EPtalk by Dr. Jayne 5/2/24

The hot topic in the virtual physician lounge this week was that another company has decided that delivering healthcare is more difficult than it thought.

Across the board, members of a primary care discussion group felt vindicated that Walmart plans to close all 51 of its Walmart Health centers as well as its Walmart Health Virtual Care telehealth offering, citing rising costs and “the challenging reimbursement environment.” These are the same struggles that physicians are facing, usually without any kind of corporate subsidy.

The health centers locations by state are Florida (23), Georgia (17), Texas (7), Arkansas (3), and Illinois (1). Non-provider associates are eligible to transfer to other Walmart or Sam’s Club locations, otherwise they’ll be paid for 90 days and then receive severance benefits. Providers will be paid “through their respective employers” for 90 days and then will receive transition payments. Walmart Health is an Epic client, making me curious as to what breaking that contract looks like.

I’m a fanatic about scheduling my next dental appointment before I leave my current appointment, so I was surprised recently when I started receiving reminder text messages that my appointment was due and I needed to schedule. I called the office and they confirmed that my appointment had disappeared from the system, but offered me the “recently opened spot” that was actually my original appointment. It turns out that they migrated their electronic dental record to a different system and apparently some appointments became casualties. I’ve done enough practice management system conversions in my career to know that sometimes things happen, but it sounds like they may not have had as rigorous of a QA plan as they needed since they said other appointments had disappeared as well.

On the Saturday morning prior to my appointment, I received a text message to fill out some forms. I was busy doing other things and didn’t do it, only remembering as I was in the car on the way to the appointment. I had some extra time in the parking lot and tried to fill them, out but discovered that the web app wasn’t really configured for a mobile device and the fonts were too small to read. I couldn’t figure out how to make the fonts any bigger, so gave up and went into the office. They tried to send me the text again to have me complete the forms on my phone. I explained the problem with the font size and they had no suggestions other than to hand me an old fashioned clipboard. They mentioned that “none of the information from the old system came into the new one,” which made my informaticist heart shudder.

The paper forms were a sorry lot, with the first page having been printed without all the desired data elements on it, so someone had gone through and written “Emergency Contact Name and Number” blanks by hand. I zoomed through to the medical history form, and only after answering the first question did I realize that the format made no sense at all. I made my best interpretation at what they were wanting and handed back my clipboard as quickly as possible.

It’s embarrassing that professionals think these kinds of forms are OK. I secretly wanted to offer some clinical consulting services. I mentioned my confusion about the form to the dentist, who reassured me that my records had indeed been migrated into the new system, showing my chart on the in-room display. He said that he would follow up with the front desk to find out why they’re making people fill out a full history, so at least that’s something. I’m not sure who the vendor was on the electronic dental record, but if you work for one and are reading this, please check your mobile app to make sure it’s accessible to those of us who are experiencing the visual changes that come with age.

An ”Inside Story” feature in JAMA Internal Medicine tells the story of what resident physicians feel like when the EHR goes down unexpectedly. The resident describes an “unexpected fatal error to the system that the IT department was working to resolve.” There is no mention of a downtime solution, with the author stating that “samples for the morning laboratory tests could not be collected because the phlebotomy team did not know which patient needed which tests.”

The resident arrived at the “simple answer” of asking patients about their conditions and talking to the nurses who had most recently cared for them. They changed to a “minimum laboratory testing approach” after realizing that it was likely that patients had been undergoing tests that weren’t necessary, but rather were ordered simply as a result of order set use.

The author notes that “the EMR downtime made me realize that while the system seems to make our clinical routine convenient, it may not result in increased efficiency or better patient care.” Patients continue to receive daily labs that are part of an admission order set and those caring for them aren’t asking each day whether those orders are necessary or appropriate. They mention that “I look unprepared to my team when I do not know my patients’ latest basic metabolic panel and complete blood count values during rounds, but no one would ask me how much time I spent talking to my patients.” The author also enjoyed actually talking to members of the care team rather than communicating through the EHR, closing by saying that “our patient care on that day was the most patient-centered and most collaborative than ever in my 2 ½ years of residency.” Only one comment has been left on the piece so far, but I’ve got my popcorn and am sticking around.

It’s time to update those health maintenance settings in the EHR, now that the US Preventive Services Task Force (USPSTF) has issued an updated Recommendation Statement on breast cancer screening. Women aged 40 to 74 are recommended to have screening mammography every two years. The previous recommendation that was last updated in 2016 called for women to begin screening mammograms at age 50 and that women aged 40 to 49 should engage in individualized decision-making to determine a screening plan.

In a situation where we don’t have enough physicians who have the time to truly do health-related counseling during their visits, individualized decision-making can be problematic. Patients are reluctant to schedule a dedicated appointment to discuss screening, so it becomes one more thing that has to be crammed into a well woman or other preventive visit. I wonder how quickly people will be updating the recommendations in their EHRs and how organizations plan to educate physicians and care teams.

What is your organization’s plan to roll out the new USPSTF recommendation? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/29/24

Following my recent piece on bro culture, a number of people reached out to me to share their opinions about culture changes in healthcare and healthcare IT over the years. One of them, who I’ll call Nurse Elaine, had some commentary that was absolutely spot on. We ended up having a lengthy back-and-forth correspondence, which is always fun when you’re an anonymous blogger and still can’t believe at times that people are willing to pour their hearts out to you.

“For most millennials (or later) growing up, healthcare wasn’t typically viewed as a field ripe for entrepreneurial breakthroughs, where one could establish a privately owned billion-dollar unicorn enterprise. Becoming a clinician was a stable career path, often seen as a gateway to a comfortable life with dinner-table respect. Professionals in the 1990s, especially those deeply entrenched in healthcare, didn’t speak of any foreseen disruption looming over the healthcare landscape. The sixth graders of 1994 (today’s professionals) marveled at their first encounters with computers, explored the groundbreaking wonders of Microsoft Paint, and navigated the Oregon Trail. Innovation seemed far removed from the realm of healthcare. However, technological promises have increasingly become intertwined with care delivery with each passing era. For better or worse, it’s interesting when you consider how we got here, to a healthcare landscape filled with unicorn promises, some fulfilled but most not.”

Elaine had some amazing commentary about how enthusiasm for healthcare grew out of the dot-com bubble and talked about companies such as Theranos, Outcome Health, Amwell, and Teladoc that “emerged as darlings of the venture capital world, armed with ambitious plans to clear their consciences and revolutionize healthcare delivery with visions aimed to simplify care processes, address complexities, alleviate fears, and enhance accessibility.” Her next comment had me doing a combination cry/laugh: “Sound familiar? Twenty years in, and we’re still marketing to the same problems.” She went on to describe some of the players as “a wave of powerful novices … who eagerly entered this domain despite their lack of profound understanding of clinical care delivery, wearing glasses tinted with the allure of returns.”

She noted that while sexy startups were expanding their funding sources and building infrastructure, the founder generation of EHR companies was “patiently laying the groundwork for documentation process disruption,” which as a nurse, she sees as some of the only true disruption the industry has seen. Companies like Epic and Cerner were ready to reap the rewards of economic stimuli such as the American Recovery and Reinvestment Act and HITECH, which led to Meaningful Use and a record $35 billion flowing to incentivize EHR adoption. (Spoiler alert: it worked.) We had some great conversation around the rise of the chief information officer role within care delivery organizations and the fact that the role continues to be held largely by men over the age of 50. Sure, we’ve seen some amazing newcomers and some bold women, but for most health systems the balance of power hasn’t shifted tremendously.

I always love conversing with readers who have spent time in the trenches, especially those who have served in an informatics capacity, and Elaine definitely had the “been there, done that” vibe, recapping some of the negatives that had come out of the HITECH Act and Meaningful Use that we’re still facing today: “poorly designed user interfaces, coding issues, burdensome documentation, disconnected quality reporting, inaccessible vendor roadmaps, data sharing without meaningful context” and more. Although vendor quality issues have improved at some companies, others in the same sector remain plagued by it, and other than a handful of companies who have gotten it right, vendor roadmaps are often no better than a pirate-inspired treasure map that may or may not lead to what you seek.

From there we fast-forwarded to 2014 with the rise of Theranos and all that brought to the industry. Elaine reminded me that Elizabeth Holmes was the world’s youngest self-made billionaire, but we know now that it was all sizzle and no steak. That segued into a conversation about the 2016 US presidential election and the impact it had on healthcare, as well as women in leadership. She made some great points about the role of women in decision-making roles at venture capital firms (17%) and the fact that so-called femtech funds established by women “tend to be small due to the perceptions of women as investors – smaller ventures can only offer smaller check sizes that typically do not secure a board seat or significant decision-making power within portfolio companies, which lessens the impact on care delivery and investment strategy.”

She brought up some great points about there being “abundant evidence indicating that women primarily make healthcare decisions within their households and that nurses, predominantly female, form the backbone of clinical care delivery, but corporate boards are often dominated by men.” She went on to say that “this gender disparity fosters decision-making based on a camaraderie mentality rather than merit” as well as failing to consider what’s best for care delivery. I pointed out that some of the decisions I’ve seen also leave out the people for whom this entire industry is designed to exist – the patients, and that unfortunately some people in the industry still act like patients are somehow pesky or some kind of a nuisance. She closed on that train of thought by noting that “while healthcare may not be intentionally anti-woman, it is unmistakably pro-bro.”

By this time, I had learned that Elaine has been in the startup space for much longer than I have, and I wish I had someone like her to bounce ideas off of when I first began working with startups. She captured the most recent decade of investment in healthcare technology as “a frenzied gold rush” with a focus on disruption for its own sake rather than as a method to improve care delivery. She pointed out that investor funding has surged since 2016, growing from $4 billion that year to more than $29 billion in 2021. She had me spitting Diet Coke on my keyboard when I read her comments about “flashy conferences headlined not by expert clinicians but by D-list celebrities” and the “sea of investors swarming in puffer vests,” and looking back at some pictures and conference write-ups from the time period, she’s not incorrect in her assessment.

We talked about Theranos, and she gave me a summary of the billion-dollar fraud at Outcome Health, which somehow I had put out of my memory (the Department of Justice write-up on the incident reads like a bad soap opera plot if you’re interested). The short version involves things many in the industry have seen, misleading investors by inflating performance metrics and exaggerating market penetration. Oh yeah, there was also the part about overbilling customers.

By this point, Elaine and I had been emailing back and forth a couple of times a day, and we had finally reached 2020 and the arrival of the COVID-19 pandemic. This is where I really enjoyed hearing her impressions as a nurse, because it’s always good to commiserate with someone who knows what it feels like when your job decides that you’re expendable and not worth the $5 a day in personal protective equipment that might literally save your life. She talked about some companies that she was exposed to in her work that “emphasized flashy growth rather than gaining a profound understanding of clinical care delivery” and what it felt like to see outsiders showing up at her institution via Zoom call to offer solutions where “the well-established best practices and protocols in healthcare, developed over hears of research and learned from the challenging experiences of malpractice suits and undesirable patient outcomes clashed with the breakneck speed of ventures trying to meet their inflated valuations.”

Clinical leaders had to figure out how to cope with what she describes as “aggressive marketing tactics” and “massive ROI promises” and solutions that had the risk of worsening the pressure on clinicians. Some of these vendors in turn delivered lackluster solutions and shared some information about vendor employees she had gotten to know through her role that reported toxic work environments where teams were tasked with keeping customers quiet about defects so that the company could achieve a unicorn valuation – resembling “the cutthroat world of investment banking more than a mission-driven service sector focused on building sustainable, effective businesses.” She went on to say that “somewhere in this whirlwind, the essence of care delivery to patients and the dedication of clinicians who invested their education, finances, and daily lives into their work became lost amid the pursuit of profit.”

From there, we segued into the bursting bubble that was health tech in 2022 and 2023, with the inability of companies to raise funds among “rising inflation rates, unfulfilled growth, and frivolous spending” and the collapse of Silicon Valley Bank following a classing bank run by frightened companies. Of course, US taxpayers funded yet another bailout. She had me laughing with her advice to the industry: “Going forward, lessons must be well understood to collect $200 and move past go.” She pointed out the need for solution consolidation, the abundance of competitors, and market saturation in certain healthcare technology areas. She had some great stories about vendors who failed to understand the difficulty of selling into large health systems, including lengthy sales cycles and the need to be able to trust your vendors when you’re focused on clinical care and human health. Many healthcare leaders find the traditional tech mantra of “move fast and break things” to be not only ineffective, but at times frightening, and plenty of vendors fail to understand that.

We both shared excitement for the increase in the number of clinician innovators moving into the space. Some of these are coming from innovation groups at established care delivery organizations. In contrast to the disruptor generation, these individuals have personal knowledge of healthcare delivery and operations and understand the highly regulated industry that they’re working in. However, they’re going to have to work hard to compete with the flash and sizzle that’s out there. In my career, some of my biggest wins have been with solutions that aren’t sexy, but they get the job done and don’t increase burden to patients or their care teams. Elaine hopes that venture capital firms, which will continue to be an essential part of the industry, start taking a more sophisticated approach to innovation with attention to experts in the field and clinicians who understand the industry and its end users, including patients.

Ultimately all of us need healthcare and its associated technology to not only work, but to work well. Most of us will end up in a hospital at least once in our lifetime, whether it’s in childbirth, following an accident, for surgery, or for management of a serious illness. When we get there, we’re not going to care about the sizzle. We’re going to want the care delivery equivalent of a four-course meal and we’re going to want it done safely, respectfully, and ethically.

What do you think about the state of healthcare information technology, how we got here, and where we need to go? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/25/24

The CMS Innovation Center has announced its proposed Transforming Episode Accountability Model (TEAM), which will incentivize coordination during surgical procedures and for the 30 days following the procedure. The model is expected to improve care quality including reducing readmission rates and decreasing recovery time. It is also projected to reduce Medicare expenditures and create more equitable outcomes. The model will initially focus on lower extremity joint replacement, hip and femur fractures, spinal fusions, cardiac bypass procedures, and major bowel surgeries. Participating hospitals will receive a global payment to cover all expenditures during the procedure and follow up period in exchange for requirements that they coordinate with primary care teams to promote long-term health outcomes. The model also includes coordination around therapy and rehabilitative services, home health, medications, and hospice services related to included procedures. The model is included in the FY 2025 Inpatient and Long-Term Care Hospital Prospective Payment Systems Rule for those of you who need some light bedtime reading.

Low tech but cool: Michigan Medicine is incorporating Barbie into virtual visits for pediatric rehabilitation to help patients understand how they should be moving. Physicians can use the doll to illustrate how their joints should move as they complete various portions of a virtual examination. A recent study showed that Barbie-enabled mock visits required less verbal prompting and led to an improved understanding of the physicians’ directions without any increase in the time needed for appointments.

Violence against healthcare workers continues to be on the rise, often in ways you might not expect. The Vermont State Police arrested a 27-year old man after he destroyed property with a chainsaw and assaulted staff at Northeastern Vermont Regional Hospital. At the time of his arrest, troopers noted he was “in the parking lot actively assaulting staff.” Vermont classifies “Assault on a Law Enforcement Officer/Health Care Worker” into a single violation. I’m glad to see crimes against health professionals receiving the same visibility as those against members of law enforcement.

Sometimes the combination of items in my inbox tells a greater story than any of them on their own. Two subject lines fell into that category this week: “AI’s Influence on Provider Verification, Credentialing and Enrollment” followed by “The credentialing game is a joke! It is easier to buy a gun than to get a job.” I have empathy for the physician making the latter statement in a comment on an article about credentialing. I’m now at the six-month mark waiting to be credentialed to work for a care delivery organization, and at least in my current state of residence, I could walk into any sporting goods store and walk out with a firearm. I have a clean clinical record without malpractice claims, reports to the state medical board, or shady resignations. Anyone who works with physicians and wants to understand another way in which we might be frustrated should check out the article and its comments. If AI can help solve the problem, I’m all for it. Unfortunately, the email about that led to registration for a webinar that will happen while I’m on a plane, so I’ll have to wait to see how that solution might pan out.

Another interesting inbox item discussed research looking at how to use a smartphone compass to measure things like blood glucose. It leverages the magnetometer properties of the compass in conjunction with magnetic-hydrogel composites that are responsive to different analytes. The authors used glucose-specific hydrogels as part of a proof-of-concept experiment that measured glucose in one of my favorite substances – wine. They compared levels in sangria, pinot grigio, and champagne. For those not inclined to drink wine, they also measured pH levels of coffee, orange juice, and root beer. It’s an interesting way to avoid the additional processes needed when using human subjects. The authors agree that additional work using biological fluids is needed. Having spent some time recently in California wine country, I can suggest a few additional non-biological substances to sample.

A friend of mine whose company is developing a technology solution reached out to me today to make sure his demo script was believable before putting it in front of prospective clients. I gave him a bit of a talking-to about his company’s approach to development, because if you’re doing the process well, you should have examples of customer use cases that were gathered prior to the creation of the solution in the first place. Those can easily be employed for testing purposes as well as the creation of demo scripts. Unfortunately, that wasn’t the situation here, where they built the solution based on an idea and never really obtained the voice of the customer. Sometimes we refer to that as crafting a solution that’s in search of a problem. I’m guessing that having tens of millions of dollars of someone else’s money to spend might have something to do with their approach.

It certainly doesn’t qualify as healthcare technology news, but the ongoing saga of the Voyager 1 spacecraft has captivated me for the last several months. In short, the 46-year old spacecraft, which is 15 billion miles away from Earth, had been steadily sending back data until late last year, when it started sending back nonsense. For those of us who look at things through a clinical diagnostician’s lens, it sounded like the system had the technology equivalent of a stroke. Scientists have been painstakingly working with the craft, sending various messages and commands that take 22 hours to reach it and the same time to return. Fast forward to last week, when NASA announced that it had identified the problem and was working to solve it. Apparently a single chip in the spacecraft’s Flight Data Subsystem had failed, and there wasn’t enough space anywhere else to move the code that resided there. They split the code into four pieces and moved it elsewhere and are in the process of making other code adjustments to help the system route data appropriately to ultimately restore normal communications.

It’s remarkable that the craft is even functioning at all, given its exposure to the hazards of space. The Voyager support teams have performed the ultimate remote surgery to try to get as much life out of it as possible. I probably have more computing power in my wristwatch than Voyager has on board, which is simply amazing to think about. Other notable happenings in 1977 include the release of the original “Star Wars” movie, initial operation of the Trans-Alaska pipeline, and the introduction of Radio Shack’s TRS-80 computer.

What other technology from the 1970s has stood the test of time? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/22/24

I recently spent some time in Silicon Valley, meeting with both existing and potential new clients. I have to say, this is the greenest landscape I’ve seen in this part of the world in a long time. The area has had a lot of rain in recent months and the vistas look very different when they’re not painted in shades of brown. I’ve worked with a number of startups over the years, some of which are headquartered here and others in other tech-heavy parts of the country including Austin, Atlanta, and Las Vegas. It’s been interesting to see how the places have changed and the nature of the business has evolved in recent years. Some of the players, however, don’t seem to have evolved much.

When I first became involved with healthcare technology, it was definitely male dominated. My health system had one or two women analysts, but none in IT management or executive positions. Our ambulatory EHR project was led and managed entirely by women who had a reputation for taking charge – especially since we were the organization’s first technology project that was run by the customer rather than by IT. We opted to lease IT resources from the organization rather than having them run things, since we had several years’ experience with ambulatory EHRs and practice management systems and they had none. Even though we had a bit of friction due to that project structure, everyone was professional, and we were able to get an amazing amount of work done.

Our vendor had a bit more of a boys’ club vibe, with nearly all executive functions held by men. There were a few women in management positions, mostly in more supportive departments like training and accounting. This was my first exposure to what we now call “bro culture,” but at the time, the bros were more outliers and it seemed like executive leadership humored them because they drove results, but only to a point. The guy who took clients to a strip club disappeared from the company shortly after the incident, and people who made inappropriate comments were quickly sidelined. Fast forward half a decade and I was introduced to my first real “bros” – who espoused not only the culture but who somehow brought leadership under their spell and convinced them to spend millions of dollars on projects with questionable merit and even more questionable management. It was the first time I saw people throwing money around with abandon and marginalizing the people who were actually experts in the field and who were doing the work but who didn’t buy in to the culture.

Over the years, we’ve seen the rise of tech bros and pharma bros, and lots of bros behaving badly. Especially after my recent travels, it’s clear that bro culture is still going strong. There are numerous articles out there about the phenomenon, including in the human resources literature. There are some common features seen as people define the issue – including a culture that places winning (and hustling) above all and that excuses the bad behavior that often happens along the way. Bro culture often includes excessive partying, bullying, and harassment of colleagues who don’t play along. If you’ve been in an environment where coworkers make comments because you’re not drinking alcohol or not drinking as much as everyone else, you might be in a bro culture. If you’re hearing snide comments about parental leave, blocked time for breastfeeding, or colleagues being “no fun,” you might be in a bro culture.

I find the phenomenon interesting, because some of the most hustling, winning people I’ve ever worked with are distinctly not bros. At one company, the teetotaling sales reps who were eager to get home to their families did some of the best work, closing deals all over the place. They won by understanding the voice of the customer, prioritizing customer and prospect needs, and valuing the people who worked with them. When working in those environments, I never experienced the level of malicious gossip, toxic commentary, or foul language that I’ve seen in recent times. Don’t get me wrong, I’m not afraid to drop the F-bomb when it’s warranted, but it’s all about knowing your audience and the situation. But if you’re in a situation where inappropriate comments are the norm and not the exception, you might be in a bro culture.

In some organizations I’ve worked with, investors play a role in supporting the bro culture. The New York Times ran an article about this back in 2017, and there are many things about this that haven’t changed. The piece noted that change will only come “… if the people in charge of Silicon Valley – venture capitalists, who control the money – start to realize that the real problem with tech bros is not just that they’re boorish jerks. It’s that they’re boorish jerks who don’t know how to run companies.” I felt validated when I read other comments in the Times piece. As a physician, I’m often one of the only “licensed” people working with a company – the other area being legal. Physicians working in clinical informatics are highly attuned to regulatory and legal requirements and use that knowledge to keep stakeholders out of trouble. If you’re working with people that push you to ignore regulations, you might be in a bro culture. Recent settlements between the Department of Justice and various tech vendors tell that story.

The Times piece uses Uber circa 2017 to make many of its points, with some of those being that “toxic workplace culture and rotten financial performance often go hand-in-hand” and that “bros do best when they hire seasoned executives to help them out.” The author referred to “adult supervision” and “institutional restraints” as essential to avoid a situation where bro “vices end up infecting the culture of the workplaces they control.” One thing not mentioned in any of the articles I found but that I’ve heard about from a couple of people is what we might call the “girl bro.” She definitely has bro tendencies but also functions as an enabler for bad culture and sometimes as a “fixer” trying to clean up messes as they occur. Most of the girl bros I’ve heard of have been in sales roles, but I’ve also heard of them filling an HR function, and if you identify one of the latter rare creatures in the wild, you’re definitely in a bro culture.

I agree with the Times piece that sometimes it takes the business cratering before you start to see a change. That’s unfortunate for the people who work at those companies and who are just trying to get by. Especially in healthcare technology, it’s important to remember that not only are workers there because they’re trying to support their families, but also because they’re often “true believers” who want to do the right thing for patients and their loved ones. I think for those types of individuals it’s especially difficult to be in a bro culture and they often vote with their feet.

What do you think about bro culture in healthcare, and in healthcare technology in particular? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/18/24

It’s long been known that women make many healthcare decisions for their families, if not the majority of healthcare decisions. A study published last month in JAMA Network Open shows that patients who are female or who have chronic illnesses are more likely to use telehealth. The data in question is from 2002 and was part of a cross-sectional study of 5,400 adults where 43% had telehealth visits during that year. Video visits were less common among patients aged 65 to 74 and those without Internet. The authors found no differences when patients were segmented by education, race/ethnicity, or income. Other interesting tidbits included the fact that nearly 20% of patients reported technical difficulties and that 30% of telehealth visits were conducted using only audio connections.

From Doomsday Prepper: “It’s not just the bulging cans anymore. Did you see this writeup about the CDC investigating counterfeit Botox that’s giving people botulism?” I have to admit I don’t spend as much time in the epidemiology literature as I once did, but it looks like patients in the pursuit of youthful appearances may be turning to low-cost or unlicensed providers who are placing them at risk of serious illness. The Centers for Disease Control announced that it is looking into incidents in nine states where 19 people have reported serious illnesses following botulinum toxin injections. Affected patients may have visual changes, trouble swallowing, or even breathing problems. Symptoms were severe enough in 60% of the patients to warrant hospitalization. Patients can protect themselves by asking if providers are licensed and trained to administer the injections, and whether they’re using FDA-approved products obtained from a reliable source.

I’ve spent more than a decade working with organizations that span multiple time zones, so I’ve had to be continuously conscious about how I schedule meetings. Ideally, employees will specify their working hours in the organization’s calendar application, but I’ve seen several articles recently about whether “8 am meetings” should be done away with. The phrase implies that the time would be 8am for the majority of employees, but in a distributed organization 8 am on the east coast could be 5 am on the west coast, or even earlier for employees in Hawaii. Early morning meetings can make for difficult childcare arrangements – as someone who used to have to round at 6:30 am, I feel that pain acutely. Although healthcare organizations run 24×7, I’ve seen more of them opting to avoid early morning or late afternoon meetings in order to create more flexibility for employees.

Although I’m supportive of making team operating agreements around meeting hours (and even banning meetings at certain times, like Friday afternoons, when everyone’s out of brain cells) I think it’s even more important to make sure meetings are necessary, well-planned, and well-executed. One of my favorite organizations to work with has questions people have to walk through before scheduling meetings. For example, if there are multiple people from the same team invited, do they all have to be there, or can one person represent the team? Is there an agenda that includes expected discussion points and anticipated outcomes? Who will document minutes and action items so that those who are not in attendance know what happened? It seems simple, but the majority of organizations I work with have little to no framework for productive meetings. That same organization has also implemented a policy where meetings are scheduled in 20- or 50-minute increments, allowing people to check email, take care of personal needs, or just decompress when they’re subjected to back-to-back meetings. With those breaks in place, there’s an expectation that meetings start and end on time, which I’m sure everyone appreciates.

In the spirit of “what goes around comes around,” telehealth company Cerebral gets hit by the Federal Trade Commission with a multimillion dollar fine for deceptive practices around data sharing, security, and cancellation policies. In addition to the fine, Cerebral will be prohibited from using health information for advertising purposes. Cerebral is widely regarded by physicians as having contributed to overprescribing of ADD and ADHD medications and a subsequent shortage of those medications for patient use. Although they’re not getting the smackdown for that, they are being penalized for providing sensitive information to third parties including patient demographics, medical and prescription histories, IP addresses, and more.

They were also cited for mailing postcards to patients that included language revealing diagnosis and treatment information for anyone to see, allowing former employees to continue to access health records, allowing non-providers to inappropriately access patient records, and having a faulty single sign-on process that allowed patients to see the sensitive health information of other patients during simultaneous logins to the company’s patient portal. The company will pay $5 million for consumer refunds, a $10 million civil penalty, and a $2 million penalty due to inability to pay the full amount. The company will also have to place notices on its website about the allegations and its ongoing mitigation plans. It feels a little like putting Al Capone in jail for tax evasion rather than other crimes, but given the damage this company has caused to patients and their families, we’ll take it.

The American Medical Informatics Association is conducting a survey on documentation burden among health professionals. The AMIA website lists the primary goal of the survey as being “to capture perceptions of excessive documentation burden across various healthcare disciplines frequently (e.g., every six months) to trend changes over time.” The survey is open through April 26 and will reopen in August. Licensed and unlicensed health professionals who provide patient care and document in an EHR are invited to participate. The survey took less than two minutes to complete.

I didn’t know much about public health informatics until I began to prepare for the initial Clinical Informatics certification exam more than a decade ago. As I read a couple of textbooks that covered the field, I found myself fascinated by the ability to use data to drive health outcomes. Fast forward a few years and we found ourselves living in a public health research project, and informatics efforts in the field accelerated dramatically. The CDC recently updated its Public Health Data Strategy to include addressing gaps in public health data and to reduce the complexity of public health data exchange. Although we’re seeing improved funding for public health informatics efforts at the federal level, it’s still a patchwork when you look across the states. Some of the state-level efforts in public health are pathetic, which is a sad commentary on how those states value the individuals living and working within their boundaries.

What is your community doing to support public health? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 4/15/24

I spent this weekend at a class reunion for my medical school. They host a reunion event every year, but the attendees are only invited in five-year increments. It was interesting to see the breakdown of registrations. No one attended from the class of 2019, which seems expected since those physicians are likely still busy with training or are in their first few years of practice and might have trouble getting away. The class of 2009 also had no attendees, but many of the other classes had about a dozen members in attendance. The class of 1974 knocked it out of the park with 31 attendees. The oldest representatives were from the classes of 1954 and 1959, which each had one representative. My class is distinctive because we were the first one to have more women than men. I was speaking with a woman who graduated five years before me (and who happened to be one of my chief residents when I was on clinical clerkship rotations) and she mentioned that she was one of only 20 women in her class. It’s amazing that the university was able to shift the demographic that dramatically in only five years.

The weekend was full of educational events, campus tours, city tours, and several social events. One of the highlights of the week was a scholarship dinner, attended by some of the scholarship recipients as well as those who had donated to class gift funds that provide scholarships. I had three students at my table – one was in his first year of medical school, and the other two were in their third years and were knee-deep in clinical rotations. It was interesting to hear about the specialties they find most interesting and what they might plan to pursue as a career and why. Primary care is at the bottom of the list, at least among the students I talked to throughout the weekend, despite the university moving towards a “zero debt” financial aid program that is supposed to allow students to “follow their dreams without fear of student loans.” It became apparent in other conversations that the university is really pushing for students to go into academic medical careers, which are historically lower-paying than those in private practice.

Although the members of my immediate graduating class know what I do for a living, nearly everyone else I spoke to started the conversation with “Where do you practice?” and I had to explain my career as a clinical informaticist. None of the people I talked to outside of my classmates knew that clinical informatics was a board-certified subspecialty or that you could make a career out of it. Upon learning what I do, several attendees went into some pretty serious rants about how electronic health records have destroyed the practice of medicine. Fortunately, most of the social events allowed me to keep a gin and tonic in hand so that those conversations went more smoothly than they might have otherwise.

Of the members of my class attending, only two are still in full time clinical practice. The rest are either in academic positions where they only see patients one or two days per week, or they are in pharmaceutical or other industry roles where they no longer perform patient care. As someone who is trained in primary care, I’ve had plenty of times in my career where I’ve felt bad about not being in full-time clinical practice – that I’m part of the physician shortage problem. However, looking at what my colleagues are doing, I don’t feel so bad. Even when I’m not seeing patients, I’m generally working on projects that are directly applicable to patient care and helping those on the front lines be able to deliver it in a more seamless way with less burnout.

Speaking of burnout, I wasn’t surprised to learn that the most burned out member of our class is in emergency medicine. She was talking about working during the worst parts of the COVID pandemic and about not having appropriate personal protective equipment. Her comments immediately took me back to being in that same position four years ago. Others in the conversation acted like it was their first time hearing about such things, and it sounds like most of them spent the pandemic doing administrative tasks, performing research, or seeing patients via telehealth. She mentioned the push of private equity organizations into the emergency medicine staffing space and the fact that it’s driving people out of practice. Fortunately, one other class member who happens to be in a specialty heavily impacted by private equity acquisitions (dermatology) took up that charge and spoke about how that transition has nearly destroyed practices in his city. His private practice is a holdout and continues to do well, although he admits they did consider being acquired but felt it would be a bait-and-switch situation.

Our class was about 50/50 with medical versus nonmedical spouses, and in contrast to previous years, only a couple of spouses showed up to all the events. I guess by this point in their lives they figured that listening to their spouses reminisce about graduate school wasn’t the most exciting way to spend an evening, especially when a ticket purchase was required. It will be interesting to see who is still in clinical practice when we meet again in five years, and who has decided to hang up their white coats for good. Speaking of white coats, our school’s students now receive theirs during the first month of school as part of a professional initiation ceremony, complete with the class writing its own oath of professionalism and with many family members in attendance. The students I had dinner with were surprised to learn that we received ours folded up in plastic wrappers from the bookstore, only a couple of days before we went to our clinical rotations. We certainly didn’t have luxurious coats embroidered with our names and “Prominent School of Medicine” logos.

I’m glad those in charge have improved things in the intervening years, but a bit sad that they hadn’t figured it out back in my day. Our alma mater has completely revised its curriculum, integrating clinical experiences very early in the first year and encouraging students to take elective courses in areas they find interesting. Compensation has improved for those teaching, which hopefully means fewer professors that act like it’s a chore. The facilities are top notch, and I wish we had access to advanced simulation labs rather than having to practice certain skills on each other or even patients. It’s nice to see things changing for the better and I wish these up and coming students the best.

What do you think about the future of your profession? How can we do better for the coming generations? Leave a comment or email me.

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EPtalk by Dr. Jayne 4/11/24

I recently saw an article talking about the creation of chief AI officer roles at several organizations. Artificial Intelligence is here to stay and we need to be proactive about its consequences. Politico ran a great article recently that looked at the intersection of AI and medical malpractice. It cites comments from AMA President Jesse Ehrenfeld, who says that lawsuits are already being filed about the use of AI in healthcare. In speaking with some of my friends who are attorneys, they noted that there will be some interesting case law created over the coming years. Tech vendors will be pointing fingers at the clinical end users who leverage AI in patient care, and those practitioners will be pointing their fingers right back at the AI technology’s creators. Physicians are already left holding the bag for a variety of things, including patients who refuse recommended care and patients who get caught in the crossfire when insurers won’t cover recommended care. What’s one more point of liability?

From Madge in HR: “Thanks for mentioning employee handbooks last week. I think the majority of people just sign them blindly and don’t read them. It’s always interesting to me when a company deploys a new policy to the wild, but especially so when you know that the policy is the result of a recent event. My company just announced our new ‘Professional Behavior Policy.’ While it’s shocking to me that we need such a policy in place, it’s reassuring to know that the company values professionalism and is willing to require it of every employee. The prohibited behaviors that stuck out to me included: slamming doors; refusal to communicate or communicating dishonestly about business matters; obstructing, undermining, or preventing another employee’s work performance; and possession of objects that are sexual in nature. Long story short: Be nice to each other. Don’t throw a tantrum. Don’t lie. Don’t keep others down. And for the love of all that’s good and right, keep your bedroom toys out of view when you’re on a Teams meeting.” Although I agree with the intent behind these, I don’t envy those that have to handle complaints on some of the more subjective issues. Most of us have at least some experience at companies where people stretch the truth to varying degrees and where politics and blocking are a daily event. It’s sad given the fact that we’re all in an industry where the ultimate use case is about helping people.

The US Food and Drug Administration has cleared its first AI tool for sepsis detection. Developed by Prenosis, the Sepsis ImmunoScore tool was approved through the FDA’s De Novo pathway. Sepsis is a serious health condition, leading to more than 350,000 deaths annually. The tool looks at more than 20 clinical parameters including vital signs and laboratory results to help identify sepsis risk. Although other organizations, including Johns Hopkins University and Epic have built sepsis detection systems, this is the first one to receive FDA approval. The Prenosis tool sorts patients into four different risk categories but is not considered an alert system. Testing was performed on a dataset that included more than 25,000 patients.

Having spent a good chunk of my career working in emergency department and urgent care settings, a recent article about “rat snacking” really resonated with me. Although the headline was mostly about physicians, the piece applies to anyone whose work schedules disrupt traditional mealtimes. The authors define “rat snacking” as when “people consume whatever type of food they can scavenge.” Anyone who has ever subsisted on graham crackers and apple juice swiped from a hospital unit’s floor stock feels this in their bones. A local hospital recently curtailed the availability of what one nurse describes as “real food” on the night shift, citing cost control measures. Maybe they should be more aware of the literature that shows that disordered eating can lead to nutritional deficits and excess consumption. Of course, the answer is planning ahead and packing your own food, but that only goes so far when your eight-hour shift suddenly becomes 12 or 14.

The Change Healthcare ransomware debacle continues to be a thorn in the side of many physicians, as they await claims and payments to catch up. Several of my local colleagues have had to take out lines of credit or personal loans to cover office payroll and they’re eager to eventually reach resolution with their revenue cycles. Change Healthcare’s parent company, Optum, isn’t winning any friends with recent headlines about practice acquisitions that leave patients without physicians as theirs jump ship. This particular story includes a vignette of a patient who has been part of the practice for more than two decades but cannot be accommodated after the departure of his physician. The patient panels carried by primary care providers these days are more than twice the size of those that existed when I was in a traditional family medicine practice, and those bloated panels make it difficult to recruit replacement physicians.

The happenings going on at this particular organization, Oregon Medical Group, have led to the introduction of legislation designed to slow the influx of corporations into healthcare in the state. The reality of the entry of these parties into the healthcare ecosystem is that their goals are not the same as the owners they replace – often physicians. Where physician-owned organizations will generally continue to participate with low-paying payers, such as Medicaid, many corporate entities move quickly to try to push those patients out of the practice. Non-physician owners that have shareholders are motivated primarily to deliver profit to those shareholders, which can increase provider burnout and place patients at risk.

Given the challenges facing primary care physicians, I was surprised to see the number of medical students who requested to participate in my local medical society’s “Coffee with a Doc” program. I took a first-year medical student to lunch and was surprised to learn that her school is incorporating classes on “the business of medicine” as early as year one. She had some good questions about RVUs and physician payment, and I introduced her to the concept of Direct Primary Care, which apparently wasn’t included in her curriculum. I’m seeing increasing numbers of my family medicine colleagues moving in this direction, so I’m glad the topic came up. Kudos to her school for adding information to the curriculum that can help students learn more specifics about what they’re getting themselves into.

From Stage Mom: “Given your previous comments about health systems sponsoring stadiums and other facilities, I thought you would appreciate this article about a $5.4 million theater naming deal.” BayCare Health System, based in Clearwater, FL, will pay the amount over a 10-year period in exchange for naming rights at the BayCare Sound amphitheater. The agreement has an option for a 10-year renewal in 2034. BayCare also has a ballpark under its belt. According to ChatGPT, that amount of money would pay for more than a quarter million influenza vaccines, or more than a hundred thousand cervical cancer screening tests, or more than 36,000 mammograms. I wonder which the community would rather have?

Will health systems keep slapping their name on everything, or will they start to put their non-profit profits to better use? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 4/8/24

I found myself working this weekend in the path of totality for the solar eclipse. I’m glad I booked my travel almost a year in advance because standard rental cars aren’t available from the usual national brands. Rates for the remaining luxury vehicles are upwards of $400 per day, so I was glad to have locked in at $47 when I did.

My conference-rate hotel was also locked in at $104 per night and my hotel is sold out. I’m fairly certain they are not used to having so many guests, because they don’t have enough towels to restock the guest rooms in real time. They’re picking up towels in the morning, laundering them, and replacing them around dinner time. Management has been extremely apologetic, and I feel for them having to staff around a conference that always happens during this particular timeframe and then having an eclipse thrown on top of it.

It’s been interesting to hear people in the hotel restaurant talk about it. This morning, I sat next to someone who traveled 1,700 miles to experience a total solar eclipse. Based on the weather forecasts, there’s a good chance it will be cloudy on Monday, but even if you can’t see the sun, the eclipse will still happen. I was in the path of totality in 2017 as well, and it was pretty wild to feel the temperature drop and hear the bird song disappear, only to be replaced by the sound of crickets.

The pinhole viewer that I built worked well despite the fact that I made it from a cereal box and aluminum foil. Since I’m traveling this year I plan to just stick with a pair of certified eclipse viewing glasses. A recall has been issued for certain glasses that were sold at convenience stores in the area, which is sad as well as potentially devastating that someone would create counterfeit glasses that could lead to serious eye damage.

In anticipation of everyone wanting to go outside for the minutes of full totality, I made sure we have a gap in the agenda to accommodate it. I did something similar in 2018 when the first SpaceX Falcon Heavy rocket was launched, taking advantage of a high-end conference room projection system to see it live. For the people who were paying my salary back then, don’t worry, I worked it into the change management seminar I was presenting. I guarantee that people walked away with lessons in teamwork and diversity as well as having experienced history being made.

With respect to this year’s eclipse, several governors have made emergency or disaster declarations in advance of the arrival of throngs of people to their states. When people question why they might do that, I explain that it’s all about scarce resources and disruption of processes. I’m in an area that’s not exactly a tourist mecca and I guarantee that people will be pulling over on the interstate tomorrow, creating increased risk for first responders and ambulance traffic around the regional medical center. I’m sure there will be fender-benders as well if people are driving distracted.

It’s going to be in the 80s here tomorrow, which is unseasonably warm for this area, and that will increase the risk of heat-related illness. I met a traveler whose medications were in a piece of checked luggage that went missing, so they are going to need to get a replacement prescription and possibly need to visit an urgent care if their physician doesn’t manage the request on a weekend. I also chatted with some adults who were chaperoning a school trip to see the eclipse. They mentioned that so many teachers requested time off to experience it with their families that they didn’t have enough substitutes to fill the gaps, so the school decided to cancel for the day. They were planning on spending Sunday visiting some sites that were important to the Civil Rights Movement in the 1950s, so learning will going on that goes beyond just science.

A lively discussion is underway in one of the American Medical Informatics Association forums about the use of Microsoft Teams as a clinical communication platform. Many people have chimed in about their experiences with various types of messaging, including EHR-based secure chat, third party solutions, and use of old-school telephones and pagers. An article from the Journal of Medical Internet Research that was mentioned looked at use of an integrated EHR-based secure chat in a large Midwestern health system. Data was collected from July 2022 to January 2023 and analyzed with regard to message volumes, response times, message characteristics, user roles, work settings, and messages sent and received by users.

Researchers identified 9.6 million messages that were sent by 33,000 users. Nurses sent 40% of them, followed by physicians at 25% and medical assistants at 12%. Many users interacted with 20 more more messages per day, leading the authors to raise concerns that short message response times (average 2.4 minutes) and high volumes “highlight the interruptive nature of secure messaging, raising questions about its potentially harmful effects on clinician workflow, cognition, and errors.”

We hear a lot about workflow and the burdens that are associated with increasing message volumes, but I don’t see a lot of people talking about the impact on thought process and errors. Research has shown that true multitasking is a myth, and we’ve all seen the negative impacts of trying to do too many things at one time without enough focus.

The always-on nature of communication these days tends to make many clinicians I know feel edgy, like they can never turn off their workday. In my online forums, I routinely see questions from clinicians on how to disable messaging during non-work hours. One physician resorted to getting a separate work phone and having her spouse lock it in a drawer during her off times because she couldn’t help but check it all the time, fearful of missing something. Hopefully, that’s an outlier scenario, but it illustrates how caregivers are being impacted by technology.

The study also found that across 14 hospitals and 250 outpatient clinics, weekly message volume grew by 31% in a six-month period. It had some limitations, one of which was that they were unable to link the data with work schedules or to identify when messaging was being conducted during non-working hours.

The authors noted that additional work is needed to better understand whether secure messaging is replacing other methods of communicating, such as phone calls, or whether it is “simply increasing the overall burden of communication.” They also cited concerns on whether secure messaging is less efficient than other real-time modalities and whether the asynchronous nature of messaging increases the time to resolution of patient issues, since messaging conversations had a median duration of 25 minutes compared to what would likely have been a much shorter phone call.

Notwithstanding the need for additional research, it’s important to make sure that healthcare delivery organizations have their systems configured correctly so that the right people are receiving messages at the right time. Clinicians shouldn’t be expected to respond to secure messages 24×7 unless they are on call. Being able to have true downtime is essential to healthy functioning, whether people realize it or not. Clinicians should also be well-educated in how to set their accounts as “away” or similar so that other users don’t simply fire messages into the ether and hope for the best. From the virtual water cooler, it sounds like there are some opportunities in setup and education.

How does your health system handle secure messaging? Is it a helpful tool or an electronic tether that clinicians feel they can’t escape? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/4/24

As usual, Epic put smiles on peoples’ faces with its annual April Fools’ Day webpage, stating that “the newest building on Epic’s campus will have the coolest theme, like, ever: Barbie Dream House.” It went on to say that the fictional building would include a pool slide and conference rooms named Beach, Girls’ Night, and Mojo Dojo Casa House.

The page also joked that Epic had been selected by television network ABC as the official EHR of “Grey’s Anatomy” to add more medical realism to the series. It wrapped up with a discussion of MyHeart: Epic’s New Dating Portal that “runs advanced searches to find patients near you who might be a good match based on hundreds of criteria, including your problem list, allergies, medications, and more.” Well played folks, well played.

I’m in the middle of an onboarding process for a new position, and although I was dreading the experience, it’s one of the better ones I’ve been through. As a consulting CMIO, I’ve worked with dozens of health systems and care delivery organizations and have gone through either full onboarding processes (when I’m an employee) or through modified onboarding (when I’m a contractor.) The experiences have varied dramatically. One of the worst processes I’ve ever seen involved demands to sign documents attesting to the fact that I had received and read policies that didn’t exist, which I only found out after asking to see them. I wonder how many of their regular employees just signed blindly? Some of the better processes have a clear onboarding checklist to ensure that you’re doing everything in the right order, and the best have that plus the ability to ask questions real time.

I’ve been through dozens of HIPAA training courses, as well as education on fraud, waste, and abuse, to the point where I could probably teach the curriculum. For this position, even though the role is technically non-clinical, I had to go through training on proper lifting, ergonomics, and the importance of non-skid footwear, none of which I’ve gone through for patient care despite the fact that they would have been useful. If you’re looking for an example of training that will engage people rather than make them snooze, I highly recommend Skip, the workplace safety superhero. It will be interesting working in an actual office again. Even though I’ve done patient care in person, this will be a different type of environment, and I’m excited that it doesn’t require navigating a TSA checkpoint or wondering whether my rental car will be there when I arrive. It’s time to dust off my trusty lunchbox and pack my Thermos for what I’m sure will yield many good stories.

From Jimmy the Greek: “Re: telecommuting. I’m a fan, but also recognize that with privileges come responsibilities. Now that I’m fully entrenched in a hybrid model where employees within a one-hour commute of an office are required to be in the office three days per week, it’s been interesting to see how our remote employees still enjoy a certain relaxed atmosphere in their home offices. The company I work for has a strict tobacco-free policy on all company campuses, but it also covers remote work, where employees are prohibited from ‘smoking or using tobacco products’ while visible on a web conference. It was a bit jarring, therefore, when one of my fully remote co-workers stepped onto her front porch to enjoy a smoke while fully visible on a Zoom meeting. I don’t smoke, but if I did, seeing someone light up a Marlboro while I was stuck in a conference room almost a kilometer away from an area where I could smoke without fear of disciplinary action would definitely reduce my overall job satisfaction.” I’ve read a number of employee handbooks in my career and this is one place where the devil might be in the details and sentence structure is everything. The use of the phrase “prohibited from smoking or using tobacco products” implies that they are only blocked from smoking tobacco cigarettes and not others. Vaping, which is certainly as distracting as smoking cigarettes, isn’t mentioned, nor are marijuana cigarettes. Perhaps the human resources department might want to consider more specific language that includes all the different things one can smoke as well as vaping and/or use of other tobacco-containing products. For the employee in question, a refresher on learning how to operate camera controls might be in order.

I was excited to see that the Department of Veterans Affairs is implementing some solid use cases for artificial intelligence. One model called REACH-VET is designed to help identify veterans who are at highest risk for suicide. Another uses natural language processing to flag patient feedback for comments that suggest homelessness or other issues where human intervention might be appropriate. A third model looks as veterans with prostate cancer to differentiate those who will do well after initial treatment from those who need more frequent follow-up. Congressional subcommittee members responsible for VA oversight want to ensure that safeguards are in place when AI is used, with Technology Modernization Subcommittee Chair Matt Rosendale pushing the VA to make veterans aware of instances where their data is being used in AI models.

I was also pleased to see the US Senate looking into whether emergency department care delivery has been harmed by the involvement of private equity firms. The inquiry follows interviews with emergency physicians who are concerned about patient safety issues related to aggressive cost control activities. The most recent investigation falls under the Homeland Security and Governmental Affairs Committee and follows one that is already in progress by the Budget Committee that is looking at hospital systems that are associated with private equity.

I’ve worked for some of the companies that are part of the investigation, and based on my experiences, I don’t think the Senate is going to like some of the things they uncover. It’s no secret that what are considered the most cost-effective ways of delivering emergency care often involve the least-trained and least-experienced clinicians. When things get wild, there is no substitute for a seasoned emergency department physician with decades of experience under their belt, but organizations are certainly eager to replace them strictly on cost alone.

How do you feel about the rise of private equity in healthcare? Have you seen examples of where it’s helping or hurting? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/1/24

I’ve spent the last couple of weeks catching up on some reading, after my library “hold” list went rogue. I typically keep several dozen books on hold but in a frozen status so that I sit at the top of the wait list and can release them when I’m ready.

For some reason, a cluster of them released unexpectedly, dropping on top of my already planned reading. Unfortunately, at my library there isn’t a way to send a book back to the hold list once it’s in transit, unless you want to start over at the end of the line. I dutifully picked up my books and dug in for some intense reading, since you can’t renew them if others have them on hold and I wanted to make sure I was able to read them all. One of the books was “The Chaos Machine: The Inside Story of How Social Media Rewired Our Minds and Our World” by Max Fisher.

Being in healthcare and taking care of adolescents, teenagers, and young adults, I’m acutely aware of the impacts social media has had on these groups in recent years. Even before the societal disruptions of the COVID pandemic, research tied use of social media to sleep issues, which are in turn associated with depression, memory issues, and poor school performance. As we became physically isolated during the pandemic, many young people turned to social media to fill the void, with varying results. In many communities, cyberbullying has been on the rise, and concerns about social media have increased to the point where the US Congress is stepping in.

“The Chaos Machine” is full of meticulous details, many of which are pulled from interviews with Silicon Valley executives, social media experts, gaming experts, academics, and those who have been negatively impacted by social media. It references scholarly works, court records, and other primary sources that tell a story that most of us can’t even fathom. Given the subtitle, I expected it to dig heavily into the physical and psychological impacts on individuals with the concept of world impact as an abstract. I’ve read about the impacts on social media on US politics but wasn’t aware of many of the details the book provides about how the technology has directly impacted other countries, such as Myanmar and Brazil.

Parts of the book are difficult to read, including descriptions of online mobs threatening whistleblowers with violence ranging from swatting to rape or murder. Even more difficult to read are the descriptions of indifference by social media executives when confronted with evidence that their products are causing harm. Surprise, surprise, internal Facebook documents from 2018 reveal that systems were intentionally designed to deliver “more and more divisive content in an effort to gain user attention & increase time on the platform.” The book covers the rise of medical misinformation on social media and some of its harms, but having been a frontline physician, it doesn’t really explain the magnitudes of harm that we see when people use social media for medical advice.

Especially interesting was the description of the growth of Silicon Valley, comparing it to the Galapagos Islands as far as providing a unique evolutionary environment for technology development. However, instead of the isolation leading to the development of unique animal species, it led to “peculiar conditions” that “produced ways of doing business and of seeing the world that could not have flourished anywhere else – and led ultimately to Facebook, YouTube, and Twitter.” I see some of the same conditions in healthcare IT, where people still believe that you can just throw money at problems and somehow they’ll get solved, and where the people calling the shots often have only a rudimentary understanding of how healthcare is delivered in the US.

The book takes a walk down memory lane, talking about strife that took place in 2006 as Facebook introduced its News Feed. It was one of the first documented episodes of internet outrage becoming action, complete with protesters and the side outcome of dramatically expanding user engagement. “The Chaos Machine” covers the so-called casino effect, where social media platforms use the human dopamine system to hook users with intermittent variable reinforcement. It chronicles the rise of social media “like” buttons, which provide additional reinforcement through validation from other users.

I don’t’ want to give away the rest of the book, but I think it’s worth the read. I would recommend it for anyone who is trying to raise children in this crazy world and who thinks it’s OK to just let them play on a parent’s phone or that it’s a good idea to help a child falsify their age to obtain a social media account.

I met a new neighbor whose children attend a Waldorf school, which holds the philosophy that “exposing children to computer technology before they are ready (around 7th grade) can hamper their ability to fully develop strong bodies, healthy habits of discipline and self-control, fluency with creative and artistic expression, and flexible and agile minds.” In thinking about adolescent patients, I’m supportive of this stance, although I know that for parents it’s a nearly impossible battle unless the rest of the “village” around your child is similarly aligned. In thinking about some of the adults I know, it might have been a good idea to keep them away from social media even longer because they’re apt to behave badly even though they’re of age and should know better.

The book was a fairly quick read, as well as something different from my recent binge reading of murder mysteries and detective novels. Next on the list are two novels from Stacy Abrams, followed by chef Iliana Regan’s memoir “Burn the Place.” I enjoy reading about strong and determined women who have made their mark in industries that aren’t supportive. If it’s a good read, her second book “Fieldwork: A Forager’s Memoir” also threw itself out of my rogue hold queue. After that will be “Symphony of Secrets” by Brendan Slocumb, which I’m auditioning for a potential book club selection. If you’re in a book club with a sassy CMIO, you might want to hold on reading that one for now just in case.

What kind of books do you read when you have free time? Or do you accumulate a list or stack that you might never make it through? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/28/24

I attended a recent online forum focused on a telehealth topic. I was surprised to find that some of the participants really didn’t understand the idea of a virtual-first practice. The only way they could conceptualize it was as part of a brick and mortar organization. When I started talking about ordering labs from services that would come to the patient’s home or using patient-provided data from connected devices, I got some blank stares.

The participants were from large health systems and other well-established organizations. I wonder if they’re outliers in their organizations or whether there is really a lack of interest in trying to deliver care outside of traditional office-based settings. Being able to offer services like that isn’t just about convenience. It’s also about serving patients in remote areas and helping those who have other reasons they can’t leave their homes. I hope they take the ideas back to their organizations for discussion.

I receive a ton of marketing emails and spammy-sounding connection requests on LinkedIn. It’s guaranteed that I won’t accept your request if you use made-up words to try to sound cutesy about the serious problems facing physicians today. Case in point: one vendor positioned their product as “the cure for documentitis and physician burnout.” It went on to further define “documentitis” as “inflammation caused by burdensome documentation requirements imposed by EMRs, billing systems, etc.” I’m sure their marketing folks thought it was amusing, but it shows a complete lack of regard for the true causes of documentation fatigue, including out of control regulatory requirements, expanding quality measurement, and lack of regard for the professionals in the system. As someone making purchasing decisions, this kind of messaging takes a company to the bottom of my round file.

Another one of my pet peeves seemed to be everywhere this week — the presence of large microphones in front of the participants on conference calls. I sympathize with the need to have clear audio and to want to use nice equipment, but when you’re a healthcare professional communicating with other healthcare professionals, it’s important to remember that you’re not a DJ and this is not a podcast. The majority of people I take calls with use integrated laptop microphones, earbuds, or something higher tech but unobtrusive, and they sound just fine. I’m hoping this was just a freak occurrence this week and it’s not a new trend. However, as a licensed amateur radio operator, I’ve got some solid options to put into play if it does become the hot new thing.

One of my favorite readers sent me an article about AI nurses, referring to the idea as “cray-cray.” The phrase has been added to the Oxford Dictionary, so I’m not afraid to quote it. The premise on AI nurses is that they’re designed to deliver non-diagnostic nursing care, such as education, which would help mitigate the ongoing nationwide nursing shortage. The idea was dissected recently in The Hustle, which offered some interesting commentary, including the fact that the hardware needed to run such an offering isn’t cheap.

I would add to that the fact that nursing is regulated by the states and licensure is required, so it’s going to be a hard sell that this is actually nursing care versus something else. Organizations will have to look closely at quality metrics that have been shown to be improved through effective nursing education, such as readmission rates, and understand whether AI-delivered education will meet the mark or cause other downstream consequences.

Speaking of potential unintended consequences, I was glad to see a recent article that looked at whether the hospital at home movement could be a double-edged sword. Although positive outcomes have been reported in the literature, such as reduced costs and improved patient experience, some areas haven’t been fully researched. I’ve talked about some of these in the past, including equity and the fact that patients with lower socioeconomic status might not have a caregiver in the home or a safe home environment compared to those in higher socioeconomic categories. The article brings up the idea of safe storage of medications, availability of food particularly in areas that are food deserts, and the ability to safely store meals that may be delivered in advance. Reliable and cost-effective utilities may also be an issue in some situations, as is the presence of broadband for communications and device connectivity.

The comments section on the article brings up additional points. One commenter who used RN in her name described it as “just a fancy earlier discharge scenario. We already have post-ops shoved out the door half awake, unable to dress themselves and throwing up the whole way home. What a crazy, cruel system we have created.” Another referred to the concept as “quite the pipe dream given today’s realities and limited resources.” Another commenter with experience as a home health RN noted, “I have been in extremely low income homes that were kept in immaculate condition and were exceptionally clean and have been in other homes that were in extremely well to do neighborhoods that were so dirty on the inside that I had concerns with even placing my bag on the floor.” That’s an interesting point and creates an additional burden on organizations to ensure suitability of the environment regardless of its ZIP code or other identifiers. I’d be interested to hear from organizations who are already managing hospital at home to understand how they assess potential care environments and what percentage of candidates are deemed suitable once there is a deeper dive.

I’ve always been interested in public health, so I was glad to see the US Food and Drug Administration publish information on egg safety for those who celebrate spring religious holidays such as Easter and Passover. Salmonella is always a concern where eggs are involved, and the press release offers tips on safe handling, cooking, and storage. Deviled eggs are a staple for family gatherings in our family, but I do enjoy the holiday clearance aisle at Target for all my post-Easter cravings.

What’s your favorite springtime food? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/25/24

This weekend was targeted on catching up on some journal articles and making a continuing education plan for the next couple of months. I’ve got some new projects I’m working on that are a little bit outside my comfort zone. I know from experience that unless I make a formal plan to dig into the topics and stick to their plan, there’s a high likelihood that I’ll get pulled into firefighting projects for my clients and will never get done with the reading I feel I need.

Part of today’s effort was to read through all the articles that I’ve bookmarked in the last couple of weeks because I find them interesting, clearing them off the digital reading pile. It was a good cross section of topics and I think readers might find it interesting to see what’s on the reading list of a free-range clinical informaticist.

There were several articles from the Journal of the American Medical Informatics Association, with most of the ones I found interesting arriving in the most recent issue. The first addressed “Using artificial intelligence to promote equitable care for inpatients with language barriers and complex medical needs.” This topic resonated with me since I spent a good chunk of my training at an academic medical center in a city that served a particular refugee population that grew dramatically in the span of a few years.

The authors hypothesized that in-person interpreters are “particularly beneficial for these patients” but underused, and set out to use predictive analytics to identify the patients who should be prioritized for interpreter services. They performed semi-structured interviews with stakeholders to understand what those caring for patients thought about the idea.

I’m a big fan of qualitative research. Although one can gather a lot of information from surveys that elicit specific data points, some of the best understanding I’ve gained on complex issues has come from direct conversations with those who are involved in the issue. Stakeholder analysis is frequently overlooked when organizations are scoping large complex projects, and my feeling is that organizations neglect it at their own peril since it’s an excellent way to identify those who will support your project and those who are likely to block it. The key is having interviewers who are neutral and trusted, and making sure that people feel comfortable sharing their perspectives.

The authors conducted 49 stakeholder interviews and identified significant risks that would need to be addressed, including accuracy, privacy, and supply / demand issues. They also identified benefits including the ability to overcome clinician bias and to empower interpreters. Those are sentiments that you can’t always ascertain from a checkbox.

Another article that caught my attention also dealt with machine learning, this time looking at ethical perspectives on algorithm development for healthcare. The study also included qualitative research, interviewing 10 machine learning researchers on the topic. The participants were unanimous in identifying the ethical significance of algorithm development, which is good.

Not surprisingly, they identified areas where ethics may need to play a larger role, including around “standards related to scientific integrity, beneficence, and justice that may be higher in medicine compared to other industries engaged in ML innovation.” I haven’t read a truer sentence in some time, and it resonated with me after being at HIMSS and hearing some of the things that vendors were saying about artificial intelligence and machine learning. It’s amazing that companies still think that solving the healthcare problem can be done in the same ways that they have solved various problems in other industries. The last two decades have been littered with companies that thought that they had all the answers, but ended up exiting the healthcare space quickly.

A third article looked at whether patients who read visit notes have a higher rate of so-called “closing the loop” on recommended testing and referrals. The authors set out to look at “the relationship between patient portal registration with/without note reading and test/referral completion in primary care.”

For those of you who haven’t spent time in the primary care trenches, the primary care physician is essentially on the hook to make sure that patients complete every recommendation and referral that they are given. Even if the patient says “no” and state that they have no intention of completing a recommended action, the fact that they don’t is reflected in various clinical quality measures and also can come back around and bite the physician in the event the patient has a poor outcome.

I’ve been involved in medico-legal cases where the physician clearly recommended a test and the patient clearly refused it, but fast forward to when the patient has a preventable harm and the usual allegation is that the physician should have tried harder to get the patient to comply.

The article looked specifically at colonoscopies, which are of course recommended for early detection of colorectal cancer. They also looked at dermatology referrals for suspicious skin lesions and cardiac stress tests. They looked at whether patients who used the patient portal and who had read at least one visit note had more timely completion of the tests compared to patients who had portal accounts but didn’t read notes and compared to patients without portal access.

The authors found that compared to patients who had no portal access, those who had accounts had 20% higher chance of closing the loop on recommended tests. When patients had accounts and read at least one note, the odds were 40% higher. The authors controlled for various social, demographic, and clinical factors, but concluded that there are still gaps that must be addressed when recommendations are left incomplete. They recommend increasing efforts to promote patients accessing their notes, as well as other patient engagement strategies to ensure that patients complete recommended diagnostic and preventive steps.

Having done a fair amount of work in the space, the latter is certainly a lofty goal. There are so many reasons that patients may not complete recommended testing. These include but are not limited to: perception of the importance of the test; insurance coverage for and/or the cost of the test; time needed to be off of work or to secure childcare; understanding of the preparation needed for the test; difficulties in scheduling; and transportation issues. The list goes on and on.

I’ve worked on campaigns to address the issue through patient portal messages, texting with chatbots, integrated voice response systems, old-school 1:1 phone calls, postcards, letters, community outreach, health fairs, and more. Each little bit drives the needle, but there is still much work to be done.

I still have a stack of articles to read, but I felt like I at least made a little progress today. What’s on your list for continuing education topics? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/21/24

I’ve seen several recent mentions of Vale Health, which promises to be a “national health marketplace that serves communities through trusted health system relationships and leading health and wellness solutions.” That’s certainly a mouthful.

The company was founded by former Froedtert Health executive Mike Anderes and is designed to be a consumer-facing platform. The company lists 15 founding health system members who have membership on platform advisory boards that “set guidelines for choosing quality solutions, ensure careful treatment of consumer privacy, guide our product development priorities, and create the optimal engagement experience for people they serve.”

The majority of the company’s website is still under development, with only “better sleep” having listed products. Optimal weight, healthy pregnancy, healthy skin, mental wellness, and digestive health are all listed as coming soon.

Under the sleep products page, the site promotes a phone app, smartwatch, cooling sleep blanket, and melatonin tablets. Selecting “learn more” about the products linked me out to the app’s website and Amazon for the rest of the items. The site promises to “curate the highest quality, most respected products and services to address the health needs and wellness goals of the tens of millions engaging with their providers each year.”

Given the fact that the site promotes specific branded products with sales links that clearly indicate that the company may earn a commission, this just feels icky. It reminds me of when the American Medical Association entered into an ill-fated relationship with home appliance maker Sunbeam for product promotion.

As a clinician, I’d love to see the guidelines created by the advisory boards. What led them to choose a Fitbit product as opposed to one from Garmin? What about using Nature Made melatonin versus other brands, not to mention that the use of melatonin for sleep is controversial when you read the medical literature – it’s recommended in very specific situations, which of course aren’t mentioned on the site.

If you dig deep into one of the linked pages, it says that products are chosen using product review websites, information from manufacturers, user opinion, and online research into safety certifications, etc. They “do not conduct physical assessments of the products” and apparently they also don’t post information about the relevance of the products to the current standard of care for any diagnosed condition.

I spoke to someone in the know at one of the partner organizations. They voiced concerns that it feels like the company is “the Goop of healthcare” and I don’t disagree. I’m always suspicious when organizations promote the nebulous “wellness” concept and talk about the vague “health” of a body system, which is a pretty key indicator that nothing that’s about to be presented is FDA-approved or proven in high-quality, peer-reviewed literature. It’s not surprising that when you look at the company’s board of directors, there are venture capitalists. Just one more thing that makes this feel like a money grab rather than anything else.

Speaking of money grabs, the White House is launching new efforts to address healthcare costs. A task force is being formed and will include representatives from the Justice Department, the Federal Trade Commission, and the Department of Health and Human Services. Drug and provider costs will be at the top of the list of items to address.

I’ll be interested to follow the formation of this task force and would love to see the inclusion of other types of representatives. Let’s add some patient advocates, some “average” primary care physicians struggling to keep their doors open, and while we’re at it, let’s also include real-life patients who are fighting the system daily and struggling to pay their bills. I’ve long said there’s more than enough money spent on healthcare in the US that every one of us should have high quality care at a reasonable cost. Unfortunately, a good chunk of it goes to profits and also to fraud, waste, and abuse. This is why we can’t have nice things.

The best medical article I read this week was one in JAMA Network Open that looked at the effects of tai chi versus aerobic exercise on the systolic blood pressure readings of prehypertensive patients. It summarizes a randomized clinical trial that was performed in China. Although the study was small at 342 participants, it showed that blood pressure reductions at the 12-month point were greater in the tai chi group than with group that performed aerobic exercise. A little more than half of the study participants were women, and the mean age was 49.3 years in a range of 18 to 65. The participants had to either be untreated (no western or traditional Chinese medicine treatments) or to have been off of treatment for at least two weeks. Patients were excluded if they had diabetes, coronary artery disease, chronic kidney disease, current pregnancy, or breastfeeding.

Each intervention included supervised sessions, both in person and via video, that were conducted four times per week. They involved a 10-minute warmup, 40 minutes of core training, and a 10-minute cooldown. The tai chi component included 24 standard movements of Yang-style tai chi, where the aerobic component included stair climbing, jogging, brisk walking, and cycling. The sessions were conducted between July 2019 and January 2022, which is interesting given the span across the start of the COVID-19 pandemic. Blood pressures were measured at baseline, six months, and 12 months. Researchers also looked at lipid profile, fasting glucose, kidney function, weight, body mass index, and adverse events occurring during the study, although there were no differences in the parameters between those two groups. More than 82% of participants completed the study.

I’ve been working to keep myself out of the hypertension range since having episodes of mind-blowingly high blood pressures during the COVID pandemic. It turns out that when I’m exposed to the stress of a busy emergency department or urgent care, I’ll hang out with a systolic blood pressure in the 180s. If I’m at my primary care office or any other healthcare facility, 150 isn’t unheard of. I’ve come to accept that as part of the traumatic anxiety of caring for thousands of COVID patients. At home, I’m occasionally in the prehypertension range, but that has become better in the last couple of years as I avoid salt and exercise more. I’ve never tried tai chi given the limited options where I live, but maybe I’ll have to find some online resources and see if that brings it down any further.

What’s your ideal exercise? Do you like trail running, beach walking, swimming, or something more exotic? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/18/24

My inbox seemed to explode while I was at HIMSS. I’ll be trying to tunnel out for at least the next week, I would bet.

One of the interesting articles I found was about the clinicians at telehealth provider Bicycle Health and the fact that they have filed with the National Labor Relations Board to unionize. A press release from the Union of American Physicians & Dentists notes that physicians, physician assistants, and nurse practitioners have experienced “a shift in company culture where we as providers feel increasingly overworked, undervalued, and our feedback is regularly ignored. In order to continue providing the best care for our patients struggling with opioid addiction, we knew we needed to come together.”

I’ve worked as a telehealth clinician for several different companies. It’s more likely than not that they have treated their telehealth providers as expendable despite the fact that patients can’t be seen if there aren’t licensed providers to see them. Even working for organizations that also had a brick and mortar presence, it’s clear that administrators thought telehealth providers are replaceable.

That may be true, given that a lot of telehealth providers only work on an as needed basis and are paid accordingly. As such, they are treated more like Uber drivers than knowledgeable professionals. It will be interesting to see how this shakes out over the coming months.

I spent a fair amount of time at HIMSS contemplating the marketing efforts of various companies. Some have clear and well-reasoned strategies, while others are a little bit more of what we might describe as all over the place.

Nothing says marketing drama than NYU Langone Health System suing Northwell Health over allegations of trademark infringement. Earlier this month, a federal judge dismissed the suit, citing the variability of shades of purple, intermittent use of sentence case as well as all-capital phrases in white, and other factors in the failure to prove infringement. The judge dismissed some of the claims without prejudice, which will permit NYU Langone to amend its complaint in the future.

I love some of the quotes from Northwell Health’s chief marketing and communications officer, who stated that NYU Langone has “no filed claim to the color purple” and that “If it truly is a trademark right of theirs, then they should protect the asset.” He went on to say that Northwell uses 16 colored triangles in its main logo, representing the diversity of the health system, and that continued pursuit of action is a “waste of time and resources.”

Speaking of lawsuits, I also had a blurb in my inbox about New York City (including New York City School District and New York City Health and Hospitals Corporation) suing social media companies in relation to the growing youth mental health crisis. The lawsuit was filed in the Superior Court of California, with named defendants including Meta / Facebook / Instagram, Snap, TikTok, and Google / YouTube. The complaint is 311 pages long and parts of it are a truly fascinating read. It starts with factual allegations against all defendants and then moves to specifics. Among the general allegations:

• Social media’s core market includes school-aged children, who are “uniquely susceptible” to harm from the platforms.
• The platforms are designed to addict youth who use the platforms with minimal parental oversight.
• Millions of children use the platforms compulsively, including during school hours.

Specific claims include algorithms that are designed to promote compulsive use, gambling-inspired features that create cravings for likes as a reward, and tailored advertisements. Plaintiffs are asking for an order that the defendants’ conduct “constitutes a public nuisance” that requires abatement along with funding for prevention efforts, mental health treatment, actual damages, and punitive damages. I see plenty of children, teens, and adults who are addicted to social media and who can barely function without a phone in their hand.

At the same time, Florida Governor Ron DeSantis vetoed legislation that included social media restrictions for minors. Politico noted that the governor had indicated well in advance that he wasn’t supportive of the measures. Legislators immediately scrambled to try to create replacement legislation. The vetoed legislation would have prohibited creation of accounts by those under age 16 and would have required third-party age verification and would have prevented parents from helping their children bypass the restrictions. Watered-down replacement language would allow parental consent.

During my career as a physician, I’ve seen plenty of parents make bad decisions on behalf of their children, most recently because they fear the peer pressure that might ensue if their children don’t get exactly what they want. Physicians saw an uptick in skin issues in January from parents who bought their children certain TikTok-promoted skincare products for Christmas, not understanding that powerful anti-aging chemicals would be harmful. As of the time of this writing, DeSantis plans to sign the revised bill.

Although I enjoyed the warmth of Orlando and being able to enjoy some sunshine, I certainly don’t miss the traffic or the cranky children and frustrated parents. It was 20 degrees cooler when I landed at home and that was followed by severe weather and a significant temperature drop that was accompanied by golf ball-sized hail. We’re headed back below freezing tonight, so it’s time to get out the fuzzy slippers and flannel lounge pants in preparation for a full day of conference calls tomorrow.

I must say that when I travel, it feels a little strange to wear dressy clothes on both top and bottom after several years of virtual work in a hybrid wardrobe. My clinical shifts don’t count as wearing real clothes since all of my scrubs are well worn and are softer than most of my pajamas.

I’m looking forward to slipping back into my usual routine and seeing what the healthcare IT universe throws at me next. What do you enjoy most about being away at a conference? And what are the best parts of coming home? Leave a comment or email me. 

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/11/24

Mr. H reported on this last week, but I’m still struggling with the story about Guam Memorial Hospital spending $5 million on an EHR that isn’t fit for purpose. As someone who used to do consulting work to help healthcare organizations with EHR system selection needs, it’s just baffling that this hospital’s project has reached this point.

You can try to blame the fact that there was a pandemic that caused delays, but that feels like a convenient excuse to try to cover problems that range from incompetence to willful neglect. There’s also the question on who will profit from the $20 to $60 million that it will take to replace the current system with one that will actually get the job done.

The system has been in place since October 2022. An administrator has stated that leadership determined it “really wasn’t built for an acute care hospital landscape” and would be more suitable for a behavioral health application. Because there isn’t funding to address the issues, caregivers are essentially stuck with it for the time being.

It feels like the basic tasks involved in system selection were somehow skipped: demonstrations, reference checks, and site visits with peer organizations that were currently using the system. This isn’t a magical new process for buying an EHR. I’ve done it at least a dozen times in the last two decades, and it’s pretty straightforward. Even if you claimed that the pandemic prevented site visits, you could still address a number of needs through a virtual site visit. In my experience, physicians rarely lie about the capabilities of an EHR unless they are being bribed.

I can’t throw the vendor under the proverbial bus without all the facts. It’s not entirely clear with of the vendor’s modules were actually purchased and how they were implemented.

I’ve personally been involved with EHR implementations where health systems did some pretty silly things, such as “forgetting” to include laboratory interfaces in their original Request for Proposal document, and grossly underestimating the volume of patient data that would need to be converted in order for physicians to work efficiently and for patients to be safe.

On the other hand, it feels like the facility might have skimped out on certain implementation steps as well as system selection steps, including elements such as workflow design, inclusion of patient safety and quality reporting features, and a little thing called user acceptance testing. Maybe issues were raised and leadership just plowed on through, though – I’ve certainly seen that happen a number of times.

As for the complicity of the vendor in this situation, I did a quick glance at its website, which may not at all resemble what the hospital had access to as it was selecting the system. There are plenty of areas of the website that channel language specific to behavioral health inpatient applications. There are consistent mentions of using DSM 5 to capture diagnoses in the chart rather than using ICD-10. There are also several mentions of the ability to document group visit notes, which typically don’t occur in the standard medical / surgical inpatient setting. The vendor does list a number of component products, however, and it looks like there may have been some mergers or acquisitions along the way, so that might be part of the issue too.

The news article notes that management is busy preparing a new RFP and therefore couldn’t offer additional comments on the downstream operations and billing impacts caused by the situation. I suspect they can’t offer comments because they’re actually preparing updates to their resumes as they consider pursuing other opportunities. The hospital is tied into a subscription-based contract, so they’re stuck with it until they can get a replacement live.

Hospital IT projects don’t happen overnight, and if the same leadership team remains in place, I’m sure it won’t be an efficient rip-and-replace at all. Even in the best of situations, you’re looking at an 18-month lead time to install a hospital system, just due to the sheer number of decisions that have to be made, the workflows that have to be mapped, the clinical data that has to be converted, and of course the ever-hellish hospital contracting process. That’s not allowing additional time for lots of questions to be asked, since the facility has already bought a lemon and stakeholders probably don’t want to buy another one.

Reading through the article, the organization has dealt with a number of technology problems in the past, including concerns logged during site visits from the Centers for Medicare & Medicaid Services (CMS). Those citations focused blame on the hospital’s previous EHR, which has since been discontinued. CMS cited the facility for failure to systematically track medical errors.

The administrator speaking to the media for the article noted that the new system had been recommended by the previous vendor. That’s problematic in my book, because when I have a vendor that’s failing to meet expectations, the last thing I want to do is to take their recommendation for a replacement. Apparently the two vendors were somehow affiliated, but trying to figure that out is beyond the scope of my investigative reporting motivation at this point. Apparently it was a no-bid contract situation, and that’s enough information for me. I can’t help but feel concern for and outrage on behalf of the patients who are now stuck receiving care in this environment, and the clinicians who have to try to make do with something that is clearly incapable of supporting them.

There are only a handful of comments on the article, and I wonder if any of them are from clinicians. If I had inside knowledge of the situation, I’d certainly be spilling it. I’m curious if we have any readers who work with the vendor in question or who have inside knowledge on the situation and would be happy to help you share your thoughts anonymously. Inquiring minds want to know: How do situations like this happen? Is there more to this story than meets the eye? Or is it simply a case of rampant incompetence? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/7/24

I was hanging out with some medical friends the other night, and as it happens when adult beverages are involved, the conversation was all over the place. We were talking about patient education, and one of my colleagues who is fairly new at working directly with patients admitted to having used ChatGPT to help him formulate an answer to the question of “What is a placenta?” while keeping the answer at the level a 12-year old could understand.

It points out the importance of answering questions in language that patients can comprehend, especially when medical folks are used to using larger words and entirely too many Latin phrases. Patient education is important as are communication skills, but both tend to be undervalued in healthcare today. As a side note, following that conversation I decided it would be cool to be able to peek behind the curtain of the commercially available generative AI solutions to see the kinds of questions that are being asked by the general public.

Other hot topics include a local hospital tasked with cutting 10% of its frontline nursing staff to help balance the books. Although I understand the slim margins that most hospitals operate under, I doubt that cutting nursing staff is going to be a positive as far as patient safety, nurse-to-patient ratios, or patient and family satisfaction. They’ve already gotten rid of their weight management program, which doesn’t make sense given the obesity epidemic and people’s willingness to pay cash out of pocket for obesity drugs. In addition, they’ve eliminated a number of physicians and service lines related to women’s and children’s health. I’m sure if the community knew what was going on there would be an outcry, but the hospital has been keeping it pretty hush-hush.

From Burned Out PCP: “Re: AI. What do you think about this article that looks at AI as the solution to the primary care physician shortage? I’m hanging up my stethoscope because I can’t take it any more. Thankfully, my ability to do clinical informatics work is serving as a lifeboat.” The article does a nice job summarizing some of the statistics, including the staggering savings the US could realize ($67 billion) if everyone had a primary care provider, as well as the projected primary care physician shortage ballparked in the neighborhood of 40,000 physicians by 2034. The author summarizes some of the factors contributing to primary care physician burnout, such as the fact that “most doctors enter the profession because they want to build trusting, long-term relationships with patients and see them get healthier. Instead, primary care has increasingly become short-term and transactional.”

I agree with this statement. It has been difficult to watch the erosion of respect for primary care practice since I graduated from residency training. Generational values have shifted and it feels like patients no longer value those relationships. Healthcare costs and economic realities have pushed patients to select convenience over comprehensiveness and low-cost over longitudinal relationships.

The author lists the likely suspects for AI tools to assist physicians, including digital scribing and documentation. They also include the ability to digest information from physician notes, laboratory and imaging reports, and other documents to create a more useful view of the patient and to identify potential gaps in care or recommendations for changes to the treatment plan. I don’t feel like the author really added much to the current understanding of the role of AI, and assumed it was a generic op ed piece until I got to the author info at the bottom which identified the writer as the chief medical officer for Amazon Health Services. I think I would have expected a bit more from someone in that role, especially with an article that appeared in Fortune, but that’s just me.

The US Food and Drug Administration has authorized a “first of its kind” feature for the Samsung Galaxy Watch, intended to assist with management of sleep apnea. The feature allows users over the age of 22 who have not been previously diagnosed with the condition to conduct a two-night monitoring period. I know from my experiences tent camping at a variety of locations that there are plenty of people with sleep apnea out there. Of course, some of them are likely diagnosed but haven’t figured out the logistics of bringing a CPAP machine to the woods, but I suspect a number of them are undiagnosed. Perhaps I need to start dropping hints to my camping friends who are on team Android.

The US Department of Health & Human Services (HHS) has recently published a notice in the Federal Register that explains changes to the data required for providers to obtain and keep a National Provider Identifier. The National Plan and Provider Enumeration System (NPPES) will now permit providers to list a post office box as a practice location when the provider doesn’t have an office location other than their home. It also expands reportable gender values to include X for “Unspecified or another gender identity” and U for “Undisclosed” beyond the usual M and F for male and female. The system will begin collecting these new values next month. If you love the Federal Register or just need supplemental reading material before bedtime, details on the changes can be found here.

Like many people, I’m getting ready for HIMSS and appreciate having HIStalk’s Guide to HIMSS24 to help me find booth numbers without having to use the annoying HIMSS exhibition website. The list feels a little shorter this year than it has been in the past, but it’s unclear if people didn’t submit a blurb for inclusion or if they’re simply not submitting. Based on the friends I’ve reached out to in order to determine if they’re attending, it feels like I may be at HIMSS by myself and surrounded by tumbleweed.

On the other hand, I just was “uninvited” from a HIMSS-sponsored lunch and learn session after previously being confirmed, so maybe there are plenty of cool kids going. This is the first year that I don’t have multiple party choices for the evenings, so I might be making an early night of it. If you’re looking for anonymous but sassy reporting on your event, you know where to send the invite.

A friend of mine reached out about the recent Oracle Health reduction in force, which apparently was conducted in sync with National Employee Appreciation Day. Nothing says appreciation like a layoff, so here’s a jeer to the people who decided on the timing. What does your organization do to make employees feel appreciated? Anything different they should be doing instead? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/4/24

A number of my physician friends still work for independent medical practices, which is a bit surprising given recent market forces that have been challenging even for the most well run of them. Now that the Change Healthcare ransomware attack is approaching the two-week point, many are concerned that they are going to be in financial straits.

The first quarter of the year can be difficult for medical practices, especially if they have a large percentage of patients that are covered by high-deductible health plans. Those patients often avoid care until they reach their deductibles, which means volumes can be down in the practice. This tends to pick up towards the end of the calendar year, when patients have met those deductibles and are trying to squeeze in visits before the new year rolls around. 

Several of my friends were chatting about the inability to send claims to insurance companies and are worried about cash flow. I asked whether their business continuity insurance policies would cover the disruption and was surprised that more than half of them didn’t know if their practices even have that kind of insurance coverage. One would think that after coming out of a pandemic that significantly disrupted practices’ ability to function, groups would have looked into that if they didn’t already have coverage. Maybe the reliance on federal pandemic funds made them think they didn’t need to worry about it, but they are now wishing they did.

For those that outsource their revenue cycle management functions, they have been surprised by the lack of communication about the situation and what the third parties are doing to try to switch to other vendors. Some are wondering how they’re going to be able to make payroll and are trying to get short term loans to cover practice expenses. I’ve heard that a couple of local banks are stepping up to help out, but it sounds like national banks are less excited to be doing so. For lack of a better description, everyone is just scrambling at this point.

My current clinical practice pays me on a per-visit basis, regardless of a patient’s ability to pay or what insurance they might or might not have. That provides me a bit of a buffer from the Change Healthcare situation, although I know that the organization I work with is nervous about the situation. They’re committed to caring for patients and have a decent financial reserve, however, and I feel reassured that I’m unlikely to be benched like I was during the pandemic.

I’m exclusively seeing patients via telehealth these days, partly due to volume demands and partly due to my computer skills. I think my employers enjoy having someone who can power through visits, understands the need to set up their own favorites and defaults, and doesn’t complain about the EHR.

Patients have grown to rely on telehealth. The fact that we don’t know for sure what will happen with telehealth reimbursement is making a lot of organizations nervous. A little more than a week ago, 200 organizations signed on to a letter that asked the US Congress to take action to ensure that virtual care payments that were modified during the pandemic remain favorable. A couple dozen of these organizations were health systems, but among the rest were professional societies, patient advocacy organizations, virtual care companies, and tech giants such as Amazon. Big names signing on included Ascension, Intermountain Health, Johns Hopkins Medicine, Mass General Brigham, Michigan Medicine, Trinity Health, and UPMC.

The signers encourage Congress to take action now so that patients and care delivery organizations can plan and budget, rather than leaving them hanging until the eleventh hour as Congress tends to do. Organizations can be confident when they make investments in virtual and hybrid care models, which will be essential in managing workforce challenges. They also note the need for employers to be able to plan ahead for their health plan offerings for the coming year, which they can’t do if decisions aren’t made well before the traditional open enrollment periods that most employers have in November. Additional points made in the letter include:

• Patients have come to rely on telehealth, and ending payments will be detrimental to established care relationships.
• Safety net organizations have used telehealth to extend care, including community health centers and rural health clinics.
• Continued provision of mental health services via virtual care is essential.

I’m now in my seventh year as a practicing telehealth clinician, which is hard to believe when you think about it like that. It’s a skill that physicians of my training generation certainly weren’t trained to do, but we adapted quickly to it when our organizations decided to roll out programs. Those of us who were already seasoned definitely had an easier time during the pandemic. I was fortunate to be able to use a mature platform that hadn’t been cobbled together with Zoom, duct tape, and leftover Cat 5 cable.

I still chafe having to wear a white coat to perform telehealth visits, as required by my organization, but the annoyance of the scratchy polyester is outweighed by the fact that patients genuinely appreciate the flexibility of care even when I’m just providing advice and not sending out prescriptions.

I can’t think of any physicians I know who still perform house calls, but in many ways telehealth visits have become the house calls of the future. Especially when you can add technology like connected blood pressure cuffs, scales, and imaging devices, it goes along way towards what you could say was almost like being there. Now we just need to break down the payment barriers, and while we’re at it, I’d love to see our federal government find a way to break down the patchwork licensing restrictions in the US that keep me from seeing patients who live a couple dozen miles away from me but who are figuratively in a different world as far as me being able to care for them. My standard of care isn’t going to be different just because of where the patients live, but state medical boards sure try to convince people that it’s a real risk. It’s time for licensure reciprocity or a federal license.

I’m realistic enough to know that probably won’t happen before I retire, but a girl can dream.

What are the biggest priorities that our legislators should be tackling where healthcare is concerned? Leave a comment or email me.

Email Dr. Jayne.