Traveling Nurses, Home Health Monitoring and Interoperability – NYCU
Written by Dr Nick on June 6, 2022
Month before
This month’s episode of “News you can Use” on HealthcareNOWRadio features news from the month of May 2022
As I did last month I am talking to Craig Joseph, MD (@CraigJoseph) Chief Medical Officer at Nordic Consulting Partners. This month we discuss the shortage of clinical professionals in particular nurses that was temporarily ‘solved’ (this was really Peter borrowing to pay Paul) with ‘Traveling Nurses’. In many cases, there was not a lot of traveling going on and this was nurses taking on contract roles that paid at a higher rate than their current pay. We talk about the background to this, where the money came from (hint your taxes in the form of Pandemic payments) and what the future might look like as the money runs out
We discuss some recent papers reviewing the impact of home monitoring and the use of wearables to improve health and wellness. The Cedar Sinai report on Apple watches and Atrial Fibrillation detection: Will Apple devices’ passive atrial fibrillation detection prevent strokes? Estimating the proportion of high-risk actionable patients with real-world user data and the remote monitoring of Heart failure patients using weighing scales: Remote Monitoring and Behavioral Economics in Managing Heart Failure in Patients Discharged From the Hospital. The news was not encouraging and demonstrates the need for more data, science, and study – something that has always been an integral part of healthcare progress but seems increasingly under fire in our social media-driven world.
Listen in to hear Craig report on his recent attendance at the AMIA CIC conference and the presentation from Micky Tripathi (@mickytripathi1), National Coordinator for Health IT that gave an excellent visual of the importance of detailed data and interoperability that shares more than just the basics. As he described it the difference between low-density interactions vs high-density interactions and the fidelity of the data and knowledge we derive
Nice graphic description of where we are and where we want to be from @ONC_HealthIT @mickytripathi1 with respect to #healthIT. Intra-vendor #EHR #interoperability may be closer to the right, but still quite far away. #rabbits @AMIAinformatics #CIC22 pic.twitter.com/Vger8dth6k
— Craig Joseph, MD (@CraigJoseph) May 26, 2022
And we close with a discussion on the Lown Institute Hospital report on Hospital Overuse during COVID – counterintuitively, at least to us, low-value procedures were still being done at the same rates as pre-pandemic despite the challenge of getting into hospitals and our overwhelmed healthcare system
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Raw Transcript
Nick van Terheyden
And today as I am each month, I’m joined by Dr. Craig Joseph. He’s the chief medical officer at Nordic consulting partners for our news, you can use segment for May 2022. Craig, thanks for joining me.
Craig Joseph
It’s a pleasure. As always, thank you for having me.
Nick van Terheyden
So let’s get straight into it. One of the trending topics that we’ve seen is traveling nurses, lots of traveling nurses, lots of complaints about traveling nurses who really weren’t traveling, but were doing it to essentially increase their income in what was a very tight job market. But there seems to be a little bit of a pullback from that, right.
Craig Joseph
Yeah, well, it’s super expensive to pay traveling nurses. And, you know, I’m not sure where we came up with that name traveling nurses, I think it’s, it’s, it’s a, it’s a throwback to some some other other time. But yeah, you know, traveling nurses are typically used in the past for when you’re facing an acute problem. For some reason, you don’t have enough nurses. And these are folks that come from all over the country, or sometimes all over the world. And, obviously, it’s much more expensive, you have to pay them more than you typically we pay your nurses that live in the area, plus, you have to cover their expenses. And it’s very expensive, and what what has happened during the pandemic is that the need for these nurses took off. And some nurses who never intended to travel, couldn’t say no to that money, and started traveling. And as you mentioned that I think we have to start questioning the word traveling because sometimes nurses quit their job when across the street, as it acted as a traveling nurse. And significantly 20 3040 50% More money just to go across the street. And, and now we’re seeing some of that kind of being pulled back. So some of those contracts are being cancelled a lot of that money, extra money came from the federal government as part of COVID relief to to hospitals to help them stay afloat, and some of that money is is rapidly disappearing. And so it seems we are slowly kind of getting back to the I don’t want to say normal, but three COVID times, of course, reasonable people have said, well, if you if you just pay them, I think you might want to be one of those reasonable people. If you just pay nurses more money, probably what they’re supposed to be getting, then you don’t have these problems of having to entice nurses from other countries or other regions of the country.
Nick van Terheyden
Yes, I will say that, and I would say that, but it I’m married to a nurse. And as a direct consequence of that I have an inbuilt bias. But that bias is also driven by my experience as a physician, especially as a junior physician. And the experience I had was the smart physicians were the ones that realizes that nurses were absolutely our best friend, you know, really delivered a lot of the care that we directed at the time, although I was a little bit more involved clinically in the era that I was practicing medicine, but they were a total godsend, they were really the patient’s confidence, you know, support everything in so many ways. And you’re right. I mean, if if we were paying them appropriately, perhaps we wouldn’t have seen quite as much of this. But the other thing I would say that I’ve seen, especially in this country is that the the tilt away from actual clinical, you know, ultimately you can’t spend all your life working that hard at the bedside, as you grow older, and you want to progress in a different career and do other things. And the career structure is such that we take all of these really experienced nurses and they start to ascend the ladder into you know, less patient contact type roles, and we lose some of those skills. And we don’t, I think the methodology is not quite as good as it ought to be to fill the the incoming ranks with enough experience and folks that can deliver it and pay them a reasonable wage. We’ve certainly imported I think nurses have been on the list of preferential immigrants to this day. I don’t think they’ve ever come off so they get a fast path through the immigration process. So it seems like it’s a long standing problem. You know, the fact that the government has stopped producing money for it has, you know, stopped many people because now they don’t have the money? I think they’re pulling back on actual clinical activity as a result of it. I mean, it’s I think it’s not, we haven’t solved the problem by stopping it. We need longer term solutions
Craig Joseph
needed indeed. And ultimately, it does come down to money. And, you know, I think if you believe in the marketplace, the fair marketplace, we saw what was happening that people were willing to pay. And so you know, how much is how much is my house worth? Well, it’s worth what other people are willing to pay for it. That’s how much it’s worth. So what is the proper nursing salary? Well, and nursing salaries, the it’s whatever the nurses are willing to work for? And I think that’s a concern. Our our nurses who were who had decided to start traveling to get that extra money, are they willing to go back to the traditional, you know, way that they worked? And to go back to the traditional amount of money? Or are they have they seen the light? And they’re not coming back? And that would be that would be tragic, tragic for them and tragic for society? What else would they do? I don’t know. There are, we certainly know there are other roles that are both clinical and non clinical, for people with that kind of skill set. So there, there are options for them. And some of them, I think just, you know, did it, they really didn’t need the money for chant, per se, they had other options. And they did it for the love of taking care of patients. And we might lose a big chunk of those of those nurses.
Nick van Terheyden
Right, losing all those skill sets. I mean, I think, great question. I think the the flip side of that is let’s hope that the institutions that, you know, some of them got pretty mad, certainly based on some of the articles, posts and commentary, I’ve heard about this, that, you know, they have nurses who then left, and then they show up again, earning more money, I hope they don’t react. And, you know, refuse those individuals opportunities back in the workforce, because I think that would just add additional fuel to this particular challenging circumstance. So I think we need to welcome and find better ways. I know many people are thinking about it, but this is this problem hasn’t been sold. Let’s talk a little bit about wearables. I know I’m probably well known as a wearables. Positive person, although I actually the only wearable I wear is my phone, I’m not very good about anything around my wrist. I’ve tried all of these things, not because I don’t believe in them. But because I’m just I don’t like things. I don’t have any jewelry. So it’s a little bit of a struggle. But we’ve seen at least I’ve seen recently, a couple of reports that came out one that talked about atrial fibrillation and the Apple Watch, I think it was out of Cedars Sinai, and they were looking at the monitoring, and whether that was actually finding the patients and helping or improving things, I think, questionable if there was value from that, and especially with those kinds of devices, we’re talking high expense items, and with a group that you might not associate with illness, you know, there may be pre selected as healthier number one. And then the other group, or study I saw was looking at behavioral economics around heart failure. And what for me has always been, it seemed like a just a brilliant, obvious solution for congestive heart failure. We want to watch those patients closely. When they go back into heart failure, they’re typically holding on to water in the body. So they gain weight, we see it, you know, so you issue them with a set of weighing scales, they report it on daily basis. And you could see it and play some intervention. That always seemed like an obvious thing. But actually, the report showed, not so much. And I think there’s a lot of I don’t want to say cynicism, but at least resistance to big rollouts of these things, especially with insufficient data at this point. What are your thoughts?
Craig Joseph
Well, like you I’m surprised whenever my assumptions are questioned by actual data and evidence. I’m disappointed when things don’t work out. I agree. You know, sometimes it’s what are you measure? Right? And so, so as you said, that, I think with with congestive heart failure when patients are are getting worse, they generally gain weight because they’re retaining fluid. And if you can see that weight gain, then it makes common sense that you’d be able to then say, Aha, that weight gain is coming. Clearly this patient’s hearts not working as well as it should be, we need to intervene and do something, whether that’s make sure that they’re taking their medicine or change their medicine or some kind of intervention. So perhaps that’s where the breakdown is, right? Maybe these scales are doing a great job, but no one’s looking. Or they’re looking, but they’re not able to convince the patient to change or for the patient to come in, because they feel fine. Or they’re not noticing the side effect. So I think it’s, you know, with any one study, it’s a little bit unclear, but you have to look, it’s the bottom line, that patient not go into significant failure, did that patient not go into the hospital? Or, or after the year of intervention? Did that patient cost as much to the insurance company as other patients? You know, what, what are we? What are we actually looking at? And and those are some, you know, I think, valid questions. But yeah, this is why do we do science? Right? This is why we, sometimes things that seem obvious and not debatable, are neither of those two things. And, and that’s, you know, I think a lot of people that’s part of the problem that we’ve had in communicating science, during the pandemic is that people make assumptions. And not only late lay people, but sort of physicians and scientists and kind of communicating how the how the ugly process of science works. And it comes in fits and starts. And sometimes everyone, there’s one study that shows some improvement, and everyone jumps on that bandwagon because it makes sense. And then you spend a lot of money and people continue to question as they should. And sometimes it turns out that what you felt was brilliant, wasn’t wasn’t all along.
Nick van Terheyden
Yeah, the science of medicine is filled with, you know, both sides of that particular coin, including the ones where actually the data showed or demonstrated, you know, this huge improvement and that the story that always strikes me when I think about this is that the Helicobacter pylori, or the causative agent for stomach ulcers, which we in the medical profession associated with acid and, you know, irritation in the stomach. And ultimately, it was shown to be associated with the bacteria and the two individuals that identified that and even tested it on themselves. It’s a tremendous story. And yet they were still rejected out of it. I mean, it took, I want to say years before we started accepting and now we, you know, have a much better approach to that. So filled with all of this, you know, that’s the science and the difficulty of following science. For those of you just joining, I’m Dr. Nick the incrementalist today I’m talking to Craig Joseph, the Chief Medical Officer at Nordic consulting partners were talking about the latest news from May 2022. We discussed the whole atrial fibrillation and the use of wearables. I think, Craig, you spent a little bit of time this past month, actually traveling and attending a conference and Mickey Tripathi is often a producer of some, I think some great insights clearly passionate about interoperability, and I think you saw something that really resonated when you did and you’d shared. Tell us about that.
Craig Joseph
The conference was a bunch of nerdy doctors and scientists going to Houston to talk about health care and and technology and make you Tripathi as the as the director of the coordinator for national health IT in the United States. So the federal position and he oversees a fairly significant number of folks who, who help us exchange who help us create the infrastructure so that we can exchange data and make sure that patients are being helped and not hurt by by technology and information technology. And he was showing a slide that I thought really did a good job of kind of encapsulating where we are and where we want to be with regard to exchanging information. And typically people think about this is with their electronic health record. So you go to doctor a and in your town and they’re using an electronic health record and then for some reason you refer to or you’re extra Playing and you’re going to a different doctor. And hey, can’t they just see everything that the other doctor had put into the into the record into the into the chart? And the answer is sometimes yes, oftentimes No. And typically right in between there. And this, the slide that he showed, basically was kind of saying, hey, it’s really about the number of data points that we have. And the fewer data points the less rich picture that we get. And he illustrated this by showing a picture of a rabbit with just a small number of data points. And so it’s really quite blocky, you can kind of make up the ears, but not really that well, as you were just asked to look at it like, well might be a rabbit, but I’m not exactly sure. And as you get more data points, it becomes very clear that Oh, I can, I can totally make God exactly what’s happening here. And his point was, hey, where we’re at today, it’s kind of like that, first, that first photo with a low data kind of interchange, where it’s not obvious what’s going on with a patient, just based on some of the data that can be transferred from one electronic health record, to another, at least the bottom line requirements as the government has defined them. And we’re striving to get to the point where everyone’s looking at the same picture. And that’s an actual picture, right of the of what’s going on, so that you can really compare apples to apples at this point. So I thought it was a was a was a good way of kind of visualizing the problems of current state with respect to electronic health record, data interchange, it’s not that everyone can see everything. And it’s going to take us a long time to get there. Because a it’s complicated, and B we can’t agree on ways of of saying the same thing in the same way. In fact, doctors within one hospital system can often can’t agree on saying the same thing in the same way. So it’s not surprising that we’re not agreeing from one part of the country to another.
Nick van Terheyden
Yeah, I think the visual is fantastic. The best way of describing it, obviously, this is radio, so people can’t see but there is an accompanying blog post will link to that picture. And the detail of that was, it just reminded my of my childhood and painting by numbers. And, you know, the first version of this was painting by numbers when I was, you know, five, and there was, you know, maybe two colors, three colors, and they were big spaces and wide lines, and whatever. And then the better higher resolution version with much smaller and more detail. And I, I love that visual, I think that’s really about bringing things into clarity in healthcare. And it’s no surprise that he’s a big champion of this, this has definitely been his, you know, one of his major areas of focus, to try and pivot. The Office of the National Coordinator for technology and see towards this is this interoperability because he came from the HL seven fire Foundation, where, you know, he spent a lot of time really trying to sort of push that. And I think it’s, you know, it’s one of the things that we missed in the creation of a lot of this, I think, even the folks that were part of the original architects of meaningful use, and so forth, I’ve heard them say, you know, we missed an opportunity, it should have been integrated, and we’re playing catch up, and we shouldn’t have to. And there’s an awful lot of politics and economics that are involved in this not as much technology, I think, I think it’s easier to do personally. But it’s not always the thing that people want to do for economic, all reasons of, you know, protecting their domain and in many instances, so I think great visual, I’m glad to hear that. And I’m glad that, you know, we continue to sort of push that. The other thing that I know you sort of looked at and talked about was this whole concept of what we call low value procedures or procedures that are less desirable. And there’s some shocking statistics associated with this, when you consider that essentially, if I correct me if I’m wrong, but I think low value procedures, and the ones that the science doesn’t generally support then being used, it’s questionable whether there’s some actual value. I’ll pick one that’s easy, and that would be the Jade egg that’s sold by one other name that organization is that Uh, you know, not just questionable, but you know, almost dangerous. But, you know, these are actual clinical procedures. But we saw something that was a little bit counterintuitive. I think
Craig Joseph
you’re right, there was a, you know, for a long time, we’ve been trying to or I would say, you know, medicine. In the US, we’ve been looking at tests and operations that people have that are always come with risk, everything comes with risk, but may not actually help either solve the question that we’re trying to solve, or our make problems go away. And so there’s been a push for years to try to not do those procedures, right, like, hey, we don’t want to do this operation, we don’t think it’s actually going to help you. And there was a thought, which, again, seems reasonable that, well, maybe, during the pandemic, we know that people were afraid to go to the hospital for good reason, or that hospitals stopped doing elective in quotes, procedures, because they needed to reserve the oars for very sick patients, or some of the bars and other spaces that have been converted to take care of COVID patients. And so one might reasonably expect that, wow, since a lot of these procedures were canceled, probably some of these low value or no value procedures also didn’t happen. And you’re referencing a report that came out earlier this month that showed that nope, not indeed, people still got some of these procedures that they probably didn’t need didn’t, didn’t bring them a lot of benefit. And so it’s kind of shocking at the same time. Maybe it shouldn’t have been. But yeah, so you know, and maybe we can talk about what some of these, some of these are, you know, one, one procedure that that is commonly used as spinal fusion. And that certainly that that isn’t indicated procedure, that’s an operation that some people should have. But if the reason you’re doing it is for back pain, it’s quite questionable based on the research, so that actually will improve with it. It might be that you’re at you’re at a coin flip, some patients are better, some patients will get worse, and some will remain the same. And if you don’t know who those people are, then maybe this is not a procedure, we shouldn’t be doing so much.
Nick van Terheyden
Yeah, it’s I intuitively, you would have expected that to have been a decreasing number. But as as they discovered that wasn’t the case. I think there were some other procedures that are on their back pain is I think, I want to say well known, but perhaps it’s not. I mean, I think what’s interesting to me is who’s driving that? Is it the patient? Is it the physician, you know, probably a combination of both of those, but we saw continued numbers, which is troubling. And, you know, again, that’s part of the science and the conflicting art, because in many instances, you know, they started out as well, this makes it let’s try it. But when you go back and look at the data, it shows, you know, either questionable value or less, you know, worse than that actually causing more harm. And yet we continue to deliver those services, which has to be part of that same problem that we were talking about the reassessment of science, it’s, you know, accepting challenges to our pre existing notion of what good care should be because I don’t think anybody goes out with the intent. I mean, I, I certainly don’t sit here and think physicians are trying to deliver care that’s not delivering value. I think it’s more about, you know, the failure to communicate correctly, the science behind that.
Craig Joseph
But it’s also sometimes physicians who, who, I think I shouldn’t say physicians, you know, we believe what we see with our eyes. And, you know, if I’ve taken care of 100 patients, and 80 of them has gotten better and 20 of them have not, that’s going to be a procedure that I think it’s worthwhile because, hey, four or five people that I do this thing to, they get better. And that’s my goal is to make you better. What I’m not saying is the million patients, right? I’m seeing 100 patients and it’s hard for me to believe what I see in some journal article or hear from some authoritative organization, when the patients in front of me argue are getting better at a rate that is higher than the national so You know, I get that. Sometimes you just you believe what what you’re seeing, even though your sample size is much, much, much smaller than the research that you have access to you, you believe what you see. And also, let’s be honest, I’ve had back pain, you’ve had back pain. I get people who are having problems that are affecting their lives, kind of desperate for something. And yeah, I see for a lot of these things, why people will do what what they do.
Nick van Terheyden
It starts with identifying that bias that we all have. And it’s not just a single bias. There’s like 150 of them in the chart that I’ve seen. And reflecting on on the data, as you say, it’s easy to get sucked in. Unfortunately, as we do each and every week. We’ve run out of time just remains for me to thank you for joining me on the show as ever. Craig, thanks for the conversation.
Craig Joseph
Always fun
