US still believe is a hoax, I’ll take any positive thoughts I can get.

Having spent time pursuing my studies deep in the heart of Texas, I became a fan of the chili pepper. Since then, I’ve been on enough camping trips to know that a splash of hot sauce can help overcome many a bad meal. As an added bonus, daily consumption will also tell you if you still have your sense of taste and smell and whether you need to take your “essential worker” self for a COVID test, since many of us are exposed regularly but never tested.

What’s your COVID prevention regimen? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/30/20

November 30, 2020 Dr. Jayne 8 Comments

A recent study looked at the idea that including a patient’s headshot in the EHR could reduce order entry errors. Although providers typically place orders on the correct patient greater than 99.9% of the time, researchers wanted to address the remaining 0.1%. The study was performed in the emergency department at Brigham and Women’s Hospital over a two-year period. They concluded that “wrong patient” orders were 35% lower for those patients who had a photo in the EHR compared to those who didn’t.

Although I’m supportive of the concept, I’d like to offer my own shortlist of solutions for error reduction in the EHR. Unfortunately, all of these were scenarios I’ve encountered in the last few weeks seeing patients. For the ones that are specific to the EHR (as opposed to operations or staffing), I’m not sure if the issue is truly caused by the EHR or by my group’s implementation of it. Because they so tightly control access to the vendor’s documentation, I have no way of knowing.

Medication Order Entry

Formularies should be configured to only support appropriate routes of administration. For example, in my EHR, if I select a medication to be prescribed to a pharmacy, I’m limited to the routes that are appropriate for the drug. Eye drops only display “ophthalmic,” oral medications only display “oral,” skin creams display “topical,” etc. It’s physically impossible for me to accidentally tell a patient to take their amoxicillin tablet topically unless I personally type it in the free text notes to pharmacy box, and even then, the pharmacy is going to catch it. For our in-house medications, however, some of them have options that aren’t appropriate, such as an IV push route of administration for drugs that should never be administered that way. It’s easy to click the wrong button, but removing the button would make the error impossible.

Similarly, doses should be hard coded so you can’t goof them up. If the office protocol is to prescribe famotidine 20mg IV every single time and to never use a different dose, why are we presented with a free-text field where we have to hand type it every time? We also have an issue where the in-house prescribing screen has navigation issues. You can’t tab from field to field, but rather have to move your hand back and forth from the mouse to the keyboard, which increases the chances that you might accidentally type “30” or “10” rather than “20” in the field if you’re in a hurry.

Orders should also be linked to avoid errors of omission. For example, if I’m ordering a liter of normal saline for IV hydration, I shouldn’t also have to order an IV catheter. I guarantee no one is going to try to do a straight venous injection of saline – of course they’re going to use an IV catheter. The system should also default timed infusions where appropriate. If the practice requires all infusions to be administered for at least 31 minutes in order to play the CMS coding game, then why not default 31 rather than making each of us type it every time?

Discrete Data Fields Should Be Appropriately Discrete

I cringe every time I have to document vital signs in our EHR. Blood pressure is a single field and requires the user to type the “/” in the middle and has no limitation on the field size. If my tech is having a bad day, I can get things like “180/1000” and the system doesn’t bat an eye (although it does flag it in red, at least). Someone at the vendor must have missed the memo on usability and not having a color change be the only indicator of an alert, though, because there is no other flag on the screen.

Especially for something like a blood pressure that you might want to graph or trend, the numbers should be captured separately, and the fields should be limited to reduce the risk of nonsense data entry. We have similar issues with height fields that aren’t configured to block nonsense entries. If someone doesn’t notice there are separate fields for feet and inches, you end up with patients that are 67 feet tall rather than 5’7” or 67 inches. Don’t get me started on our lack of use of the metric system with pediatric patients, which is the gold standard trained at most academic medical centers.

Use Technology to Assign Diagnoses That Make Sense to Both Provider and Patient

I’m a huge fan of systems that map ICD codes to patient-friendly and clinician-friendly terminology. Patients don’t want to see “R42: Dizziness and giddiness” documented on their charts. They want to see “vertigo” or “dizziness” or “lightheadedness” as appropriate with the ICD code behind the scenes. This is a pretty straightforward example, but there are dozens of wild and wacky codes and descriptions out there. Physicians hate it and I’m sure other clinicians do too. Patients end up with the wrong diagnosis on the chart when the provider struggles to find the correct one. Kudos to the IT folks who installed “the good stuff” technology wise to prevent this issue.

Use Technology to Keep Up with the Times

My EHR still does not have patient instructions for COVID. It’s ridiculous at this point. I diagnosed my first patient eight and a half months ago.

Reduce or Eliminate the Need for Multi-tasking Behaviors

This isn’t an EHR issue per se, but it’s the root of many of the errors we see. Clinicians need to be supported by their organizations and not expected to see patient volumes that are unsafe. Looking back to the pre-COVID world, my organization placed constant pressure on us to make sure that more than 95% of our patients were treated and released in under an hour. Sometimes that meant having one provider trying to juggle care for up to 15 patients depending on the number of rooms at the clinic. This can only lead to disaster depending on the experience of the clinician and the acuity of the patients’ issues. All staffing is driven by dollar signs, however, regardless of where you work.

One good thing that has come out of the pandemic is that they’ve capped the number of patients that can be roomed at a time based on the number of support staff, which means I rarely manage more than six patients at a time. It’s been a godsend and I can’t help but think it’s helped reduce errors, but at times it can still be unrealistic, especially when the patients are really sick and have a lot of labs and tests to manage. I have no idea whether those caps will stay in place as the pandemic eases, but I’m hopeful.

What error reduction strategies has your organization employed, or what seems obvious but hasn’t yet been implemented? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/23/20

November 23, 2020 Dr. Jayne No Comments

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The Center for Medicare & Medicaid Innovation (aka the CMS Innovation Center) announced the list of participants in the Primary Care First initiative this week. The program was delayed due to a variety of issues prior to the pandemic, which really pushed it back. It’s finally slated to start on January 1, 2021.

I wonder how the selected participants feel about having roughly 40 days to get everything in place? Most of them have been working on other initiatives that share the same goals as this program for some time, but it’s an entirely different thing to actually get a new program ready to launch in your organization. Trying to do so in what most people are experiencing as the largest peak of the pandemic is yet another level of pain altogether.

What is Primary Care First? It’s been so long since I talked about it that many of us have probably forgotten. It was designed as a voluntary alternative payment model slated to “reward value and quality by offering innovative payment model structures to support delivery of advanced primary care.” The program is supposed to last five years. More than 900 primary care practices were selected and there are 37 identified regional partnerships with commercial, state, and Medicare Advantage plans. Practices had to be in an area with a regional partner in order to participate, which excluded a good chunk of the country.

The program changes the payment structure for patients in participating plans, with the idea that even though not all the patients in the practice may be covered by one of the partner payers, that the practice would effectively up its game in delivering the same level of high-quality primary care services to all patients.

In exchange for performance-based payments and reduced administrative burdens, practices agree to assume financial risk as they try to reduce the total cost of care. There is also a so-called “seriously ill patient” option for practices that treat high-need, seriously ill patients who don’t currently have a primary care provider.

Overall, the model is supposed to revolve around patient-focused care and a high level of care coordination. The reduced administrative tasks are supposed to free providers to spend more time with patients. The program is also designed to “foster practitioner independence by increasing flexibility for primary care, providing participating practitioners with the freedom to innovate their care delivery approach based on their unique patient population and resources.”

Practices are scored based on clinical quality and patient experience measures which include: a patient experience care survey, controlling high blood pressure, diabetes hemoglobin A1c control, colorectal cancer screening, and advance care planning.

I’m sure the practices that applied many months ago had no idea where we would be come January 1, and I wonder if many of them might try to opt out. The final selection of 900-odd practices is quite a way off from being representative of the roughly 210,000 primary care physicians in the US. I’m not even sure, given some of the other variables that were involved in selecting the participants, that the cohort will be able to generate the statistical power needed to prove whether its outcomes (clinical and financial) are truly better than other care delivery paradigms. These practices have been at least dipping their toes in the waters of value-based care for years, with many of them being mostly submerged.

The list of payer participants is dominated by Humana, with a handful of other plans and a sprinkling of Blue Cross / Blue Shield players. Looking at the practice list, it’s a little tricky trying to tell who is who because the participants are mostly listed by the name of their brick and mortar entity, which may not portray the health system ownership behind them. I learned about these naming relationships the hard way: when I was employed at a practice owned by Big Hospital System, they were keen on each practice having its own brand, which wasn’t always the greatest idea when they upcharged you for customizing various things with the practice name versus just being able to say “BHS Medical Group” in your outbound reminder messages, etc.

A couple of the big players show up with a handful of practices each: AdventHealth (formerly Adventist), Ascension, Baptist Health, Beaumont, Cambridge Health Alliance, Cedars-Sinai, Cleveland Clinic, John Muir Physician Network, Temple Physicians, Virtua Primary Care, and Warren Clinic. The University of California has the most participation with 39 sites, and OhioHealth is the runner up with 26 locations. My state isn’t part of the identified Primary Care First regions, so I won’t be able to get very many in-the-trenches stories from regional peers, but I did see at least four of my former clients on the list. Hopefully my contacts are still working there and are willing to keep me posted on how things are going.

Even for the practices with the most value-based care experience, trying to launch this program during a surging pandemic will be key. Colorado is a participating state, and recent reports estimate that 1 in 49 Coloradans are COVID-positive right now. Practices that are reeling with those kinds of numbers are going to be hard pressed to spend time preparing to embrace prevention and management of chronic diseases, which are certainly being exacerbated by the pandemic.

In the urgent care space, I see so many patients who either can’t get in to see a primary care physician or whose physicians have frankly abandoned them. My friends in telehealth report dramatic increases in the number of patients requesting visits for COVID-like symptoms. There’s even a surge in people who have had COVID tests at drive-through clinics but who are struggling to reach their primary physicians and are reaching out to telehealth providers to get documentation that they meet CDC guidelines to return to work.

I wish the best for the Primary Care First practices. We need to bolster our primary care and public health infrastructures – of that, there is no doubt.

We had a conversation at urgent care yesterday around what the health care system will look like in the US after it’s been completely decimated by COVID. This was right after we were notified that four providers had been diagnosed the day before, including the one who had been sitting at my workstation less than 12 hours previously. The nearly 100 patients I saw have no idea what kind of bills are coming their way, especially if they are positive and need hospitalization. I see a tsunami of medical bankruptcies on the horizon. If the Affordable Care Act is repealed and more people have to pay out of pocket for preventive services, I don’t see them having tremendous cash reserves to do so, and this could drive even greater healthcare expenditures down the road.

I’ll continue to follow the adventures of Primary Care First and report back with what I find. If you’re involved in the initiative, I’d love to hear from you. Until then, stay healthy, stay safe, and stay six feet back.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/19/20

November 19, 2020 Dr. Jayne 6 Comments

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Although telehealth has certainly been helpful for many organizations trying to boost patient access during the COVID pandemic, a recently study shows that it was not fully able to offset the loss in available patient care slots. Overall, telehealth was able to help organizations recoup about 40% of the decline in ambulatory office visits. Not surprisingly, patients from low-income ZIP codes and racial / ethnic minorities were less likely to use telehealth services than those from more affluent areas.

The study looked at more than 6 million private payer claims, but there’s still a gap in understanding visits for patients with public payer coverage (Medicare, Medicaid) as well as those telehealth visits that may have occurred but not been billed since providers were struggling to understand how to get paid for telehealth.

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Office visits were most dramatically affected, but vaccine administration, mammograms, colonoscopies, and HbA1c tests were also reduced significantly.

I have to admit that I was part of that mammogram cohort and didn’t end up getting my semi-annual imaging until August. The facility where I usually have my mammogram didn’t bother to send me a reminder that I was overdue or let me know when they had resumed services, so it was completely on me as a patient to make sure I caught up. Good thing I did before COVID spiked and services were limited again.

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Sometimes the titles of articles say it all, and this piece in JAMIA definitely caught my attention: “Unveiling the silent threat among us: leveraging health information technology in the search for asymptomatic COVID19 healthcare workers.” The article reviews the National Institutes of Health Clinical Center’s approach to rolling out an Asymptomatic Staff Testing System. The Center is the 200-bed hospital arm of the NIH that delivers patient care and research support. Due to the type of research being performed, over 60% of the patients admitted are immune compromised either from an underlying health condition or an experimental treatment. This underscores the need to deliver continuous surveillance of healthcare workers and prompt identification of those who may be positive for COVID-19.

One of the program’s goals was to deliver weekly testing for eligible healthcare workers. They used existing EHR and other systems to identify workers and allow them to self-schedule their testing appointments. Automation was prevalent throughout the process, including check-in, specimen tracking, and laboratory interfaces. As the process was designed, they “identified the difficulty in following the organization’s formal software development process under the time requirements” and mitigated this by using existing systems where possible. The whole process from task identification to early adoption was only four weeks, which would be a near impossibility for many healthcare organizations.

To determine how successful they were, the team looked not only at the primary outcome of identifying infected workers, but also surveyed the healthcare worker customers on the process as well as the facility process owners. I wish I saw more organizations follow this approach with a 360-degree evaluation where they pay attention to all the feedback, not just internal customers such as infection control departments or human resources. One of the findings was a need to ensure that patients / workers set up accounts on the patient portal, which is a common challenge among healthcare organizations.

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I always get a kick out of articles that cover poor password management habits, and this year’s list shows that the more things change, the more they stay the same. Review of data from hacking forums and the dark web revealed that the most commonly used passwords in the US include “password” and “123456.” The latter (and the multiple variations similar to it) shows that it’s not just users behaving badly, but vendors who should have logic behind their password requirements that would disallow such sequential numbers. Humorous options in the top 20 include superman, iloveyou, football, and letmein.

Although some vendors may be complicit, the other side of this coin is the vendors or entities that make ridiculously complicated password requirements or rules for frequent changes. These approaches have been shown in some studies to actually increase security risk, as users may be more likely to write passwords down.

One of my clients falls into this bucket. They make you change your password every 30 days, and the requirements include upper case, lower case, numbers, symbols, and a length of at least 10 characters. Maybe their goal is to push people to use randomly generated passwords coupled with a password manager, but that’s not always practical when using shared workstations. Regardless, I wasted half an hour of their tech’s time this morning (and a billable 30 minutes of my time) dealing with an expired password after I missed the prompt to change it.

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Big thanks to the gals in my life who sent a couple of recent care packages. Jenn knows my love for putting my feet up with a good book and surprised me with the world’s softest socks, along with energizing foot lotion and an Amazon gift card, which I promptly swapped for a new read. There were also some addictive gummy bears, but I’ve had to tuck them in my snack drawer lest I eat the whole bag. My favorite revenue cycle informant, Bianca Biller, sent the famous “Bionic Apple” from Merb’s Candies in St. Louis. Let me tell you, this thing is a Granny Smith apple covered with the smoothest caramel you’ve ever seen and rolled in chopped pecans. Did I mention it was the size of a softball? It made an excellent lunch while I enjoyed a webinar presented by some of my favorite folks.

For your friends and colleagues at the tip of the clinical spear, the next few months are likely going to be some of the worst times they’ve ever experienced professionally. I’m thankful for my friends and their support. Hopefully my newly energized feet will give me a bounce as I head back to the trenches tomorrow.

What are the best pick-me-ups you’ve ever received? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/16/20

November 16, 2020 Dr. Jayne No Comments

We’ve officially crossed into COVID hell in my part of the country.

The largest health system just announced the rescheduling of elective surgeries at all 15 of their hospitals, starting Monday and extending for the next eight weeks. Employed physicians have been instructed not to travel and must be ready to return to the hospital within 24 hours when summoned. Operating room capacity for scheduled cases is being reduced by upwards of 30% to allow for redeployment of staff to other areas. Another system has redeployed their operating room nurses to the medical/surgical floors and has brought in travel nurses to staff the ORs, but not everyone can find enough travel nurses even if they can afford them.

I imagine this is what it felt like to be in New York City in the spring. It doesn’t feel like we learned anything from their suffering because we’re now officially in the same boat.

Our urgent cares have tried to reduce volumes by limiting the number of COVID tests we do for patients who are asymptomatic, but it’s not much help since we’re in a phase where nearly every patient has symptoms. Schools are moving from in-person and hybrid models back to fully virtual, and parts of the state are headed back towards stay-at-home and safer-at-home orders.

My staff is working harder than ever, but they are most definitely at the breaking point. Sometimes I feel guilty about being only part-time for in-person care, and then I remember the work that I’m trying to do with my clients to better manage patients without the need for in-person encounters and their associated exposures.

Here are my free consulting tips for practices trying to figure out how to manage patients in the outpatient space more efficiently, since we’re all trying to do more with less. These are things that I have been recommending to practices for years, but for some reason, they still are trying to do things the hard way:

Refill management

If your system has technology to help with refill management, use it. If you don’t, consider a solution like Healthfinch to help tame the beast. If you don’t have technology, consider creating a policy that allows delegates to manage refills on behalf of physicians.

I still work with a lot of physicians who can’t let go of the idea that only they can manage refills, and their inboxes are flooded with refill requests. These are usually the same people who aren’t giving refills to their patients to last through the next scheduled visit, let alone to last through the year. I recommend that physicians who struggle with this idea start with one or two health conditions where medication refills are the lowest risk, and let their staff dig in. Make a list of the criteria for refills – this may include a visit within the last 365 days and no overdue labs – and start letting your support staff support you.

Inbox management

I’m a big fan of the “touch it only once” mantra. Use your technology to help you sort your inbox and then work it deliberately by section. If you only have a minute or two, select a lab result to manage or a refill request to manage, not a patient phone call. Don’t go through your inbox looking at things and trying to re-prioritize it over and over. You’ll waste a ton of time along the way.

Set up dedicated time during the day to manage the inbox, or plan to work it before or after seeing patients. Even if you’re used to calling your patients with results, consider leveraging the patient portal or secure texting if patients have opted in for these services. They’re much more convenient for patients and will save you time.

Invest in technology that can free your staff

Practices are still using humans to call patients and ask them COVID screening questions. If your organization has the ability to screen patients through a portal or other tools, use it. If not, there are many cool technologies out there such as Asparia that not only manage appointment reminders, but can help provide a safe arrival experience and triage patients who may need to avoid coming into the office.

You should also maximize the use of digital check-in or other workflows that might be available in your patient portal. For my most recent new patient visit, I uploaded copies of my insurance card and photo ID on my phone before even walking in the door, resulting in a contactless visit. When you save those minutes for your staff, it adds up, and those resources can be redeployed for use with patients who need real-time or face-to-face contact, or to better support you as you embrace telehealth visits.

Don’t be afraid of telehealth visits

With everyone being concerned about COVID and the availability of inexpensive devices for home biometric assessments, you would be surprised how many patients can provide a full suite of vital signs for a telehealth visit. Blood pressure cuffs and thermometers are plentiful, and pulse oximeters are becoming a regular part of the home first aid kit for many families courtesy of Amazon, Target, and other major retailers. Of course, this may vary depending on the patient population served, but I think physicians might be pleasantly surprised if they ask about access to these devices. If the patient doesn’t have one, they might have a neighbor or family member who does.

I’ve been practicing telemedicine for a while now and I’ve found it useful for picking up factors that I might not pick up at an office-based visit, such as fall risks in the home. I’ve also seen full ashtrays on the coffee tables of patients who claim to have stopped smoking, so you never know what you might find. Learn the rules for telehealth billing for your specialty – many specialty societies have published cheat sheets for their members.

Leverage your staff for telehealth visits

Staff can meet with the patient prior to the visit and update histories, document vital signs, flag medications for refill, etc. All too often I see the physician trying to do all these tasks even though they would have allowed support staff to do them in the in-person world. Sometimes the technology doesn’t make this easy, but there are ways to work around it to maximize the physician’s time.

Many of these elements go back to something that is so hard for some physicians to learn, and that is that they need to run their practices with everyone working to the top level of their licensure. If you’re lucky enough to have a registered nurse in the office, make sure you’re truly using them to deliver nursing services and not to do things that could be done by a medical assistant, patient care tech, or receptionist. I’ve been hearing the same arguments from subsets of physicians for decades, and if there’s one thing 2020 has taught us, it’s the need to break existing paradigms because “business as usual” is effectively over.

How has your organization tried to streamline the ambulatory paradigm in 2020? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/12/20

November 12, 2020 Dr. Jayne No Comments

My inbox has been bountiful this week, with so many good stories that link to healthcare IT that I just kept flagging items to come back and read later, only to find my entire screen full of flagged emails.

My urgent care is swamped with patients wanting COVID testing, and although there are enough supplies to go around, there simply isn’t enough staff. Since most of our payer contracts require patients to see a physician to document medical necessity for testing, and there’s only one of us at a site, it’s just an endless parade of testing visits. That is, until something acute comes in, and then there is an adjustment as we remember how to see “traditional” urgent care patients again.

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I was excited to see this article in Nature Medicine looking at how fitness trackers might be useful to detect biometric changes associated with COVID-19. I know patients will always want testing “to know for sure” as well as to make sure they can take advantage of workplace policies that require a positive test for paid time off, but it would be nice to have other tools that patients could use to help risk stratify themselves. That way they could figure out if they really need to stand in line for hours for a test at an urgent care center or if they could do a video visit with their primary physician and arrange testing at the health system’s drive through tent in a day or two.

The study Digital Engagement and Tracking for Early Control and Treatment (DETECT) study looked at data from more than 30,000 individuals from all 50 US states. They found that adding sensor data to symptom-based models improved their accuracy. Regional health officials in my area are lamenting the inability for temperature- and symptom-based screeners to identify infected patients, so at this point anything would help. Our schools just went back in person, and within 24 hours, were sending people home to quarantine due to exposure. The idea is that using device data could help identify clusters before infection spreads. That would have been useful in the aftermath of a recent parent-approved Halloween party thrown by some local teens, where over 200 high-schoolers attended.

A recent article in JAMIA looked at the advantages of human scribes compared to other options, particularly looking at patient safety aspects. They used a multidimensional sociotechnical framework to look at how different health systems use scribes. The dimensions were technical, environmental, personal, and organizational; 81 individuals were interviewed, including scribes and clinicians. They were asked about why they chose to use scribes as well as the background and training of scribes, along with pros and cons of their implementations.

One interesting finding was that since many health systems rely on college students for scribing, that geography is a factor in whether a practice can find a good scribe or not. That would definitely underscore why virtual scribe solutions are popular, since not every town has college students, let alone highly-motivated pre-medical or nursing students who would make good candidates.

Respondents did note a preference for real-time scribes versus using voice recognition software after the fact. The turnover in good scribes is an issue that was also validated in the research, and I experience that every year when medical school and physician assistant school acceptances are issued.

Fortunately, our scribe program staffs ahead of those transitions but it’s always a challenge to have the new scribes ramped up prior to flu season. You can bet that with COVID they’ve definitely earned every bit of experience they claim. I’m still waiting to hear from any readers (or friends of readers – come on, help a girl out here) who might be using one of the Ambient Clinical Intelligence solutions offered by Nuance or one of the other voice recognition vendors. There was a great deal of interest in the system at HIMSS a couple of years ago, but I have yet to encounter anyone actually using it in the wild.

The Journal of the American Medical Association tackled a weighty topic recently with its piece on “Science Denial and COVID Conspiracy Theories: Potential Neurological Mechanisms and Possible Responses.” Although this was a “Viewpoint” article rather than a research article, it has some interesting points. The first is the relationship between neurodegenerative disorders such as dementia with the adherence of an individual to false beliefs. Other psychiatric disorders include similar manifestations, such as delusions of grandeur and paranoia. The author proposes that false beliefs form due to faulty sensory information and impairment of brain systems designed to evaluate thoughts and beliefs.

Until reading the article, I had forgotten about Capgras syndrome, where certain dementia patients believe that a loved one has been replaced by an impostor. He explains the mechanisms by which that occurs as well as other delusions associated with dementia. He goes further to discuss the role of social media in amplifying conspiracy theories and other misinformation.

Based on what we know about dopamine and the addictive nature of social media, I can concur with his assertions. Mix in some low science literacy and we wind up where we are, with patients who legitimately believe that COVID is being spread by 5G cellular towers. He calls on the medical community to “mount systematic efforts around science education beginning in childhood and across the lifetime.” It’s a nice idea, but right now many of us are simply too exhausted from treating COVID patients.

From the Hall of Shame: Several towns along the east coast trusted a private physician to set up COVID testing clinics, but he proceeded to over test while billing exorbitant rates. Some patients were charged upwards of $1,900 and he was also recommending daily telehealth visits for a separate fee. Of course, his game wasn’t discovered until the bills started hitting, which typically takes at least 30 days for most patients with health insurance. Towns were effectively duped, with promises of a speedier economic recovery through greater testing. They in turn promoted the services, and then the physician took advantage.

Seems like a pretty clear ethics violation and I hope the relevant licensing boards take note. The physician is clearly delusional, stating that he tested for all kinds of other respiratory viruses because “just testing for coronavirus is one of the most dangerous things you could do… it is crystal clear that mentality is bad for public health.” I’d argue that unnecessary testing is also bad for public health, as is medical bankruptcy. People like him are the reason patients don’t trust the medical establishment. It takes far too many good experiences to undo the damage caused by a bad apple like this one.

Have you received a balance billing statement for COVID testing or related services? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/9/20

November 9, 2020 Dr. Jayne 6 Comments

It’s been a busy week in the clinical trenches. If you had ever told me that I would see nearly 150 patients over two urgent care shifts, I would have told you that you were crazy. Nevertheless, it’s the world we’re living in.

I’m continually impressed by the ability of my team to dig down deep, but we’re starting to push hard against leadership for some kind of daily cap on the number of patients we can see. As an urgent care, we’re not subject to the same rules as hospital emergency departments, which means we can turn people away. It’s not ideal, but neither is the reality of 12-hour shifts turning into 14, 15, or 16-hour ones, especially when staff is scheduled to see patients again the next day with less than eight hours turnaround time.

I’ve asked to cut my schedule down for our next scheduling block, but it doesn’t start until January. I have a sneaking feeling they’ll give me the same number of shifts regardless, because I don’t see us becoming less swamped when the projections show that COVID cases will likely be at their peak during the third week of January.

I’m keeping myself grounded with informatics projects as way to try to preserve my sanity. A couple of articles caught my eye, because even with a pandemic upon us, clinicians are still dealing with heavy burdens of non-clinical work and technical systems that don’t always deliver the support promised.

This piece in the journal Pediatrics highlights the fact that pediatricians are averaging nearly seven hours of EHR use each day. Researchers found that EHR documentation and review of patient records totaled 6 hours, 40 minutes of the time that the EHR was in use. That’s an average of 16 minutes per visit, with approximately 12% occurring after hours. Researchers looked at EHR log data from January to December 2018 for all pediatricians and adolescent medicine physicians who practice in the 2,191 health care organizations represented in the Cerner Millennium EHR Lights On Network database. This encompasses over 20 million outpatient encounters by 30,000 physicians.

The study is interesting because researchers could look at the variability in time as it compared to optimization efforts across similar EHR platforms, as well as roles and responsibilities for data entry and the differences in implementation and training across organizations. I’ve seen wide variability across organizations’ use of the same platform that can lead to “make or break” type workflows. The quality of training physicians receive also seems to be directly proportional to their success with the EHR and whether they succeed in the system or struggle. Other interesting facts from the study:

  • More than 94% of pediatricians in the US use an electronic health record.
  • Active users were defined as those who logged into the system with activities recorded <45 seconds apart; clicked  the mouse at least three times per minute; completed at least 15 keystrokes per minute; and who had mouse movement of greater than 1,700 pixels per minute.
  • After-hours use was defined as that between 6 p.m. and 6 a.m. local time on weekdays and anytime on weekends (which may not accurately reflect “non-office” times for those working half days or coming in early to work on the EHR).
  • Physicians practiced at various locations: integrated delivery networks (34%), regional hospitals (30%), independent physician groups (22%), and academic medical centers (11%).
  • The physicians monitored on the Network represent a 44% sample of US pediatricians based on comparison with the 2018 American Board of Pediatrics database.
  • Pediatric rheumatologists spent much longer in the EHR at 30 minutes per encounter.

The study was limited by the fact that it only looked at physicians on Cerner Millennium. It also excluded other provider classes, such as physician assistants or nurse practitioners. The authors conclude that a need exists to “continue to identify and eliminate unnecessary and low-value activities across the entire physician workflow.” I don’t think anyone would disagree with that.

The second article, from JAMA Network Open, looked at the impacts of e-consultations on the workload of primary care providers. The authors looked at Veterans Health Administration primary care providers who were using e-consultations to interact with subspecialists. Researchers interviewed 34 clinicians who had experience with e-consultations in 2017. Although primary care clinicians felt that the process improved clinician communication, they also felt that the burden for additional diagnostic testing and follow-up was shifted from the subspecialists to themselves. They also thought that they were being asked to diagnose and manage conditions that were not only outside their comfort zone, but possibly outside their scope of practice.

The study was limited by its small sample size as well as its qualitative approach, and researchers were not confident that participants were objective. Participants also noted the need to track and follow up on e-consultation requests as a barrier, which seems tangential to the actual consultations themselves, although still important. Participants also felt that the templates that were  used to document were not user-friendly and/or included required fields that were not relevant to care. I love qualitative research and appreciate the fact that the authors included actual respondent quotes in the article. The authors conclude that various workflow improvements could be made in tracking and documentation systems that would help the primary care clinicians.

However, they didn’t seem to mention the need for further analysis on the other end of the e-consultation request. What do subspecialists think about it? What kind of burden does it add to their day? Are there other modalities, such as virtual visits, that deliver the same outcome for the patients (including decreased time to subspecialist consult) that would be more acceptable all the way around? As in many studies, more research is needed, but I hope next time they look at both sides of the workflow.

These articles underscore the need for those of us on the healthcare IT front to continue to do what we can for better outcomes for patients and clinicians alike. We also need to feel empowered to challenge operational and clinical teams to address dysfunctional workflows that might not be helped by technology and to help those teams think through the idea that tech might not be needed to save the day.

Have you been involved in the e-consultation process at the VA? What’s your take on it? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/5/20

November 5, 2020 Dr. Jayne No Comments

Our friends at the Massachusetts Institute of Technology have created a cough detector that claims to identify COVID-positive patients even if they do not have symptoms. The system uses artificial intelligence models to identify characteristics of cough sounds that can’t be detected with the human ear. Researchers propose embedding the technology in cell phones as an early detection device. The work leverages technology that is already in process for early identification of Alzheimer’s disease. Researchers note that AI algorithms can identify various factors from a cough, including a person’s gender, language fluency, and emotions.

Researchers used thousands of recorded coughs as well as voice recordings to train the model. In the COVID analysis sample of 1,000 patients, the model was accurate for 98.5% of COVID-positive patients, including 100% of asymptomatic patients. They acknowledge that the algorithm is no substitute for proper testing, but see it as a tool that could differentiate between healthy and unhealthy coughs, alerting people to the need for testing.

I started a new project this week with a client whose attempts at value-based care delivery were in shambles. They had someone on staff who was designated as the manager of quality initiatives. Apparently she would come to meetings and “talk big” about the work she was doing, but actually had a complete lack of understanding of the work that needed to be done in order to drive the quality needle. When the physicians’ contracted health plans would send membership rosters to the practice, she simply stuck them in a binder rather than actually doing anything with them, such as confirming whether the patients on the roster were active patients in the practice or seeing whether they were current on preventive screenings or recommended health services.

In meeting with the practice’s leadership in scoping the engagement, it was clear they didn’t understand some of the basic concepts of value-based care, including the need to understand patient attribution and to reach out to those patients for whom they had been deemed responsible. I felt like we needed to take it back to a 100-level course, so this week began with some educational sessions to explain the basics of attribution and empanelment.

They seemed so surprised to hear that a payer would use claims to attribute responsibility for care that it made me wonder whether they had been completely absent from all discussion of value-based care over the last decade. Certainly they hadn’t been reading the literature that was regularly put out by their specialty society. I’ve found that the American Academy of Family Physicians has done a great job creating materials for physicians, but unfortunately, they can’t force their members to read them.

The empanelment discussion was a good one as well, since it immediately devolved into an argument about how large their panels should be or whether it was acceptable for some providers to have larger panels than others. Fortunately, our engagement includes a subproject to look specifically at physician panel size since their wait times for appointments seem to indicate that their panels are too large. They have physicians who have cut back their hours due to health reasons, but who continue to accept new patients, and the process is creating a mismatch in supply and demand. I’m surprised no one ever recommended that they close panels, but then again by the time I wind up consulting with a practice, usually there has been a series of “things no one ever told us.”

Even though these engagements can be challenging because the client has a lot to learn and I have to figure out how to get them where they need to be without them feeling like I’m completely upending their world, they can be really enjoyable. I’m usually able to make a difference for staff as well as physicians, because staff has often been compensating for overloaded schedules and isn’t experiencing the fulfillment they could be if the practice truly embraces team-based care. The project will be a little slower going than I’d like because we’re doing everything remotely, so there’s not that burning platform of having a consultant on site. It should be a good counterbalance to the grueling months ahead in the land of urgent care.

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I had the opportunity this week to spend some quality time around a backyard fire pit with one of my favorite clinical informaticists. Even though we live in the same metropolitan area, we used to just run into each other at the annual AMIA meeting. Since there aren’t any in-person meetings this year, we made it a point to get together since the scheduling stars aligned to provide us an evening where we were both free.

He has always worked in the academic space, where I’ve been more in the health system and vendor arenas. We still face many of the same challenges, though, including clashes with upper management who don’t always see the value in physicians who work on the technology side. We’re also tasked with helping bridge the gap between organizational leadership and end users who might not understand why applications are implemented in a particular way that best supports organizational goals but might not meet specific users’ expectations.

Both of us have had a lot of job changes in the last several years, and it was good to get his perspective on how the pandemic has (or in many ways, hasn’t) transformed care delivery at his organization. Some things never change, and his practices are still doing manual appointment reminder phone calls and manual COVID screening, which seems to me a shocking waste of human capital. As a clinician, I’d much rather see those staffers redeployed as care navigators, health coaches, or in working with patients who aren’t candidates for digital reminders or screenings, or who have complex situations to navigate such as arranging rides, coordinating with family caretakers, etc.

I enjoyed filling him in on some of the interactions I have with startup companies and how they’re trying to solve various healthcare workflow issues as efficiently and economically as possible. There’s definitely some inertia at his institution, but it would be fun to do a project together some day. Until then, we’ll have to settle for commiserating by the fire, six feet apart.

What new solutions is your organization deploying to handle the next wave of COVID or to prepare for vaccination? Leave a comment or email me.

Email Dr. Jayne.

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