Curbside Consult with Dr. Jayne 6/29/20

Back in the early days of Meaningful Use and the beginnings of the transition from volume-based payments to value-based care, I used to be knee-deep in politics, legislation, and regulation. Over the years I gradually spent more time with my nose to the grindstone helping organizations figure out how to transform and adapt to what were then final rules. From there I moved into more technology roles, helping vendors tweak their offerings and helping clients optimize their implementation.

I got away from following legislators and the courts, but the year 2020 has brought all that back on my radar. Understanding how closely tied the US healthcare system is with the US political system, especially through lobbying by powerful interests, I’m once again following the US Supreme Court and US Congress more carefully, along with various parts of government that are responsible for promulgating rules, policy, and guidelines. It’s a different place to be in, but still within the CMIO wheelhouse.

The US Supreme Court was busy last week, and although I thought I understood the meat of the DACA (Deferred Action for Childhood Arrivals) program situation, I failed to fully appreciate its ramifications on healthcare. When thinking of those impacted by DACA, most news stories feature high school students, college attendees, or young people in the workforce who are concerned about being deported after being brought here as children. An article put out by the AMA notes that approximately 30,000 of the workers impacted by the DACA decision are in the healthcare workforce.

What would our healthcare delivery situation look like with 30,000 fewer workers, some of whom have skillsets that are in shortage? Those impacted include physicians, nurses, and pharmacists. Looking at just the physicians and physician trainees, they have the potential to care for anywhere between 2 and 5 million patients during the course of their medical careers. Our nation continues to have a significant nursing shortage, to the point where we bring in travel nurses from around the world to staff patient beds in many parts of the US. Many of the lower-wage jobs in large urban health centers are staffed by immigrants, and I’m sure some of them fall under DACA as well.

The Department of Homeland Security will be re-visiting this issue and providing documentation to try to have the matter heard again, since the decision hinged on some specific details. If they do, I’m sure the more than 30 healthcare organizations that submitted a “friend of the court” brief for this case will continue to advocate on behalf of those impacted by an additional consideration of the program. In the mean time, hospitals and healthcare organizations should work to gain a better understanding of the immigration status of their workers.

CMIOs have historically been a lightning rod for complaints about physician burnout since EHRs were the vehicles used to add additional documentation burden and cumbersome workflows as part of federal incentive programs. In more than one client situation, I’ve been pulled in to use this expertise to try to address burnout that’s being exacerbated by the ongoing pandemic. I never sought to be known as “the EHR guru and burnout expert,” but that’s how I was introduced the other day. Although I’ve helped a couple of organization streamline their workflows, mostly around ordering and results management related to COVID, I’ve been doing additional work on the organizational development side to help leaders work better with clinicians who can only be described as shell-shocked.

I feel validated every time I see an article about this phenomenon. The AMA wrote about it recently in a piece titled “Four ways COVID-19 is causing moral distress among physicians.” I’ve worked a string of back-to-back shifts at urgent care, which essentially has become the emergency department because people are afraid to go to the hospital and come to us instead. I even had a gunshot wound the other night who required a trip to the operating room, which freaked my staff out, but given where I did my residency training, didn’t make me blink.

Already existing physician burnout is being exacerbated by not only a lack of effective treatments for the COVID-19, but lack of adequate personal protective equipment, which receives zero media coverage but is do-or-die for most of us. Now we’re dealing with either an extended first wave or a nascent second wave populated by patients who refuse to social distance or wear masks but desperately need our help when they find out they’ve been exposed at the neighborhood block party or their child’s sports practice. Frankly I’m tired of exposing myself personally while trying to help patients who just don’t give a damn or who are all about instant gratification.

Today I had every room in the center fully utilized, some rooms with 2-3 patients in them as part of a family unit, and was still 10-deep in the waiting room (which was actually 10-deep with people waiting in their cars in 90-degree weather.) Fortunately, I had my favorite physician assistant to help me fight the battle and we kept each other’s spirits up. We could only be described as “medieval warrior meets LL Bean” since I was wearing a modified welding face shield that looked like I meant serious business, and she was wearing a face shield with plaid trim. Based on our shifting case mix, I’m once again isolating in a corner of the house mostly away from others, and I guess if it continues to get bad, I could always go back to staying in a tent in the yard.

At least I’m a fully trained physician and making the choice to expose myself to this craziness voluntarily, which can’t be said of the thousands of resident physicians who are staffing hospital beds and clinics across the country. Earlier this month, residents in New York staged a walkout at their Brooklyn hospital, sharing a list of demands they want met prior to a potential second wave. During the peak of the surge, residents felt alone and abandoned by their facility’s leaders, forced to cope with a lack of supplies and little recourse. I found the statistics in the article staggering, including the fact that by May, a whopping 70% of the emergency medicine residents had tested positive for COVID-19. Residents also cited 160 patients in an emergency department that was 100 patients over capacity. Needless to say, this is not ideal.

A couple of readers have asked why I focus so much on the “in the trenches” experience lately rather than writing about healthcare IT. In addition to it being what I’m living on a regular basis, it’s something that all of us on the technology side need to understand. Organizations are trying to roll out numerous solutions to help solve problems and make things smoother for us, but I truly believe that to be effective in that effort they need to understand where we are, physically, mentally, and emotionally. We’re not going to show up on a web-based training session when we’re post-call and exhausted, and if we’re not focusing on what a trainer is saying because we haven’t eaten in 10 hours and really need to go to the bathroom, it’s something that should be considered.

I’d be interested to hear from readers on how your organizations have modified rollout plans for new solutions or how you’re addressing changes to functionality while your end users are on the edge. Are you making tweaks to try to streamline systems, or are you staying static to allow people to focus on other matters? Leave a comment or email me.

Email Dr. Jayne.