EMR Messaging Woes (4.11.2025) Save

It's Friday, 04/11/2025. This is the RheumNow podcast. Hi, I'm Jack Cush with roomnow.com. A lot of interesting things this week. Reports from Korea, reports on infection, reports on ANCA associated vasculitis, and of course, what are we gonna do about cannabis.

Let's lead with what I think the thing that's most on your mind these days, why am I getting so many GD messages on my EHR? I've heard this over and over from a lot of my colleagues. It's kind of like become a major part of their workday. It was enough that, you know, to see the patients, to write the notes, to review the labs, to go through all the things that were patient related, whatever. But now to spend more time on the EHR dealing with a myriad of questions is a real big burden.

And we know that the EHR is like the primary culprit in burnout. So, interesting report this week that looked at EPIC EHR data. This comes from you and everybody else that uses EPIC, spelled e p I c, not e p o a c h, which is what I thought when we started because it took forever to get going. Anyway, enough about that. They looked at messaging, and there was a clear cut increase in, messaging from patients on Epic, starting with the pandemic, and it has remained elevated since the pandemic.

And interestingly, while that went up significantly, there was no change in other means of patient communication, mainly phone calls, but other written messages, etc. At the same time this is going on, the amount of time that physicians are spending on their EHR has gone up significantly and remained elevated for pretty much all medical subspecialties post COVID nineteen. It went up 6.5% for primary care, almost 10% for subspecialists, and 5% for surgeons. And the question is, is this the new normal, or are you going to do something about it? I think when I don't like the behavior of patients, I like to blame myself, because that means I haven't educated my patients on what the right behavior is.

Nobody knows how to be a patient. Nobody wants to be a patient. Nobody wants to be sick. Nobody wants to have to write their email an email or a message to their doctor about, do I take two or three green ones a day, or should I, quit it and and just take pot? You know, crazy questions that make no sense.

Well, you are, have the responsibility of training your patients on how to communicate and what to communicate about. So that's my first suggestion. It's up to you. Set the rules, write them out, hand them to the patients, send me messages about A, B, C, D and F. Really important.

Don't send me messages about one, two, three, four and five. We can discuss that at next visit. So, see how that works. It's somewhat dissatisfying, I must say, it's just something I tell my patients, I'm going to review your labs when they come back this week, and if I don't call you, that means everything is good. That doesn't work.

Patients kind of want to know what their labs are. Why they need to know what their chloride levels are, I don't know. But again, as I've written about in the past, patients think labs are the official arbiters of health, and if that's so, again, that's you're not educating them. So work on this, otherwise it's going to continue to plague you. Two interesting studies from Korea, a claim study study from 2008 to 2021 on one hundred and eighty three thousand patients with both psoriasis and psoriatic arthritis compared being on a biologic to not being on a biologic using phototherapy as the comparator, and it showed that if you were on a biologic you had a significantly lower risk of new onset or recurrent major adverse cardiac events aka MACE.

Turns out that this was also seen with non biologic systemic therapies, meaning methotrexate lowered MACE risk, but only in people with a prior history of MACE risk. So, it looks like biologics are probably better than methotrexate in lowering that risk, and it makes sense, as we know, because if you lower systemic inflammation, risk of cardiovascular events, MACE events goes down significantly. A study from Korea also, and with Jeff Sparks in there as an author, looked at their KORAIL, K O R A I L, that's a Korean RAILD prospective cohort study that they looked at biomarkers, usual assessments and CT scans for outcomes. And they showed in this cohort, followed over time fairly large, thirty five percent of them had progression of their ILD within a three year period. That the biomarkers that we should be doing in rheumatology, that our pulmonary colleagues are doing all the time, mainly KL6, it's available in commercial labs, was significantly higher at baseline, as was HEAT shock proteins D, HSPD, about half the patients elevated at baseline and associated with progression.

Mainly increases in KL6 at one year showed the greatest change in overall progression of their RAILD as measured by CT scans. Those who were in the upper levels of change with KL6 had a twofold higher risk of progression in one year. So again, the point here is, KL6 is a new, measure that should be probably done in following people with chronic ILD. And this is a study of RA, but I think it probably applies to other ILDs as well. The FDA approved a new drug this week, Oblinsa from Amgen.

It's inebilizumab, inebilizumab, inebilizumab. It's an anti CD9 monoclonal antibody meant to target B cells, CD19 I said, meant to target B cells. It's the first approved therapy for IgG4 related disease. It is IgG4 related disease is estimated to affect twenty thousand people in America. This is obviously not going be first line therapy, because the price of it is over $140,000 per dose, and you give two initial loading doses and then queue six months after this, so this is very expensive therapy, but it's been shown to be effective.

We reported that in a New England Journal article, I think it was last quarter of twenty four, and you should know about this. This inebilizumab is approved now for IgG4 disease, also approved for neuromyelitis optica, another approval. Another report this week on the same drug inebilizumab and its use in myasthenia gravis is not approved. This is a phase three clinical trial result of three thousand two hundred patients showing significant improvement in function and reduced disease severity, and only in the patients who were antibody positive either had the anti acetylcholinesterase receptor acetylcholine receptor antibody or muscle specific kinase antibody positivity as markers for myasthenia gravis and inclusion into this study, or certainly those are the ones that had the best responses. A really important, I think good reference that you should download or read from JAMA, a full read review on staph aureus and staph aureus bacteremia.

As you know, it's a big problem, it's dangerous, all those people are symptomatic with fever and systemic illness. A third of them will develop systemic infections, metastatic infections, and, led by endocarditis at twelve percent, but arthritis seven percent, osteomyelitis, vertebro osteitis about four percent. Turns out if you've got bacteremia for more than two days you have a thirty nine percent mortality in the first ninety days. All these people are febrile, but and I put this up because as much as endocarditis is the main thing we think about, osteoarticular manifestations of bacteremia with staph aureus fourteen percent. So you should be knowledgeable and aware.

Interesting study of childhood SLE, pediatric SLE, you know is usually much more severe than adults. This is a cohort of one hundred and eighty five patients looking at long term outcomes and twenty percent of them had serositis. That's not really surprising, but what is surprising is that serositis in pediatric SLD is associated with worse disease. It happens, in younger patients, it happens, to be associated with more disease activity, a higher degree of comorbidities and higher mortality rates. Specifically, if the child has serositis and end stage renal disease, that the twenty year survival is really poor.

Now that sounds like The surprising part is the serositis. End stage renal disease sounds like it would be a risk factor already, but serositis adds that risk. So it should be something that you should stow away as this is a more even more severe patient if serositis is in play. A study of ANCA associated vasculitis comes from the Danish registry on ANCA associated vasculitis, fourteen hundred patients, median age 69, half male, half female follow-up about five years cardiac manifestations associated with ANCA associated vasculitis. Now, remember the median age here was 69, so I think that taints some of what I'm going to tell you.

But, there was more LVH 17 versus twelve percent, more STT elevations, AFib, QT prolongations. You know, it sounds like it could be age, but I wasn't really that keen on cardiac complications of Ankia associated vasculitis. You know, it certainly is more prevalent in, EGPA, less so with GPA. But anyway, it turns out in this study, only the patients who had ECG abnormalities, as I just described, were at increased risk, a twofold increased risk of cardiovascular mortality. So, again, maybe important, maybe not.

You decide. The APeX-three study, the APeX study, a phase 3b study, was reported this week as a press release. This is a study of guselkumab versus placebo in biologic naive psoriatic arthritis patients showing significant ACR20 improvement, and significantly less x-ray progression, compared to placebo at week twenty four. These are top line results, they didn't give you good numbers. I think I put this out there for those of you who, are looking for this data and know that it's probably going to be presented at either EULAR or ACR upcoming.

A twelve month study, two studies this week in JAMA talk about the use of non pharmacologic measures, and I talked about this last week, I think we should be paying attention to this. This is a twelve month, seven seventy patient study of those with chronic low back pain, taking opioids, and they found that mindfulness based therapy and cognitive behavioral therapy, CBD, was, they were both non inferior, they were both effective, and they both significantly reduced opioid usage. The question I asked on the tweet is, why are we not using more mindfulness based therapy and more CBD? CBT. CBD, that's another thing I'm coming to in a minute.

And I think it really behooves you to go out there and find someone or a few people that do, cognitive behavioral therapy in your community and start using them. I think it's smart. I have a friend who likes to tease me all the time about what is it with you doctors and your prescriptions? You know, why aren't you using other forms, non pharmacologic, you know, natural things, whatever. And I think we should be thinking about these things because they are adjunctive and they are generally well received by the community, the patients who need them most.

Another report in JAMA looked at compared yoga versus strengthening exercise in patients with chronic knee OA, And it was like a hundred and seventeen patients or something like that, and again they were, non inferior to each other. They both showed improvement. In a quarter of the measures, yoga was superior to strengthening alone. So, I do recommend, you know, leg strengthening for knee OA. It helps to maybe keep them away from surgery, it helps with their symptoms.

But yoga can do the same, and maybe again well received. I don't really believe a lot of my patients are running out and doing the leg strengthening exercise I ask them to do, whether it's bicycling, or pool, or isometric quadricep strengthening exercises. I'm going to end with ACP, it came out with guidelines published in Annals of Internal Medicine this week, best practices on cannabis and cannabinoid use for non cancer pain management. You know, I believe that this is a useful adjunct. I've complained that there are no guidelines, because the best guidance on the use of cannabinoids or cancer comes from some guy named Paco behind the counter at the dispensary, and he's saying all kinds of goofy things.

So anyway, at least the ACP has jumped into this. It's a reasonable thing to look at. It looks at the harms and the benefits and the level of evidence that's out there. They came up with four statements: best practice one. A.

Says counsel patients regarding the benefits and harms of starting or continuing cannabis or cannabinoids for chronic non cancer pain. Best practice advice 1b: that you should counsel certain groups of patients that the harms may outweigh the benefits. Specifically, they're concerned about young adults, adolescents, those with substance abuse disorders, those with mental illness that's not well controlled, and frail patients and those who are at risk of falling. Best practice advice number two: avoid these drugs for non cancer pain in women who are breastfeeding, pregnant, or actively trying to conceive. And the last advice is, advise patients against the use of inhaled cannabis to manage chronic non cancer pain.

If you read the article, I didn't write down why, and as I was putting this together I thought, well, why why they got a thing about inhaled weed, where which is what most of the use really is, right? And the article goes into this saying a few things: one, that there are no good studies to really discuss to to confirm its value Two, that there hazards to inhaled cannabis that are akin to inhaled tobacco. Three, the risk of bronchitis is real with inhaled cannabis, and they are particularly worried about older adults with established lung disease being, you know, poor candidates for inhaled cannabinoids. And then there was a, you know, a line in there about that there are no studies about a potential for COPD risk with chronic use of inhaled cannabinoids. So, it's better to go to the dispensary and spend more money, probably, and have to endure the advice of Paco than to, you know, meet in a dark alley and buy a bag of of weed from Paco's cousin, Ernesto.

I don't know why I'm calling them these names, I'm just making this up. But I think you get my point. That's it for the podcast this week. You can go to the website, check out these citations and the links. I want to remind you that if you are in RheumNow Live, it is available on demand.

Over 20 lectures, over 12 TED Talks, all the downloads, all the learning, really high quality stuff. I would encourage you to tell your friends about it. Two things coming up, on RheumNow. One is maybe in two weeks or one week or so, we're gonna start with something called RheumIQ. We're going to invite you to participate in a weekly quiz of last week's news, and it's a quick way of learning what you may have missed.

I think you'll find it fun, interesting and useful. And the other thing is that in the month of May we're going to have a month long campaign on lupus. We're developing the content right now. I think you're going to like it. It's really interesting to me in developing.

I think you're going to like the content that comes across your inbox and also on the podcast. We'll talk next week. Take good care.