Episode 127: Evolving Your Practice with the Ages

Speaker 1:

You're listening to "Your Practice Made Perfect" support, protection, and advice for practicing medical professionals brought to you by SVMIC.

J. Baugh:

Welcome back to Your Practice Made Perfect podcast. It's no secret that our world is ever changing, and it appears that evolution was kicked into high gear at the start of the COVID 19 pandemic. Emerging technologies, new ways of working in the office, and cyber security are just a few key factors affecting the medical field. In today's episode, SVMIC's Katie Musacchio will take us through some insights, information, and tips from prior episodes to help you navigate your practice in our evolving world. Thanks for being here Katie.

Katie Musacchio:

Thank you, Jay. In prior episodes, SVMIC has had the pleasure of speaking with multiple guests who shared their expertise in areas such as cybersecurity, telemedicine, and technology. I'd like to share with you what we at SVMIC have found to be some of the most insightful tips to take note of and implement into your own practice. In episode 109, Telemedicine Task Force, our host Jay spoke with SVMIC's medical practice services expert Michael Cash on the topic of telemedicine. Let's take a listen to Michael's explanation of how telemedicine has changed during the pandemic.

Michael Cash:

Well, the biggest difference is that payers cover telemedicine during the public health emergency. Prior to COVID, many payers had a site restriction requiring the patient to be in a physician office or hospital setting. There were a few exceptions. Some payers offered a telemedicine benefit to their members via corporate platform, but it was not open access, and a few physicians implemented telemedicine as a self pay service if it was considered a non-covered service prior to COVID. Some patients also access telemedicine as a self pay service to a corporate vendor. While it's important to research state laws, since medicine is regulated at both the state and federal levels, most states have revised laws allowing patients to be treated via telemedicine. In other words, we have the infrastructure in place to continue telemedicine beyond COVID. We'll have to see how payers respond. One argument for telemedicine is that it improves access, decreases cost, and improves the patient experience.

Michael Cash:

On the other hand, some are concerned about increased utilization and quality associated with telemedicine. Prior to COVID, I thought payers were testing telemedicine via limited access. There are legislative efforts at the state and national levels to implement payment parody and require payment payer coverage after the public health emergency. Another thing, providing care across state lines is another issue. Many states require the physician to be licensed in the state where the patient is located at the time of service. During the public health emergency, many states have implemented a temporary waiver allowing physicians to treat patients in other states. However, many states still require the physician to submit a temporary application. The Federation of State Medical Boards list the requirements for each state during the COVID emergency. Malpractice coverage is another issue to consider. Currently there's very little claims history to write premiums for telemedicine, SVMIC covers telemedicine under the physician's existing policy and coverage area.

Michael Cash:

We encourage physicians to notify us if they're seeing patients in other states to make sure that they're covered in that state. Other malpractice carriers may have a separate policy for telemedicine or may have limitations on the telemedicine modalities, advanced practitioner supervision, or scope of service. Furthermore, laws regarding the standard of care may be different across state lines. Some states adopt a national standard, other states have a regional standard. Finally, prescribing controlled substances across state lines should be considered. Physicians are required to have a DEA in each state for prescribing controlled substances. There's federal and state guidelines apply. Many physicians have had negative experiences with EHRs, patient portals and payment reform.

Michael Cash:

Also, there's a portion of the population that's not comfortable with technology. COVID was the catalyst that moved the dial and now we'll have to see if it's here to stay. Prior to the public health emergency I witnessed most states increasing flexibility for telemedicine. Many pairs also expanded coverage, although it had restricted access. Medical schools are implementing telemedicine in the curriculum and residents are becoming more comfortable with the service. It's not appropriate for every situation, but I think it will be an integral part of care moving forward.

Katie Musacchio:

It will be interesting to see how things continue to evolve with telemedicine as we hopefully move out of the pandemic. Dr. Kevin Johnson, a pediatrician and specialist at the Vanderbilt Medical Center in Biomedical Informatics, also spoke with us about the topic of Clinical IT. Dr. Johnson's informative conversation with our host Jay, back in 2020, is something to pay attention to as technology continues to evolve and drive clinical care. Dr. Johnson spoke with us about emerging technologies to know about that may be implemented in the future, and continuing to enhance how medical practices provide care to patients. Let's take a look back at this conversation.

Dr. Johnson:

Atul Gawande, in his most recent story "Why Doctors Hate Their Computers" talked about the fact that the fastest growing group of users of the electronic health record are actually patients, and it's very true. So with that comes the idea of digital health. Digital health is something that Eric Topal, and a lot of other people have written about. I've done a little bit of work in that space through Robert Wood Johnson funding years ago. That's become the other really pressing issue is; how do we take and democratize access to the data, so that we can have appropriate disruptions in the healthcare system? Hopefully, aspirationally, without negatively affecting the existing healthcare system in any way that is adverse. That is actually the real challenge. We can talk about that more if you'd like, but fundamentally the idea that we are going to use smartphones and technologies that might attach to smartphones and portals and all of the consumer health informatics environment to move health and healthcare beyond the walls of a typical health system, is one of the most current areas in the field.

Dr. Johnson:

I think we are squarely in the Gartner Hype Hope Cycle right now. Where if you follow the New York Times five years ago, this is all about promise, big data. What if we could do machine learning on these big data and reinvent the treatment of cancer, or discover new medications. And all that's happening, but we are also aware now of some of the concerns of that. Including the idea that some of the people who have access to those data might scare people. Patients might be afraid for their privacy when groups like Facebook, Amazon, Google, Microsoft, and I could go on, are the ones who are really leading the charge toward democratizing access to their information, using AI and prediction to possibly help patients to make better choices or help providers make better choices about the way to care for groups of patients.

Dr. Johnson:

Everybody's talking about AI and prediction. There's also this big concern about health equity. The fact that, as I sit here looking out of the building where my office is located, I'm looking at North Nashville and I'm looking right by HCA, which is one of the largest for-profit companies for healthcare in the world. And beyond that, an environment of people who have enormous problems with data access, and realizing that this equity piece only is going to potentially get worse. If we don't come up with ways to educate, to integrate this knowledge into the routine of people who are coming from all different walks of life in this country. If we don't come up with technologies that help to capture data from all of these different walks of life, so that AI and prediction is equally valid in populations that aren't just white middle class males, but also all of the other groups whose data need to contribute to the types of AI and predictions that we're building.

Katie Musacchio:

Dr. Johnson also touched upon the evolution of health records and the potential technological advancements to come.

Dr. Johnson:

Medicine as we know it, they feel that is thousands of years old. Everything that we think about with the present day electronic health record is decades old, like three or four decades old. So it's very new. It's a very new innovation. And what I've often told my students is "Imagine what a car would be like today, if Mario Andretti had actually developed it. It would be really safe, it would be roll proof, there would be no cup holders." And so there's a point where we have to say, the EHR of today was developed by geeks like me, who saw major problems in patient safety and in interoperability and focused mostly on the engineering to improve safety interoperability, the integration of clinical decision support. Even though we might be physicians, we're a different lot. We're a group of physicians who type almost as quickly as we talk. Point and click is a part of what we've been doing since we were between two and five years old for some of the newer people who are coming out.

Dr. Johnson:

And so, you wouldn't expect the first EHRs to get to this level of adoption, to necessarily be as good as they should be. They've clearly demonstrated that they're not as good as they can be. So what I think is going to happen first is, feedback and response to feedback. Having had a chance to watch what the commercial vendors are researching and thinking about, especially frankly, in areas like voice recognition or speech recognition technology. As one of the newer pieces and ways in which we can use smaller devices, like mobile devices to actually run the EHR. I'm very confident that we're going to see changes in the EHR that make it more useful. Everybody knows it has to happen. There are people who believe that the commercial vendors have no interest in that particular area. I am quite certain that it's not true.

Dr. Johnson:

Where we end up, it's kind of anybody's guess. Sort of following the model that Gibson once put out years ago, which essentially is "The future is already here. It's just not evenly distributed." There are groups of people who are using the electronic health record in very different ways. Vanderbilt has had two very exciting projects. One we call VIVA, which is an enhanced voice assistant, which I think revolutionizes the way we think about information retrieval. The idea being that if I can make a well formed vocal query to the EHR, let it process the information and then give me back a context dependent summary. So for example, if I'm sitting in front of a computer screen, show me a trend of data if I ask for something about the data. If I'm in my car, read back to me the trend in the data. That kind of a technology I think could revolutionize the searching capability of the EHR and stop a lot of, what Paul Tang has called, foraging that currently goes on with existing clinicians trying to find information in front of a patient in EHR.

Dr. Johnson:

The biggest challenge is also the challenge of data entry. And I think there's a lot of work to be done. First in the regulatory space to take the pressure off of physicians, nurses, and advanced practice nurses in particular, to document everything that was done in a note to send to a payer to get reimbursed. My personal belief is that we need to work closely with the HELP Committee to pass legislation that allows the definition of what documentation looks like, to include things like the video of the visit. Once we have the ability to broaden our definition of what a documented visit looks like, we can start thinking much more creatively about, what are we really trying to do with the actual ASK based or text based summary of a visit. It may be that we go back to the summaries of the 1950s and 60s, which is: 18 month old, painful ear, no other concerns. Ear is red and inflamed.

Dr. Johnson:

Diagnosis, otitis media. Treatment, amoxicillin per usual. And that we then, look into the EHR, which is the system of record to see that the physician did do a review of systems. That the physician or nurse practitioner did actually prescribe a particular dose of amoxicillin with some frequency and some duration and some comments, et cetera, et cetera, et cetera. So that the notes can actually take on a completely different role in the world in which an EHR surrounds that node than what we think about right now. I'm really kind of optimistic that if we can just make a couple of big changes in the regulatory environment, in which we are building electronic health records today, we will enable people like researchers around the country and the world to redefine the systems that our doctors are using and get cup holders in that car.

Katie Musacchio:

With all this talk about emerging technologies and telemedicine that have already begun and will continue to grow as we move forward, another subject of importance to touch upon is cybersecurity. This topic has been increasingly important since even before the pandemic. However, with the enhancement of, and the added value to technology that so quickly occurred due to the pandemic, online security is booming now more than ever. SVMIC spoke with Robbie Morris on privacy and security. Let's listen to Robbie's important insights to help you better implement cybersecurity in your practice.

Robbie Morris:

Just like continuing education for clinicians, we've talked about fish testing, you train, train, train your end users. Training to be consistent throughout the culture of the organization and that security culture, not just when people are hired. It should be an ongoing thing. Because the changes, the technology evolves. So as that does, so should your training. Back to the basics, the firewall, making sure you've got the antivirus and all the things are up to date. Disaster recovery plans, conduct user reviews with your HR department to make sure that everybody that's got active profiles, actually still is involved here. And of course, make sure that your processes, your business process, documented and up to date.

Katie Musacchio:

Robbie also shared tips on the essentials you should look for when searching for a cybersecurity expert to work with your practice. Let's take a listen to his recommended requirements.

Robbie Morris:

Given the fact that I do perform risk assessments for a living, documentation is paramount. That is something that, when you're looking at hiring someone, it's like going to hire a builder. If you're going to hire a builder to build onto your house, you're going to look at fixtures of what the work they've done. You're going to talk to the people that they've worked for. You're going to do some due diligence around those people. You do the same thing with your IT vendor. You ask to see the documentation examples, because if you ever decide to change vendors, then are you going to be locked into those people? That they're the only ones that know anything about your environment. No, not if there's documentation, because you hand that off in the transition.

Robbie Morris:

I would always recommend avoiding long term contracts, not just in IT, but in life. Whatever that is, I don't like being locked into something forever. I would absolutely talk about the IT support company's ability to be proactive, not reactive in their support. I would also say experience in the same industry. Because if you don't understand the challenges that come with being in the healthcare environment, then maybe you don't understand the actual enormity of the job that you've got and the importance of that. I would absolutely make sure they've got cyber security expertise, because if they don't have some degree of security services that they offer, then you're not hiring the right people.

Robbie Morris:

I've mentioned training, I've mentioned performing SRAs. Those are huge things. I would identify in any given environment, whether it's 10 users or 100 users, identify the user population, then the risk levels of the people that are using devices. Again, if you're only connecting with a mobile, an Android or an iPhone, you don't have the logs that you should have, like you would on a windows machine. So that's a higher risk because you can't look at logs. So, I would identify the user population in my environment that has the highest risk of unauthorized access. Absolutely use complex passwords, and change them often, because there are really easy programs to use that can guess your password. Literally again, training new users because they are your first line of defense, people do make mistakes and people do overlook things. Understanding what your environment looks like at a high level, identifying folks and taking the steps necessary to help keep everybody safe.

Katie Musacchio:

Thank you for listening to me walk you through another cluster of past episodes today, regarding the many insights of wonderful experts and physicians who we've had on our podcast.

J. Baugh:

Thank you Katie for leaving us through these evolving topics that affect the medical profession. We hope this recap of information on cybersecurity and the evolving technological landscape can help you navigate as we head toward a post pandemic era. You can find links to the full episodes we touched upon today in the show notes. We at SVMIC strive to assist our members in any way we can, and we hope these tips and insights can contribute to your success moving forward.