DEA buys time on proposed telehealth rules for controlled drugs

This is. Big, Very Big

Fierce Telehealth reports. 

Facing major backlash to its proposed rules released in February, the Drug Enforcement Administration (DEA) is looking to buy some time to reconsider whether it should enforce stricter limits around the prescribing of controlled substances via telehealth. 

The Biden administration said at the time that the new rule seeks to provide safeguards to prevent online over-prescribing of controlled medications. Teleprescribing has been touted as a robust tool for bringing medications for opioid use disorder (MOUDs) to rural areas in the ongoing treatment of the opioid epidemic. 

The agency received a record 38,000 comments on its proposed telemedicine rules, according to a statement from the DEA Administrator 

Last week, the DEA filed a draft temporary rule with the Office of Management and Budget titled “Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications.”

Milgram said further details about the rule will become public after its full publication in the Federal Register.

The DEA issued proposed rules three months ago that would reinstate strict limitations on the virtual prescribing of controlled substances and roll back telehealth flexibilities extended during the COVID-19 pandemic. The proposed rules would once again require patients to be evaluated in person by a doctor to receive prescriptions for some controlled substances (PDF) including stimulants like Adderall and opioids

Provider groups, telehealth advocates, and patients submitted comments largely panning the proposal, arguing that it would create barriers to care. 

Under the proposed rule, Schedule 2 medications or narcotics would require (PDF) an in-person prescription. Schedule 3 or higher medications, including buprenorphine, can be prescribed for 30 days via telehealth but would require an in-person visit before a refill. Non-narcotic drugs like Ambien, Valium, Xanax, and ketamine also fall into this category. If a patient is referred to a provider, an in-person appointment is not required as long as one took place with the referring physician.

If a telemedicine relationship was established during the COVID-19 public health emergency, the DEA will extend the in-person exam waiver for an additional 180 days.

DEA buys time on proposed telehealth rules for controlled drugs

Why It is Essential to Review your Electronic Health Record

How often do patients who read open ambulatory visit notes perceive mistakes, and what types of mistakes do they report?

Findings  In this survey study of 136 815 patients, 29 656 provided a response, 1 in 5 patients who read a note reported finding a mistake and 40% perceived the mistake as serious. Among patient-reported very serious errors, the most common characterizations were mistakes in diagnoses, medical history, medications, physical examination, test results, notes on the wrong patient, and sidedness.

In today's world, almost all doctors use electronic health records.  It is difficult to provide an accurate percentage of doctors who do not use an electronic health record (EHR) as it can vary depending on the country, healthcare system, and specialty of the doctor. However, in the United States, where EHR adoption is widely promoted and incentivized, a 2019 survey found that about 9% of physicians still used paper records exclusively, while 84% used EHRs. The remaining 7% used a combination of both. It's worth noting that the percentage of doctors using EHRs has likely increased since then. This figure was given by ChatGPT which is current only to Sept. 2023.

It is estimated 99% of doctors use an electronic health record system. 

Data systems, ie electronic records never forget. 

You must access your EHR via a portal. If you do not know what that is you can learn from ChatGPT or ask someone in your doctor's office or clinic how to go about that.  It is your legal right to be able to obtain your medical record (Federal Law).  

In the United States, there are federal laws that give patients the right to access their electronic health records (EHRs). The two main laws governing access to EHRs are the Health Insurance Portability and Accountability Act (HIPAA) and the 21st Century Cures Act.

The 21st Century Cures Act is a United States law enacted in December 2016 that aims to accelerate medical innovation, enhance research into diseases, and improve patient care. The law includes several provisions related to the development and approval of medical products, including drugs, devices, and biological products, as well as provisions related to mental health and substance abuse.

Some of the key provisions of the 21st Century Cures Act include:

Streamlining the clinical trial process to expedite the development and approval of new drugs and devices

- Promoting the use of real-world evidence in drug approvals

- Encouraging the development of precision medicine and the sharing of genetic and clinical data

- Investing in research on cancer and other diseases

- Providing funding to combat the opioid epidemic

- Improving mental health services and resources

Overall, the 21st Century Cures Act aims to promote innovation and collaboration among researchers, industry, and patient advocates to advance medical treatments and improve patient outcomes.

Under HIPAA, patients have the right to access their protected health information, which includes EHRs, held by covered entities such as healthcare providers, health plans, and healthcare clearinghouses. Covered entities must provide patients with their records within 30 days of the request, and they can charge a reasonable cost-based fee for copying and mailing the records.

The 21st Century Cures Act, which was signed into law in 2016, expands on the HIPAA requirement by mandating that healthcare providers and EHR vendors provide patients with access to their electronic health information in a structured, standardized format that can be easily shared with other healthcare providers and apps. This is known as the "open notes" provision, and it aims to empower patients to become more engaged in their care by giving them greater access and control over their health information.

Overall, these federal laws give patients a legal right to access and control their EHRs, which can help them make more informed decisions about their healthcare and improve the quality of care they receive.

Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes | Electronic Health Records | JAMA Network Open | JAMA Network

End of the COVID-19 Public Health Emergency (PHE) Declaration - Public Health Communication Collaborative

The Federal Covid emergency declaration ends on May 11,2023.

What does this mean? COVID-19 is not over. Although the emergency declaration is ending considerable federal resources will remain in effect.

On May 11, 2023, the public health emergency (PHE) declaration will end. Among other policy implications, the end of the PHE will impact health policy measures associated with access to COVID-19 testing and treatment.

How will the end of the public health emergency affect community members?

When the public health emergency ends, COVID-19 vaccines will continue to be free for all, as long as the supply of federally purchased vaccines lasts. However, access to and cost of testing and treatment will vary on whether they have public, private, or no health insurance.

Does the end of the public health emergency mean COVID-19 is over?

No. COVID-19 cases are down sharply, but the end of the emergency declarations does not mean the virus is no longer a threat. The virus remains a leading cause of death in the United States, with about 250 daily deaths on average. Visit CDC’s website and your state and local health departments for information about local infection rates and recommended precautions.

CDC continues to advise that everyone stay up to date on COVID-19 vaccinations, use at-home tests if they’ve been exposed or have symptoms, stay home if they’re sick, and wear a high-quality mask when COVID-19 levels are high. These precautions are the best ways to protect yourself and your loved ones.

How will the end of the public health emergency affect community members?

When the public health emergency ends, COVID-19 vaccines will continue to be free for all, as long as the supply of federally purchased vaccines lasts. However, access to and cost of testing and treatment will vary on whether they have public, private, or no health insurance.

Vaccines

Vaccines will remain free for everyone when the public health emergency ends. As long as the supply of federally purchased vaccines lasts, COVID-19 vaccines will remain free.

Testing and Treatment

Coverage for COVID-19 testing and treatment will vary by insurance type.

For people with Medicaid coverage, COVID-19 testing, and treatment will remain covered at no cost through September 2024. For those without insurance, COVID-19 testing and treatment will no longer be covered, and the cost will be determined by individual providers. However, free tests and treatment may be available at local free clinics or community health centers.

State and County Public Health Advisories are available   HERE.  

Requirements for Masking, Indoor Activity, and Distancing will vary according to the incidence of COVID-19 from Low to Medium to High.  In addition, CALOSHA makes recommendations for masking in the workplace

Messaging: End of the COVID-19 Public Health Emergency (PHE) Declaration - Public Health Communication Collaborative

Public Health Turnover Threatens Community Health and Safety - de Beaumont Foundation

Public Health Turnover Threatens Community Health and Safety

According to a recent analysis of data from the Public Health Workforce Interests and Needs Survey (PH WINS), nearly half of state and local public health employees left their jobs between 2017 and 2021, exacerbating an existing workforce shortage and causing a critical lack of skills and experience that puts communities at risk. 

The study, published today in Health Affairs, compared intent to leave or retire in 2017 with actual separations through 2021 among state and local public health staff at agencies that participated in the PH WINS survey in both years. The study authors found that 46% of state and local employees left their organizations during that time – a number that rose to 74% among employees under age 35 and 77% among employees with less than five years. experience.

Public Health is one of those subjects which gain little attention in medical school. Med School students assign it a low priority, such as basket weaving in high school. It is a bit like being an anesthesiologist with long periods of inactivity, boredom, and occasional moments of sheer panic.

COVID-19 amply demonstrated how Public Health works, a slow recognition of an impending catastrophe and a slow ramp-up of an inadequate workforce. The workforce in good times is inadequate.  It is just not an exciting field of healthcare. In fact, the deficit is so bad that the National Guard is often 'called up" by Governors to serve. The private sector and large health institutions have the resources to address the huge increase of patients in emergency departments.

In such situations, testing and vaccination must be accomplished a remote mobile workforce is activated.

The added burden of personnel and medical devices (PPE), and pharmaceuticals (vaccines) requires emergency funding by state and federal governments.

Covid-19 Economic Relief

During such events, other agencies and specialty officials are called in to supplement forward-facing personnel, such as the CDC, DEA, WHO, and the USPHS. Politicians usually become involved as well because it enables them a public forum for recognition. This is not always a good thing, since their announcement has political implications and divides the goals of science to gain political advantage.  This became apparent during the Covid Pandemic.

The future of Public Health lies in the balance.

Understanding the size and composition of the state and local governmental public health workforce in the United States is critical for promoting and protecting the health of the public. Using pandemic-era data from the Public Health Workforce Interests and Needs Survey fielded in 2017 and 2021, this study compared intent to leave or retire in 2017 with actual separations through 2021 among state and local public health agency staff. We also examined how employee age, region, and intent to leave correlated with separations and considered the effect on the workforce if trends were to continue. In our analytic sample, nearly half of all employees in state and local public health agencies left between 2017 and 2021, a proportion that rose to three-quarters for those ages thirty-five and younger or with shorter tenures. If separation trends continue, by 2025 this would represent more than 100,000 staff leaving their organizations, or as much as half of the governmental public health workforce in total. Given the likelihood of increasing outbreaks and future global pandemics, strategies to improve recruitment and retention must be prioritized.

Public Health Turnover Threatens Community Health and Safety - de Beaumont Foundation

Health Misinformation

With the abundance of health information available today, it can be hard to tell what is true or not. We all need access to trusted sources of information to stay safe and healthy.

Why health misinformation matters

We can all benefit from taking steps to improve the quality of the health information we consume. Limiting misinformation helps us make more educated decisions for ourselves, our loved ones, and our communities.

Health misinformation is a serious threat to public health. It can cause confusion, sow mistrust, harm people’s health, and undermine public health efforts.”

Dr. Vivek H. Murthy

Vivek Mirthy M.D.Surgeon General of the United StatesThe Rest of IT

Physician Unionizing How, Why, Who? SMHS residents and fellows vote to unionize – The GW Hatchet

Medical residents and fellows at the School of Medicine and Health Sciences voted overwhelmingly to unionize Thursday.

SMHS residents and fellows voted 253-16 Wednesday and Thursday join the Committee of Interns and Residents — a subsidiary unit of the Service Employees International Union. Maryssa Miller, a physician who helped organize the unionization effort, said the union will form a bargaining committee in the coming weeks representing residents’ departments like internal medicine, emergency medicine, and obstetrics and gynecology.

Every year some group of physicians organizes to form a union. Most often they are not successful. The reasons are many.

George Washington University School of Medicine and Health Sciences is no worse than any other academic center.

1. Trainees have a limited time span 1-3 years in a position where they are subject to abuse.

2. A moral and ethical imperative to care for a patient, no matter the circumstance in hospital.

Always a point of contention is the long hours and difficulties for physician trainees.

COVID-19 exacerbated the intense work and long hours for all caregivers, including physicians.

Physicians' Unions have rarely gained strength in the United States.  Perhaps the worst working conditions exist in academic settings.

Trainees are in a captive and at times abusive environment.  This has been a never-ending story. Forty years ago when I was a trainee it was even worse.  At times I would work 36-hour shifts.  Today in 2023 Academic residency programs are required to abide by rules regarding training hours, limiting the work week to no more than 80 hours.

Medical residents and fellows at the School of Medicine and Health Sciences voted overwhelmingly to unionize Thursday.

SMHS residents and fellows voted 253-16 Wednesday and Thursday to join the Committee of Interns and Residents — a subsidiary unit of the Service Employees International Union. Maryssa Miller, a physician who helped organize the unionization effort, said the union will form a bargaining committee in the coming weeks representing residents’ departments like internal medicine, emergency medicine, and obstetrics and gynecology.

A recent report from the American Council for Graduate Medical Education reveals that despite the rules many institutions are being cited for infractions. 

Some specialties were cited more often, Internal Medicine, Family Practice Transitional year (Internship). It is common practice for trainees in the initial year of training to be expected to carry a disproportionate workload.  The reasons are a subordinate position as related to superiors, and the necessity to acquiesce to unreasonable demands to ensure being advanced to the next level of training.

What is the ACGME 16-hour rule?

In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) reduced the consecutive number of hours that post-graduate year-1 residents can work in a single shift, from 30 to 16. This rule was intended to improve patient safety by reducing residents' fatigue.

It has been over ten years since this guideline was recommended by the ACGME.  Ongoing examination reveals there has been considerable resistance to the ACGME guidelines. 

Why is this? 

The demands of clinical care are ongoing, 24/7/365/. It is a bit like 7-11.   The relative shortage of physicians creates an undeniable demand for those working in the system.  There is no reasonable solution for this confounding fact.  The result would be a lack of physicians for a considerable portion of patients in the hospital.  Can you imagine a patient needing emergency surgery at night and there would be no surgeon available?

Pros of Unionization

Unions provide an integrated and time-proven methodology of negotiations between employees and employers by an experienced third party

Cons

A Union introduces factors and dues whether you decided or not that prospective union members may not have factored into their voting.

The GWUMS provided some insights into unions

SMHS residents and fellows vote to unionize – The GW Hatchet

Where is the Pain ?

 

Why do we reduce humans who suffer from chronic pain to simple molecules and receptors? Pain psychologist Rachel Zoffness, P.h.D. returns to talk about fibromyalgia, stomach pain, anxiety, the role of trauma, and much more.

Dr. Rachel Zoffness is a Health and Pain Psychologist, international speaker, author, and thought-leader in pain medicine. She is an Assistant Clinical Professor at the UCSF School of Medicine, a Stanford lecturer, and a Mayday Fellow. Her podcast episodes on The New York Times Ezra Klein Show, Ologies (Dolorology), and The Jordan Harbinger Show are viral sensations with more than 6 million views and downloads.

Dr Zdogg, as he is known is Zubin Damania MD a graduate of UC San Francisco. His background is in intensive care and primary care.  ZdoggMD is well known on the YouTube circuit. 

Dr. Z's book, links to our prior interview, audio podcast, and full transcript:

The Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life

Rachel Zoffness, P.h.D. examines the segments of the pain mechanism in this video.

Key Topics:

0:00 Intro

1:14 The bio-psycho-social nature of pain: phantom limb pain, the limbic system & emotion-pain connection, social contributors

9:00 The stigma of “psychological” pain and holistic approaches to managing it

16:15 The concept of “pain volume” and how emotional states affect it

18:56 Releasing negative emotion: the idea of “tea-kettling”

26:21 Fibromyalgia & trauma, pain amplification and “central sensitization”

33:14 The importance of desensitization practices for chronic pain

36:14 The benefits and risks of narcotics, the danger of removing them too fast

40:41 Sympathetic nervous system, the interaction of trauma and adverse childhood experiences (ACEs)

47:44 Placebo & the mind-body connection

53:34 Anxiety/Depression and Overmedicalization by Big Pharma

1:00:00 Non-pharmacologic treatments for pain, anxiety, and depression

1:04:06 The mind-gut connection: Irritable Bowel Syndrome, performance anxiety, and more

1:11:14 Emotional repression, fear of speaking and exposure therapy, PTSD

1:18:28 Imposter Syndrome and Dunning-Kruger effect, gender roles (vocal fry/uptalk)

1:25:00 The Problem of emotional repression, and Solutions

1:28:37 How biofeedback works

Why do people experience pain in a limb that is missing? (Phantom Limb Pain)

Pain causes angst, anxiety, and physiological effects.  What is the connection between the psycho-biological-emotional aspects of pain?